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0028 BLUEBERRY LANE - Health
28 BLUEBERRY LANE � Marstons Mills _ A = 102 - 122 ha i Town of Barnsfable Department of Regulatory Services F Public Health Division MAas. bate 200 Main Street,Hyannis MA 02601 Date Scheduled Time F e Pd. Stood Suitability Assessnaent for Se Dis qs � Performed By: Witnessed By: O / LOCATION& OI;I�ItAL,EWORMATION I_,ocation Address • ' �t✓ Zt� e _ /l Owner's Address `2P'i tvehwrl - Assessor's Map/Parcel: � �10z �J `�Z Engineer's Name NEW CONSTRUCTION REPAIR _ Telephone# Land Use C �/� Slopes 96 Surface Pals�svV7/2 Ljd Ov P ( ) / Stones �/ Distances from: O ,yVaLer Bo y t ft Possible W't_Area < �r�(�(� ft Drinking Water Well ft ral'nage Way ft Property LlneSS / f other /3 " ft SI�f I'CH'(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to boles) ----------------------- rl�l AI ZE C) r—f -n 2e> . , M A' VV Parent material(geologic) C� -��1� "/��J Depth to Dedrock Depth to Groundwater. Standing Waterin Hole: UV ( Weeping ftom Pit Pllce �fT Estimated Seasonal High Groundwater / DE'I'IaY�1VIANA TIOINT FOR SEASONAL IUGH WATER TABLE, used: Depth Ob�RcadlngDute; In. Depth Io so In, Dcpth to e: In, Groundwater Adjusiment�` In Index Well# e: Index Well level Adj.faetor�-_ ALU.Ch-oundwuterl-evel l� PE R C®IiA.TIO1 r]C'I�S Date 'A' _lnt ' 'I� Observation — 'l Mole# Time at V Depth of Pere s� i Time at G' Start Pre-soakTime @ /Ot, Time(9"-6") End Pre-soak /y l Z¢ Rate Min./fach Site Suitability Assessment: Site Passed Site Failed: Additional Tesdng Needed(Y/N) e7 Originnl: Public Health Division Observation Hole Data To Be Completed on Back------- 4-14,117 percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Couservati.ou Division at least one (1) week prior to begilxn1119. Q).SF_rrtC\PrsRChORM.D0C DEEP-OBSERVATION HOLI!,LOG Hole# Depth from Soil Horizon Soil Texture .Sdil Color Soil. Surface(lit.) Ol}ter (USDA) (Munsell) Mottling (Structure,Slones;Boul ers. onsistency,q6 Caravel) Ja-YA- DEE4 P OBSERVATION HOLY LOG Hole# y Depth from Soil Horizon Soil Texture Sol Color Soil Othe ! v Surface(in.) (USDA) (Mansell) Mottlin g (Structure,Stones,Boulders. - o s' to % a el 2 Zr5 7 Q O ZGvvr� Pj/Q JDE,EP OBSERVATION HOLE LOG Mole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in-) (USDA) (Muosell) Mottling (Structure,Stones,Boulders. Cons Is tc cy,96 Oravoll DEEP OBSERVATION HOLE LOG Dole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Cons'stancy,. 6 u n Flood Insurance hate Map: Above 500 year flood boundnry NO- Yes Witldn500 year boundary n No Yes Within 100 year flood boundary No,_._ Yes tenth of Naturally Occurring Pervious Material Does at least four feat of naturally occurring pervl material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certil"ication I certify that o Yt (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required trainin is an erience described in�10 CMR 15.017. /f Signature Datl ��� Q:\.SEtrrlC\PBRCPORM.D OC TOWN OF BARNSTABLE LOCATION R 'v ' < '6 la�eC,p ;R " �-A I� SEWAGE# aO IH " 11 V , LLAGE�M 1r/$d®hS ASSESSOR'S MAP&PARCEL ! -- INSTALLERS NAME&PHONE NO. 1511 f p/4-hwrf Ca.ISI*- S CF 3 4,16,�3 SEPTIC TANK CAPACITY /�/ Se o LEACHING FACILITY:(type) p-ea yf r /FZZ (size) 41 X R),X 6�r NO.OF BEDROOMS not 57b Z- OWNER Prrern.s a-P PERMIT DATE: 14 1 aq I 14 COMPLIANCE DATE: 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 njLe�� 66aey A-At' 34' 3 y No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION.- TOWN OF BARNSTABLE, MASSACHUSETTS ftphLatlon for Disposal 6pstpm ConstrUrtion Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.pc l.