HomeMy WebLinkAbout0325 BLACKTHORN ROAD - Health L325 BLACKTHORN ROAD, ha
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i
TOWN OF BARNSTABLE
LOCATION 375 3kxc1Z-A'r%nr-m Rvk. SEWAGE# Z019 yLZ.
tVILLAGE 1n0rs4o^s in'11 $ ASSESSOR'S MAP&PARCEL 3Z• 13
INSTALLER'S NAME&PHONE NO. R iP 3 CXCQQgA i o r\
SEPTIC TANK CAPACITY 1000 o0_1
LEACHING FACILITY. (type)•Qcr-f• piPc I rrcnchcS(size)'O-Z. '
NO.OF BEDROOMS 3
OWNER O crA Ic
PERMIT DATE: I Z-G. - 19 COMPLIANCE DATE: /Z•Z y- 19
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
A i-35
d31' I`7
AV 41
02 20
A,3- G`7
A (33,
3 as- roo '
r
No. �� Fee too-
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2ppfication for Misposal 6pstem Construction 3permit
Application.for a Permit to Construct( j Repair(V/) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 31.$ 1Yo.0c0,orn (hoc►d Owner's Name,Address,and Tel.No. Anne,+}-_ Otr+le-
'Ma�6�ens M;US
Assessor'sMap/Parcel Z 1 325 GX0.c1.fMorn (,ocad mac$�r s M'.kks
Installer's Name,Address,and Tel.No.$3 6 "C4 c0.v0.4io n Designer's Name,Address,and Tel.No. FI o hec 4 u� `unu�cri
3'14 ( oDo-e. 130 Snndwi(j" AX 01543 So$• y'7-1• P.O. box �31 Ha�w��ti Ot�yJS
3 P10►•
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size 10,O 1 G sq.ft. Garbage Grinder(N o)
Other Type of Building Pies. dwe.tki Al No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 33 O gpd Design flow provided 359 gpd
Plan Date Iti�y'19 Number of sheets Z Revision Date h
Title
Size of Septic Tank 1600 OWkkon Type of S.A.S.(Z) Tf e►0its (3 it S� Y 2
Description of Soil Ste, OAns
Nature of Repairs or Alterations(Answer when applicable) QNe.Plo,cc d-box and SAS , COnneC- +0
IQ
eJC�b�1/14 IOUo Q0.«Cn '�'Gl�1t.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Boar of Health.
Signed Date oZ
Application Approved by Mft%,LAj,(A,n�(L Date ; (O
Application Disapproved by Date
for the following reasons
Permit No. �i� Date Issued `��/
No. r ! Fee
—
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Rppf ration for Misposaf 6pstem Construction 3permit
Application for a Permit to Construct( ) Repair(V) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 31 S hj I.c,c 1.1,,o , F�o c, Owner's Name,Address,and Tel.No. �+(c, pc r 1 t G
Assessor's Map/Parcel i 3 Z S ft�l c.ck+hur,, R,oc.c+ .mc,c`ko," M.115
Installer's Name,Address,and TA No. x r n vc.i,, Designer's Name,Address,and Tel.No. p G',t-1,�
31 ,cu+e 130 Snnclwch Act OZ5�3 SoFirLl, a• �.O• r`Jcx 3 1 El<..t,> fin. UZt.oc1
Type of Building:
Dwelling No.of Bedrooms Lot Size Z D,O 1(1 Sq.ft'I Garbage Grinder(N 0)
Other Type of Building Rer,. AWQ 1k,cn No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 'j,�o gpd Design flow provided �.5`I gpd
Plan Date—_ I L 141 19 Number of sheets 2 Revision Date
Title
Size of Septic Tank n \ Type of S.A.S.
Description of Soil Sf e
,Nature of Repairs or Alterations(Answer when applicable) e 0 n c c �rli (i )t n n rl 5 A 5 (anr.n
1000 ().r-l l o n
I'
Date last inspected: 1
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
i
r 'accordance with the provisions of Title 5 of the Environmental Code and�not to place the system in operation until a Certificate of
Compliance has been issued by this Boa-d of Health.
Signed E / r. Date
Application Approved by M 4AZI.s1 �l s ,\to
Application Disapproved by ` Date
for the following reasons
Permit No. _7 i 1 llii r "7 .1. Date Issued /� 1
r
THE COMMONWEALTH OF MASSACHUSETTS ,.
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
x��
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( )
abandoned( )by j (Z f,ram,dc, k n n n .
Sat � ( 1 n i k t u,r n �i�d M o f( ,,; j IS has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer ( { (�� �/ L r ny�,{ l n Designer
#bedrooms _ 3 Approved design flow p and
The issuance of t is pe it shall not be construed as a guarantee that the system w• 1 fun io as designed.
Date Inspector
----------- - --------- ---------------- ------------------------------------------------------ ----------------------
No. q Fee
' THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Misposaf *pstem Construction permit
Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( )
System located at 11 LCCiI ackl-tlor,r, R,e?,mf c+"n M, (
and.as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her.duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date Approved by AA IN, K5
V
Town of Barnstable
y°ptHETp Regulatory Services
Thomas F. Geiler, Director
" ,MASS. ' Public Health Division
y MASS.
i639.
rEn ma's" Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Date: ►Z•Zy- 1 q Sewage Permit# ZO 19 - 1462. Assessor's Map/Parcel Z -1
Installer & Designer Certification Form
Designer: F hC_r4eu 6rjv;mWIcK)vt Installer: �Xea�t;�c�io✓�
Address: O BOX 331 Address: t� -feQSerrc, z,�
14acc_3IC4% r'ak- �res-IdalL.
On /Z- G -14 R 4 fA Exco4)o_A i o✓-, was issued a pen-nit to install a
(date) (installer)
septic system at ,325 JG1g0<A\v%Qr)(\ R.::L based on a design drawn by
(address)
ohe dated I Z - Ze{-14
(designe
_ Y__ I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Stripout (if requird �' S ected and the soils
were found satisfactory. �y�k9�'�--_--•...'�syc'
DA!lJC2
{ < " FLAHERTY, Jk.. cn
( taller's Sign e NO, 1211:
°`sre�E
"44, 7A_ s'4NI TAR%R�
t
(Designe 's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
q:\office forms\desi;nercertification forrn.doc
Town of Barnstable
Inspectional Services Department
awuvfrrantt+;,
6'9. ,m Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4988 1098
November 20, 2019
OERTLE, ANNETTE R
PO BOX 403
MARSTONS MILLS, MA 02648
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 325 Blackthorn Road, Marstons Mills, was inspected on
11/06/1019 by Brett Hickey, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
C Leaching facility with standing liquid level at or above the invert pipe (per
Town Code 360-20 h).
You are ordered to repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF E BOARD OF HEALTH
as McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\325 Blackthorn Road Marstons
Mills.doc
of�►'�Toy,
Town of Barnstable
1 IIARNSfABLE.
b 9 Inspectional Services Department
ArED MA'S A
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 4/26/19
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An "x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
❑ Structurally unsound septic tank or SAS
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
OLeaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
b3a-o73
' Commonwealth of Massachusetts
�n Title 5 Official Inspection Form ,
�= 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.......... / 325 Blackthorn Road r�
u
Property Address
Annette Oertle
Owner Owner's Name /
information is Marstons Mills !' Ma 02648 11-6-19
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information LIg
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
rmn+ (508)477-0653 S113747
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑® Fails
Brett Hickey m" by
W. US 11-6-19
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/2 612 01 8 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
325 Blackthorn Road
Property Address
Annette Oertle
Owner Owner's Name
information is Marstons Mills Ma 02648 11-6-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:.
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t
325 Blackthorn Road
V�
Property Address
Annette Oertle
Owner Owner's Name
information is Marstons Mills Ma 02648 11-6-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)`are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑Y obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
325 Blackthorn Road
V
Property Address
Annette Oertle
Owner Owner's Name
information is Marstons Mills Ma 02648 11-6-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
Q ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ El Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Dorm
= I Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments
325 Blackthorn Road
v
Property Address
Annette Oertle
Owner Owner's Name
information is Marstons Mills Ma 02648 11-6-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ a Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ a Liquid depth in cesspool is less than 6"below invert or available volume is less
than '/day flow
❑ El Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ M Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ El Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ Q Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ED Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
Q ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
325 Blackthorn Road
Property Address
Annette Oertle
Owner Owner's Name
information is Marstons Mills Ma 02648 11-6-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no" for each of the following for all inspections:
Yes No
0 ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ El Were any of.the system components pumped out in the previous two weeks?
0 ❑ Has the system received normal flows in the previous two week period?
❑ Q Have large volumes of water been introduced to the system recently or as part of
this inspection?
El ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ El Was the facility or dwelling inspected for signs of sewage back up?
El ❑ Was the site inspected for signs of break out?
El ❑ Were all system components, excluding the SAS, located on site?
0 ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ El Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
❑ El Existing information. For example, a plan at the Board of Health.
0 ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
l5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
cam, Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
325 Blackthorn Road
Property Address
Annette Oertle
Owner Owner's Name
information is Marstons Mills Ma 02648 11-6-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
No design plans 3
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): NA
Description:
No design plans were available at local Board of Health
Number of current residents: 5
Does residence have a garbage grinder? ❑ Yes Q No
Does residence have a water treatment unit? ❑ Yes ral No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes EI No
information in this report.)
Laundry system inspected? ❑ Yes 0 No
Seasonal use? ❑ Yes Q No
Water meter readings, if available (last 2 years usage (gpd)): See below
Detail:
***WELL WATER***
Sump pump? Yes ❑ No
Last date of occupancy: currentDate
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
�n ,ip Title 5 Official Inspection Form
I a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v
325 Blackthorn Road
Property Address
Annette Oertle
Owner Owner's Name
information is Marstons Mills Ma 02648 11-6-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
Type of Establishment:
Design flow(based on 310 C M R 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Owner- Last pumped 4 years ago
Was system pumped as part of the inspection? ❑ Yes ❑■ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18"
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
325 Blackthorn Road
Property Address
Annette Oertle
Owner Owner's Name
information is Marstons Mills Ma 02648 11-6-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
El Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
unknown due to lack of record
Were sewage odors detected when arriving at the site? ❑ Yes ❑3 No
5. Building Sewer(locate on site plan):
1'4"
Depth below grade: feet
Material of construction:
❑ cast iron ❑I] 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >100' from well to SASfeet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
gal Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
325 Blackthorn Road
Property Address
Annette Oertle
Owner Owner's Name
information is Marstons Mills Ma 02648 11-6-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
4"
Depth below grade: feet
Material of construction:
❑E concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
1
Dimensions: 000gallons
15if
Sludge depth:
2011
Distance from top of sludge to bottom of outlet tee or baffle
8"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
911
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was in working order at the time of inspection but is in need of pumping
at this time and should be pumped every two years for maintenance.