� (�, Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel Installer's Name,Address,and Tel.No. 36j 6p'3 Designer's Name,Address,and Tel.No. n n ra,"� %t 9 =lwip 2N '�S 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(min.required) 1l(�� a a UC�r7 4'�gpd Design flow provided gpd Plan Date 1j ,n_,1 t 41 D-o tH Number of sheets Revision Date Title Size of Septic Tank /pd V Type of S.A.S. t4 y -1,0,_� M✓Y-"lyy 0 2 "N L4 h Description of Soil f? e .Sg i ) 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 Co d not to place the system in operation until a Certificate of Compliance has been issued by this Boar7ofealth. I t I SignedDate l t� 1 Application Approved by Z&v 4f> Date a'y — /� Application Disapproved by Date for the following reasons Permit No. a-OI — Date Issued No. V Fee / THE COMMONWEALTH OF MASSA HUSETTS f Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitatiott for Disposal .pstent (Construction 3pCrmit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. a�- O/ Lcl Owner's Name,Address,and Tell.No. U�{ (jam Y� . Assessor's Map/Parcel 1 V Ate+_ ��Gr� '� ?t�t1 (� ' _JC) Installer's Name,Address,and Tel.No. >r Y(a�7 (�} Designer's Name,Address,and Tel.No. ,, d4_ 1 9�) ftr��.,i=+ kv 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(min.required) ;a ; ._ f -'-= L'gpd Design flow provided 5 gpd �. -` Plan Date '� , R f t! ? r r u Number of sheets Revision Date Title Size of Septic Tank 1 f)0(1 Type of S.A.S. Lp / �1 ,��,p r• v�r, l' Sf�n/ f; •t{.„/.a . ` Description of Soil �r f r` 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 Co d not to place the system in operation until a Certificate of Compliance has been issued by this Boar of ealth. Signed 01 Date T Application Approved by I? Date a' L/ r Application Disapproved by Date for the following reasons 'Permit No. a C 1 "' 11K Date Issued -A Lt- / THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( X) Upgraded( ) Abandoned( )by `J E: ; r.,,•; 5 r at .`„� /?1 to Y( p fj n i.l ( rt M has been constructed in accordance with the provisions of Title 5 and the f r Disposal System Construction Permit No.,7 6/N-lie dated Ll N- t r Installer Designer L•4�' _ 1C4 1P ir:; #bedrooms Approved desi ow (9'J- S gpd T The issuance of this pe s 11 not be c nstrued as a guarantee that the system w' 1 o as designed. % J I Date Inspector /,// r` c No. d 1 L' w '1 � Fee 16V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction 3pPrmit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at r, 0.a y ,,( t, - 0) kiN and as described in the above Application fo-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 three years o pleted within f the date of this permit. I-1 �'t (U� Date L4 — u )`�/ Approved by f f i Town of Barnstable �tKET� Regulatory Services ti Thomas F. Geiler,Director aAmsrm MASS. Public Health Division 1 639ft. a`0� Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: Sewage Permit# AO/y- l j�+' Assessor's Map/Parcel Installer & Designer Certification Form Designer: S' r�/ZU�3` •k Installer: ��/S oEleo ' Address: y '17Z,,V Address: 2c3 61 -/&'&P/t 'GX120 c5;i-.v04v,r_*. GZfG 3 /19VlOv 7,Zf av/Z tea- o z e.7 'r On 2¢ /� CL/S �l�S was issued a permit to install a (date) (installer) septic system at *2_e 6(v6_-j5(_ZAy L, based on a design drawn by (address) �%r/lyl�1 U• �/�f/E72 art dated (designer) 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 required) was inspected and the soils were found satisfactory. /r ��H of 14,4S6,c o� DAVIDD. tiu (Installer's