t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
325 Blackthorn Road
Property Address
Annette Oertle
Owner Owner's Name
information is Marstons Mills Ma 02648 11-6-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
NA
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
325 Blackthorn Road
Property Address
Annette Oertle
Owner Owners Name
information is Marstons Mills Ma 02648 11-6-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
0"
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The d-box was in working order at the time of inspection.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
325 Blackthorn Road
Property Address
Annette Oertle
Owner Owner's Name
information is Marstons Mills Ma 02648 11-6-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
El leaching pits number: (1) 6'x6' pit
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
325 Blackthorn Road
Property Address
Annette Oertle
Owner Owner's Name
information is Marstons Mills Ma 02648 11-6-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The SAS was in hydraulic failure at the time of inspection. Pit was full over inlet invert.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NA
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
` 325 Blackthorn Road
Property Address
Annette Oertle
Owner Owner's Name
information is Marstons Mills Ma 02648 11-6-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
325 Blackthorn Road
Property Address
Annette Oertle
Owner Owner's Name
information is Marstons Mills Ma 02648 11-6-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑■ hand-sketch in the area below
❑ drawing attached separately
�J Lfutj4^A3 y v +rx`LIL)WN 01 AKNS'f At3L L
T LOCA ION I -- ��:C.�� .. s��vA��.�
VIU, ..AGE (T),i`t C ASSESSOWS &LOTJ_d-k
3NSTA1.t"Ek.S NAME,&PHONE NO..
trzPnC TANK GAPA%i 1 Y
LEACHING FACMITY:
-NO3 OF BEDRbOMS�a�
DFJ3L1:YEft Ctf t�W lF«EL _._,.
PERMITI)i4Tfi COMPLLANCE DATE:
Stsparatioa,TJiatance Tietwexu Usa€'.
b4ax mum A eljttstod Groundwater Table and Bottom.of Leaching Facility Feet
Pri,iatc Wafer Sopply'WtU and Leaching Facility (If any wails exist.
on site orwithin 200 feat of leaching facility) Feat'
Edge of Wetland and Leaching Facility(If any wetlands exist.
within 300 feet of leaching facility) t
Furnished by.
I -
F.
AC 1
FAS
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
cam, Commonwealth of Massachusetts
�e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
325 Blackthorn Road
Property Address
Annette Oertle
Owner Owner's Name
information is Marstons Mills Ma 02648 11-6-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
0 Check Slope
❑M Surface water
❑® Check cellar
❑® Shallow wells
Estimated depth to high ground water: No GW @ 12'feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
R. Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
El Accessed USGS database-explain:
See below
You must describe how you established the high ground water elevation:
Topo maps and charts were used determine high groundwater. Bottom of SAS is
greater than 4' above high ground water.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
v
325 Blackthorn Road
Property Address
Annette Oertle
Owner Owner's Name
information is Marstons Mills Ma 02648 11-6-19 .
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
❑■ A. Inspector Information: Complete all fields in this section.
0■ B. Certification: Signed& Dated and 1, 2, 3, or 4 checked
C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
■❑ D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
No. Feejo�:�V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Rpplication for o� pg �CorYa ruction Permit
22 ► L
Application for a Permit to Construct(J Repair )Upgrade( , ) don( �) U plete System [Individual Components
Location Address or Lot No./ R 0_7`£tea A,- Owner's Name,Address and Tel.No.
1-'O/P£57` 4=—/6eILt-
Assessor's Map/Parcel �� O/� /p O R CAOIl � /.r/ �/
Installer's Name,Address,and Tel.No. �U 77�,�8 p® Designer's Name,Address and Tel.No.
��46 0 0
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is e by this Board of Health-)
Signed Date 3 -.1a"ff
Application Approved by Date
Application Disapproved for the following reason
Permit No. Date Issued
No. J/ ' Fee
THE COMMONWEALTH'OF MASSACHUSETTS Entered in computer:
?- Yes
PUBLIC HEALTH DIVISION -TOWN Of BARNSTABLE., MASSACHUSETTS
4
Application for ` ov�p� ion ructionerrrtit
Application for a Permit to Construct( )Repair )Upgrade( ) don( ) ❑ omplete System &dividual Components
Location Address or Lot No. AL12�' f O"7r" � �(� Owner's Name,Address and Tel.No. _
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. r.,1.raa Designer's Name,Address and Tel.No.
h V 46 014AAC
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building q No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of:§.. h
Description of Soil �.
Nature of Repairs or Alterations(Answer when applicable) ' "P.111"O r
Date last inspected: -
Agreement: . }
'Ihe undersigned agrees to ensure-
the construction and mainY nance of the afore described on-site sewage disposal system
in accordajkce-with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is^by this Board of Healt .
Signed; Date
Application Approved by �^ Date
Appfcation Disapproved for the following reason
Permit No. Date Issued
———————————————————-——————— —————————THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO C%RTIFY,that the On-site Sewage Disposal System Constructed( )Repaired (X)Upgraded(Y )
Abandoned( )by 0,dNr0 17' AV fiyXl w
at 140 L 57 h n constructed in accordance
with the p isions of Title 5 and the r Disposal System Construction Permit No dated
InstallerDesigner
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date _ Inspector
— - -------------- �T;----------
No.—A�)M——— s � —— Fee—=��/ t / �------.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS
33f6pogal *pztem Conztruction Permit
Permission is hereby granted to Con tructt C )Repair(.Y)Upgrade( )Abandon( )
System located at GlQ,p/€",�P S .� �r� - / E
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Con lion mu be completed within three years of the date of th' e,
Date: Approved by J ! <
11.E •If � T�
00,
MAR
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS £ A Graci
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
32�'BJa�rl'v #d 9 hW CERTIFICATION
Property Address: *E-NhARSTONS MILLS
Name of Owner HUD
Address of Owner: CITIWEST 330 MAIN ST.HARTFORD CONN.06016
Date of Inspection: 1/13/00
Name of Inspector:(Please Print)JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: n/a
Mailing Address: n/a
Telephone Number: n/a
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
_ Passes The Inpection Is based on criteria defined In Title V
X Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is
Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My Inspection does
Fails not Imply any warranty or guarantee of the longgevity of the
septic system and any of Its components useful life.
Inspector's Signature: Date:1/13/00
The System Inspector shall iubmitopy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM CONDITIONALLY PASSES TITLE V INSPECTION.THE DISTRIBUTION BOX IS BROKEN AND NEEDS TO BE REPAIRED.RECOM MEND
PUMPING THE SYSTEM NOW AND MAINTAINING EVERY TWO YEARS.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 160 TROTTERS LANE MARSTONS MILLS
Owner: HUD
Date of Inspection:1/13/00
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
B. YSTEM CONDITIONALLY PASSES:
nLa One or more system components,as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the
replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached;indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass Inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
nLa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2198 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 160 TROTTERS LANE MARSTONS MILLS
Owner: HUD
Date of Inspection:1/13/00
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health In order to determine if the system is failing to protect the public health,safety
and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a
surface water supply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nt&(approximation not valid).
3) OTHER
n&
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 160 TROTTERS LANE MARSTONS MILLS
Owner: HUD
Date of Inspection:1113/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped n1a.
X Any portion of the Soil Absorption System,cesspool or privy Is below the high groundwater elevation.
X Any portion of a cesspool or privy Is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system Is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 160 TROTTERS LANE MARSTONS MILLS
Owner: HUD
Date of Inspection:1/13/00
Check if the following have been done:You imust indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates
during that period.Large volumes of water have not been introduced Into the system recently or as part of this inspection.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow. _
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
(1 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 160 TROTTERS LANE MARSTONS MILLS
Owner: HUD
Date of Inspection:1/13/00
FLOW CONDITIONS
RESIDENTIAL:
Design flow-_=g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):$
Total DESIGN flow: 3.3A
Number of current residents:A
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): MQ If yes,separate inspection required
Laundry system inspected(yes or no):JLQ
Seasonal use(yes or no):JLQ
Water meter readings,if available(last two year's usage(gpd): n&
Sump Pump(yes or no): NO
Last date of occupancy: 1015/98
COM M ERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow: n1a gpd(Based on 15.203)
Basis of design flow: n&
Grease trap present:(yes or no):JIQ
Industrial Waste Holding Tank present:(yes or no): MO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ
Water meter readings.If available:n&
Last date of occupancy: WA
OTHER: (Describe)
n/a
Last date of occupancy: DLa
GENERAL INFORMATION
PUMPING RECORDS and source of information:
lLA
System pumped as part of inspection:(yes or no):MQ
If yes,volume pumped n/a gallons
Reason for pumping: n&
TYPE OF SYSTEM
XSeptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of D E P Approval
Other: n/A
APPROXIMATE AGE of all components,date installed(if known)and source of information:
THE SYSTEM IS APPROXIMATELY 20 YEARS OLD.
Sewage odors detected when arriving at the site:(yes or no): MQ
revised 9/2198 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 160 TROTTERS LANE MARSTONS MILLS
Owner: HUD
Date of Inspection:1/13/00
BUILDING SEWER:
(Locate on site plan)
Depth below grade: i
Material of construction:_ cast Iron _40 PVC X other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: n&
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: -C
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
nLa
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ
D&
Dimensions: L 8'6"H 6'7"W 4'10"
Sludge depth: 5"
Distance from top of sludge to bottom of outlet tee or baffle: IC
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:2
Distance from bottom of scum to bottom of outlet tee or baffle: nIA
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING NOW AND EVERY TWO YEARS
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
Dimensions: n&
Scum thickness: n&
Distance from top of scum to top of outlet tee or baffle:j3&
Distance from bottom of scum to bottom of outlet tee or baffle n&
Date of last pumping: n&
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
n&
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 160 TROTTERS LANE MARSTONS MILLS
Owner: HUD
Date of Inspection:1/13/00
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
n&
Dimensions: n&
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:ji/a.. Alarm in working order:Yes_No_ NO
Date of previous pumping: n&
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert:n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
DISTRIBUTION BOX IS BROKEN AND NEEDS TO BE REPLACED
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 160 TROTTERS LANE MARSTONS MILLS
Owner: HUD
Date of Inspection:1/13/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:.
nLa
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: _n/a
leaching galleries,number: -n(a
leaching trenches,number,length: nLa
leaching fields,number,dimensions: nLa
overflow cesspool,number: nLa
Alternative system: nLa
Name of Technology: _nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION
CESSPOOLS: _
(locate on site plan)
Number and configuration: n&
Depth-top of liquid to inlet invert: nLa
Depth of solids layer: m&
Depth of scum layer. m&
Dimensions of cesspool: n&
Materials of construction: n&
Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)D&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetatlon,etc.)
WA
PRIVY: _
(locate on site plan)
Materials of construction:Wa Dimensions:n!a
Depth of solids: nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
D&
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 160 TROTTERS LANE MARSTONS MILLS
Owner: HUD
Date of Inspection:1/13/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
Uj
�jGc g
� A
A4 �0
AB 0
AC IL
ab h
c
�) 3s
a3
O tic �C L
to l09
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 160 TROTTERS LANE MARSTONS MILLS
Owner: HUD
Date of Inspection:1/13/00
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n&
Observation Wells checked: MQ
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.)
_ Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 912/98 Page 11 of 11
3OWN OF J:AR NSTABLE
LOCATION / � S SEWAGE #
VILLAGE in
\ Mi f tS ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY / ®0
LF ACHING FACM=: ( ) A 1_( , (size) /0 d
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
A� �b
4c
MA y
0 a �
V) IM
L'O C A T, 10 a / ��,�, t t�lq l9 SE CJ AGE P E U E31_T_ p 0.
VILLAGE
25 ram /�
�}= 03.2- 013
IaSTA LLEQ'S GAME b ADDRESS
'-7
a U I L D E Cl OR 0L193 ER
, (�/ani /J o� S
DATE PERMIT ISSUED r`13� _ - �
DATE COMPLIAaCE ISSUED /
4
2)3
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r 1'
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07- I
r .
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— - / G 1..5�� No.22162�0 Q
6
r
LEGEND CERTIFIED PLQT PLAN
EXISTING SPOT ELEVATION 0.0
EXISTING CONTOUR - - 0 - _ L v T l Z -T U7TC2 5 C
4
FINISHED SPOT ELEVATION ;0 O] �5-7-0 AIS
FINISHED CONTOUR 0 IN
APPROVED BOARD OF HEALTH
( c
S C t A 33 E :J..- , ATE v
DATE AGENT - - _. / _ 4 0 D 2
_
LOREDGE ENGINEERING CO. Md, CLIENTJl')-y / /c I CERTIFY THAT. THE PROPOSED '
Ilk-EGISTEREI REGISTERED'I JOB NO. P />U z BUILDING SHOWN ON THIS PLAN , :.
CIVIL LAND 1 CONFORwS TO THE ZONING LAWS
J OR. BY �l - .�1 . ���. pF gaA+r� r ALES ASS, '
ENOINEERSy' ,SURVEYORSy
33 NC MAIN Sr 72 MAIN
4Q •YAAMOI -TH, MAS: HYANNIS, MA' � SHFFT . / OF 2VD TE REG. LAND SURVEYOR,
-•-
20 FT. M/N. — . iE�gCN//vG A/r A/tE :•MuRF TNA
�. - :7N,4pE, fa. 24'D/AMET.eR CONC.��T� COiiER. .
/o 'MIN SHALL BE BROuagr.To GRAvE•CrJN .FX. 7
TB 'T "P1�C P/Pt' 1 JYEAVy CAST /RO/Y CO✓FR Sh/�4<L BE USED
CONCRE
D 3.0 COVERS FT.
1 �: C'OIV C&Z XT
LIT l 2 f• M/N. ✓E/4 CO
I - CrRAOE CLEAN SA NO
At r-o_• ./,—. -_ • . . . . ILL
—_ ----_C] L/ VID LEVEL r
Q _ '� 2 LAYER
i'•'�'.' -- � rt trr+-►-�+.P+'T'r+'T7 - I[�2'•i` C- w '�/B w
d ! 4.•CAST trrs. . o o QF
IRON JP/PAC �� /l� t✓� G,e,L. • i • •,T. • • • • '`� 04 {RYA 5 HFO S710 E
o•: M/N P/TCN , D/ST. • • • • • r r .,
BOX I P V v f 1 •� B • • I • • •° O 1
o 41 D ° 4. � r • DEPTH • • • '�• moo ' WASNEDSTO/1f
��':'� .• II � e PREG45 T SE4,111 I u E
o.•: b', n a. . • • • o • • • r • v •• P/7 DR EG1[l/
i ° : o• t , r • • • • • • • r� e o
!Nl��/CT ELE✓AT/DNS �[ L L� Y. 3°-�
6 FT D/AM
I /IVYERT AT BUILDING /0.�� D FT. /0 FT U/�/+I. C (5E-C -rxWLjLAT)ON�
INLET SEPTIC TA/V,< 99.SFT --
ouTLET SEPTIC TANK _9 p' �' FT. GRprJNU /t/fiTEft TABLE
/,W/ET U/STR/Bl/T/D/V BOX 9.O FT SECT/ON OF
OUrl-E7-D157-.A?/BJ7'/UNdOXj..�_9 FT.
/NLcT LEACHlvfr- F'/T � _FT SELVAGE G/S/�'OSAL SYSTEM -r,45411-AT/DAI
LEACH P/ T v/MENs/fin/ A --FT
SCALE
DES/GI+/ CK/TER/A D//+��/vs/On/ 8_..�°-_FT• /
,D/HENS/ON C__4 FT. /''' //• •
NUMBER OF BEZ>ROOMS _ 3
GARBAGEO/SPOSAL u/v/T_ .__.__ Sv/L LOG SD/L TEST
T.7TAI EST/MATED fLpaV_ s !.L'.GAL.1,0Ay SOIL TEST A06 / SOIL
/ -FLE✓. I O ,DATE OF SOIL TEST -
IVJMBER OF .•.Ea�NrwG: ,v/T,S_ __
. /OE �,4Grf/N5 PEK P/T _I E e SQ, FT '� R E5[/LTS I•VITNES5= BY_7�,,./�-
:1 PL`/tCOLAT/ON RATE / a " /"///v. /NCH
eUTTUM/EYq�H/NG PEK N/T_ / S4• FT L OA pE,pCt7l/4T/ON RATE fk2 7 ~/
TOTAL LEACHING AREfI SQ. FT.
4 / .
RESERI�ELEACNING AREA-�(�V SQ. F. T. S�.•.35 U/L I
r� K'y'" °'.�`• I L L L7 Zy Ti; T GT
o BOSERT, G C p/q /2 E" t
' .7+ P ^1 5.9 i✓1�
�I U BUNIKIS y
No.22162 0 o- �L DREDGE ENGINEERING CO.,INC.
v 7/2 MA//V ST. 33 "0,MA//V Sr.
�G
`9FGISTEP�•� e4� c NYANN/3, MASS. SO•YARMOC/TN,M<tSs
!8 ND,GRO�N17"Y4i4TER ENCOU/VTEh'_.O
�1 GRO U/VO PVA rjsR AT ELEI� - JOB ^/p UU I Z SHEET�-OF 2_
No.............. 031' 0l3 Fss.. d...�. .....
LTH
THE
BOARD AOF FHEALTH S
...................OF.. ✓n t e..
9 Appliration for Dispaa al Works Tonstrurttnn Prruti#
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
LLS
- Location-Address or Lot No.
..................................... -..: �Y'1.5� / 1.�I... �!� _._.�FW !±'.!6:��r M._f1...........---...
Owner Address
aW ...............................3A!L ►K...-•-----•-•-•-•................................ ......•--------•----------------...... ---••----------•-•-•-•-•---.......---------
Installer
Address
UType of Building Size Lot..Z0;_v0?.........Sq. feet
Dwelling—No. of Bedrooms.............3..........................Expansion Attic ( ) Garbage Grinder (No)
a`4 Other—T e of Building _...... No. of persons............................ Showers
YP g --------------------• P ( ) — Cafeteria ( )
dOther fixtures -----•-�----------•-••...............................................
Design Flow_.__._._.__���- '__._ 5....__..gallons per person per day. Total daily flow..........33. .....................gallons.
WSeptic Tank 1 Liquid capacity.it).0o..gallons Length................ Width.........._..... Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No.........I........... Diameter.._(:®__......... Depth below inlet......... ....... Total leaching area... ....sq. ft.
Other Distribution box ( ) Dosing to�j
zl Percolation Test Results Performed by i. ..,ter_?. ................................... Date....._"z'�"77
Test Pit No. I.....7 .....minutes per inch Depth of Test Pit.................... Depth to ground water........................
G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
------------------ -------------•---•--- ---•------------•-------
O Description of Soil /® t----y------�t s-
c.� --------------------•------------•----•------------. .....................................................................................
w
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
---------------------------------•------------•-•---••--•---••----------•--••-------------------------•.....-------•----------•-------•--•-----------•------•-------•-----------------•••---•-----•----•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITi i� 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of h
Sigd--........ .......... � -`
• Date
Application Approved BY -... ------ ----7- --- --..
Date
Application Disapproved for the following reasons:.............................................----------------------------------•-----------------------••......
...............................-.........................................................................................................................................................................
Permit No....... Issued_._.12.-
—S •` �� Date
----------•-------- ----•----
Date
No........!., ..._...... FEs.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARDL OF HEALTH
f:d.. ...................OF.....: ...:....!-n 5l :------------•----... ...................
Appliratiou for Uhipvii al Workti Tnniirurtion Prruat
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
_.. -• -• •................. ........-----------......_........---••-------••---..._---•-...._•--_..
Location-Address or Lot No.
;omes ------------- ----- ......e*.JSLbV;J1-._ '�t�'�_----.-s 1 Est ./�t�t._....---••-----"
LyyOwner Address
-----•-•-- - ..............."-•-••---•-•-------------- ---.....-"----------------------•----"------•-----...----....._....._..-- --------- ----
a Installer ., Address
Type of Building Size Lot__ZP u ...�.........S q. feet
Dwelling—No. of Bedrooms............. _________"________________Expansion Attic ( ) Garbage Grinder (No)
r4 Other—Type T e of Buildin No. ;of ersons____________________________ Showers — Cafeteria
A.I YP g P ( ) ( )
Other fixtures .......
.--------------------------------------------------------------------------------------------------------------------------------------------
W Design Flow...........__-_- _______$y_......gallons per person per day. Total daily flow..........$1q.....................gallons.
WSeptic Tank-L Liquid capacity_1 AQ_.gallons Length................ Width_,____................ Diameter................ Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total,leaching area....................sq. ft.
Seepage Pit No________If___________ Diameter._.0..--•.•-. Depth below inlet.........P_.____ Total leaching area...AA.P G....sq..ft.
Z Other Distribution box ( ) Dosing to
~' Percolation Test Results Performed by..____.___iS____. sU%X;_____________________________________ Date____.8---Z_!? 7 .___._.___.._..
Test Pit No. 1_._ ......minutes per inch Depth of Vest Pit____________________ Depth to ground water........................
fZ4 Test Pit No. 2................minutes per inch Depth of'`Test Pit.................... Depth to ground water........................
v ----- ----- ' f /
.O Description of Soil------ ---.... . •- --- ad.__...---"---"----"-----
!
-------- e9a !« � 9- .-----------------------•-•--••------------•-
W --------------------- ------
----------------------------------------------------------------------------------------------•--------------:--- ---------------------••-------------"-----..__.....-"-"--......•-•-------------•-•----
U Nature of Repairs or Alterations—Answer when applicable......................
_----------_-------------------------------------------------------------
t
t
Agreement
The undersigned agrees to install the aforedescribed,,, Individual Sewage`Disposal System in accordance with
the provisions of TIT12 5 of the State Sanitary Code— The undersigned fur her agr es not to place the ystem in
operation until a Certificate of Compliance has issued by"t board of alt .�q r
p►
Application Approved BY ---_._.....4
yF e
Date
Application Disapproved for the following reasons:....................1.........................
.................."----"-------------"--......-----------""--"-"---"-"--"--...---"-----"---"----------"".--------"------------"----"-------------"-------------"=---------- •-------••----••----------•-
Date
PermitNo....................................................... Issued...................-....................................
Date
Y �wYAA..•,_ � .,
Z sY
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEAILTH
.t
a ,.
..........................................OF...........................,............._.................................::__...
Trrfifirittr Of -�unt�rl ttnrr �-
T I If- the Indiv•duaI SSew
A
age Disposal System constructed ( ) or Repaired ( )
by.......... - ... ;G •-_---•-•-•----•--
at-------------------•------------------•-----••-••••-•----•--------------------•------•------has been installed in accordance with the provisions of ` ;r`'f(�h�State Sanitary C he%Wdr d in the
application for Disposal Works Construction Permit N ........................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUN TION SATE A TORY.
G
DATE......................... .......................................... Inspector....................................................................................
n - THE COMMONWEALT OF MASSACHUSETTS
BOARD' -HEALTH
......................................... OF...............................
No......................... FEE........................
t .ta1 j, :..-:it uVt1 nti#
Permis p% W' hereby granted 1 - -------•• -----. . ....... .....
to Const � or/Zgair �e D �/'1
atNo.............................................................................................. .
�� �:�:
as shown on the application for Disposal Works Construction ." ad
t o---- --- ._
............................................. ---------------•------••c am""" •--..._._
/ Board of Health
DATE----------••--- Z ---1 _"-------"--
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
COVERS TO BE WATERTIGHT AND SEPTIC SYSTEM PROFILE Flaherty Environmental Services
TOP OF FOUNDATION EL. 98.0' BROUGHT TO WITHI•N•6"OF FINAL GRADE (not to scalel
EL. 100.0 INSP. PORT W 3" OF GRADE P.O. BOX 331
2" PEASTONE OR EL O't CLEAN SAND Harwich, MA 02645
I.HIL lullifull * 4"CAST IRON or EQUIVALENT GEOTEXTILEFILTER FABRIC VENT(IF REQUIRED) 774.994.1166
MIN. PITCH 1 4" PER FOOT
a•scHmuLE ao PVC PIPE 4" SCHEDULE 40 PVC PIPE :• .
FLOW UNE
—�
1.9% 5' 1% — EL 95.3 iwo-c—
EXISTING J 444 15V/fA M! /
14"
— MM 2
95.4' SELL 94.5)V EL 92.W.
EL 94.7 94.5/Mp CO 005%SLOPE) ► CLEAN, DOUBLE-
" sAFFLI: H-20 DBOx 6"CRUSHED STONE OR SOIL ABSORPTION SYSTEM
MECWANICALLYCOMPACTM (2) TRENCHES 3'W X 33%X 2'D USING 5,p WASHED 42 TO 11" STONE
PERFORATED PIPE AND SURROUNDED
::•~ ✓
''" • ' 1000 GALLON SEPTIC TANK / BY DOUBLE-WASHED�" TO 1 STONE EL. 87.5'
(DATUM: ASSUMED) IEXIsnNG B�
� ` STONE
BOTTOM OF TEST HOLE EL. 87.5'
� * USGS ADJUSTMENT: N/A LOC477ONAW
100
14Q GROUNDWATER ELEV: N/A !f
1 �
LOT 12
98 20,019 SFt RSW Lane
MAP 32 LOT 13 /
� S S
100
137.1' TO WELL EXISTING
~-'_— 3 BR LOCUS
DWELLING
42.5
/ NM
PATIO / OF
\ O J I p D�"
j Fti�, l
J \ EXIST. S.T. n F J
10.0' 21 ,E
LO ~ G/STE��
SHED TH-2
NITARII
EXIST. L.P. `N
BENCHMARK:
0- TOP OF FNDN
TH-1 EL. 100.0'
15.1' SHED DATE.•12=019 REMED:
98
169. SITE AND SEWAGE LAN FOR
B & B EXCAVATION INC./
ANNETTE OERTLE
325 BLACKTHORN ROAD
SCALE : 1�I — 3 Q' MARSTONS MILLS, MA
REF.-PS 271 PG 97
PAGE 1 OF2
..... ..... . ............. ...................... ............. ........... ............................................... ................... ................................................. .......................... ...................................... ........... .................................................................................................................................................... ................................................ .......................................................................................
GENERAL NOTES Flaherty Environmental Services
DESIGN CALCULATIONS SYSTEM DETAIL
P. 0. Box 331
1. ALL PRECAST COMPONENTS TO BE H-1 0 Harwich, MA 02645
RATED. ALL COMPONENTS WITH ANY NUMBER OFACTUAL BEDROOMS 3
774.994.1166
FI
ANTICIPATED VEHICULAR TRAFFIC TO BE BS, PORT
H-20 RATED. GARBAGE DISPOSAL UNIT NO 31
Z THE DESIGN OF THIS SYSTEM DOES NOT
TOTAL ESTIMATED FLOW
ALLOW FOR THE USE OF A GARBAGE .......
GRINDER. (110 6ALIBRIVA YX 3 BR) 330 6ALAVAY
61
3. MUNICIPAL WATER IS AVAILABLE. REQUIRED SEPTIC TANK CAPACITY 660 GAL.
4. ALL CONSTRUCTION TO CONFORM WITH
310 CMR 15.000 AND ALL OTHER SIZE OF SEPTIC TANK 1000 G41-(EXISTING)
APPLICABLE LOCAL, STATE AND FEDERAL
CODES AND REGULATIONS. SOIL CLASSIFICATION 1 33'
5. INSTALLEPICONTRACTOR TO REVIEW&
DESIGN PERCOLATION RATE <5 MIN/INCH
VERIFY ALL ELEVATIONS AND DETAILS
AND REPORT ANY DISCREPANCIES TO EFFLUENT LOADING RATE 074 GALAVAYIFT2 i1111 Ifl/I
DESIGNER PRIOR TO CONSTRUCTION OR
ASSUME ALL RESPONSIBILITY. LEACHINGAREA
6. INSTALLER/CONTRACTOR IS BOTTOM.- (3'X33)X2= 198Fr 9' MIN. OF SOIL
RESPONSIBLE FOR MAINTAINING SAFE SIDES., 2' PEASTONE OR FILTER FABRIC
WORK AREA, VERIFYING ALL UTILITIES [(ZX33)X2+(2'X3)X2lX2= 288 FP
AND NOTIFYING "DIG SAFE" TOTAL= 486FT2
(1-888-344-7233) 72 HOURS PRIOR TO xa74= 369 GAL/DAY
CONSTRUCTION.
Z ANY CHANGES TO OR DEVIATIONS FROM USE(2)TRENCHES OF PERFORATED PIPE SURROUNDED BY
THIS PLAN MUST BE APPROVED IN TO I STONE,EACH TRENCH CONFIGURED AS
— 31
WRITING BY FLAHERTY ENVIRONMENTAL 3'WIDE X 33'LONG AND 2'DEEP
SERVICES AND LOCAL BOARD OF
HEALTH. RESERVE LEACHING CAPACITY NIA
8. FINISH COVER OVER COMPONENTS IS
TRENCH END VIEW
NOT TO EXCEED 3'PER 310 CMR 15.000 (NTS)
UNLESS SHOWN PER PLAN.
9. ALL ABANDONED SEPTIC SYSTEM
COMPONENTS TO BE PUMPED DRY AND J.
FILLED WITH CLEAN SAND OR REMOVED SOIL EVAL UA TION
AND REPLACED WITH CLEAN SAND.
TESTHOLE#1 7PT#19221 TESTHOLE92 TPT#19-221
10.ALL COMPONENTS TO BE PROVIDED EWWuator. DOW D.Fhft*Jr.,AS,REHS Evaluator DOW D.FM9*Jr.,RS,REHS VA OF
WITH WATERTIGHT ACCESS PORTS SE#2755 SE#2755 N
WITHIN 6"OF FINISH GRADE. BOH WiMm. David Stanton,RS B0HKftww David Stanton,RS A D
Date., Demnber4,2019 Daft December4,2019
I 1.ALL SEPTIC TANKS, DISTRIBUTION F H
BOXES AND PIPING TO BE INSTALL,E �✓� TH-I ELEV 98.& nag ELEV 96.912 N 21
WATERTIGHT.
0'-12' FILL 0'-Ir FILL tsT
NO No LANDS OR WELLS
2A WIT PROPOSED Ir Ir A LS 10 YR 312 A LS 10 YR&2
OF
LEACH,
191-311 B LS 10YR 516 Ir-31' 8 LS 10YR 518
13.THIS IS NOT A CERTIFIED PLOT PLAN
AND UNDER NO CIRCUMSTANCES IS THIS <\f- LY
PLAN TO BE USED FOR ZONING OR
BUILDING PURPOSES. SITE AND SEWAGE PLAN FOR 31'-12r C MCS 25Y614 311-12tr C MCS 25YW4
14.LOT IS SHOWN AS ASSESSOR'S MAP 32 \:-A�
"ice ,AY dW on Novembw 12 1 have passed
pem
PARCEL 13. (51) the awm1nehbnWpmv&dby&aDqp&tn"of B & B EXCA VA TZON INC.
15. LOCUS PROPERTY'S PROPOSED SYSTEM EnWmnn;*nhWProfw&wend Ad de above ans"k ANNETTE OERTLE
has been penbmW by im consistent MV?the
APPEARS TO BE WITHIN AN AQUIFER ELEV.WA G.W.ELEV.WA 325 BLACKTHORN ROAD
requftdhwn1ng awarfte and awe
PROTECTION DISTRICT-(ZONE II). In310 CMR 15.018(2).- MARSTONS MILLS, MA
80'a T*1 ELEV 87.511 BOTTOM TWELEY 88.0" 1
PAGE20F2 DATE.•121412019
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