Signature) FIAHERTY, JR. w No. 1211 0 �FGIS7��� S \P� (De ig r ignatur (Affix Desi ne mp 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\designercertitication form.doc !r R°ECEIPT Printed: Apr,y"1 22, 2014 @ 8:38:26 BARNSTABLE COUNTY REGISTRY OF DEEDS JOHN F. MEADE, REGISTER Trans#: 91919 Oper:LAUREL GEORGE Book':; 28097 Page: 71 Inst# �16447 CtlO 60 Rec:4-22-2014 @ 8:37:11a BARN 128 BLUEBERRY LN k DOC 'DESCRIPTION TRANS AMT 1 PETERSON, GEORGE K RESTRICTION County Fee $ 10.00 10.00 Surcharge CPA $20.00 20.00 State Fee $40.00 40.00 Surcharge Tech $5.00 5.00 Total fees: 75.00 *** Total charges: 75.00 CHECK PM 3568 75.00 . . t Bk 2q6 197 Pa ate'l -W 164 47 g 4-22--2ems 14 a tau o 37cc DEED RESTRJCTION i Mner'e uar i is trQ owner of MIA (hereina,fter referrers to as -- IL-..tBt e ex-1 _.�.Sdk��__/t!K Y l and beingp,_horn n erl!git;fie l iivi5iC r �J- Jubc. f. Oi 1 MA, Nopeny of C', et 31,_. _�_... -_ `duke rec,arded in Barnstable Cou ;ty R,r g ugry of Deeds in Plan Book Page Or on Land Court Plan'Number WHEREAS. M agree; with t'lE' Tovvn of Barnstab! Re-) rd of Health lth to a rests irW}c,sri � . ';o th- number car badrooms-w1hicli can be includ&l it any home built saki lt-.t prp-<*ndit;on to ob!ain ng a disposal wori:a con struction pc-,unit in, -,oly:;i; with 3110 CMR 15.000 State Ervi ironmentai Ccde, Title V, P.44-tirnIurn Requirements for the Subsurface Disposal of San;tary Sewage: V%1HEREAS, the Town of Barnstable Board of Health, as a ore-condition to granting a d#osai woelks const;uction permit for a septic system in compl`ance with 310 CMR 15.200, ;State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and auti^orizing the issuance of a building permit for the construction of a single family home on this prope-ty, is requiring that the agreement for the rastriction on the number of bedrooms in any house constructed on the lot he put on record with the Barnstable County Registry of Ceeds by recording tt,is docurriant, i l NCK T-lEREFQRE, ��rQ�° does hereby pure the owner s n—a n�Opl I folfc,Mng restriction on his ebove-ref;;re:ced ,and in socc(dance with tlr:; agreement vViYh the To wn of 93ar7stable i?card of Hies-101, which msfri:,bon shall r,.m vAth tie (and and be binding ip:on ail successors in tittle: jLrray have constructed (adcir sj' on thr� lot a ri Ulse c n fining no more than f i.bedrooms. agrC-es il:at 11his 'shad C! :)E1.T1":anent deEd — aw��era nanej rrstric-on of cting 7k)r ted on n& �YLi`�1,�. "vta„ ant ;Jeing srcwr• on the plrari reccrced in Plan Beni: Z3`2ed --lase ✓r or !nand Court Plan Fcr title of �'Vv'�ee4-th. el{c} r p � K _�%� image D� Or Land Cdurt Certtfioate of T�ie Numb='r Executedas a sealed instrument dtily of 0vcmEis sib ure Owne; s signature _ ' O�rrnar's sigr:ature COMMONWEALTH OF {t ASSACHUSETTS � -- ---_ i i Then personally a p a, id the ablrive-named roc,— -_vim P A�— known to me to be the person who executed tk foregoing in5trunient aric acknowledged' vN^ra o-• %D ��� � the same to be free act and deed, before me, -- � Notary Public My cornrnission expires: date dcedr �! a Z GERALDINE K E101AIEN LLI - �- Nary P���b��,�Coyann�o,.t ,.�IM.rof,..,,muneActlM �, .jyd� � �.+�•p`7= �� �Y➢11117f..�.�u+�r•r.+l'�aY�' .(� 'fir .'�✓ �'�6?` `\\ • J c BARNSTABLE REGISTRY OF DEEDS 04/18/2014 14:25 5088884494 ROYAL PALM & CRANE PAGE 01 11 P3 t 4 v� � �. oP C i Al oY s - Town ®f Barnstable Barnstable Regulatory Services Department j MIN j MASS.6S9. �,� Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V. Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO t CERTIFIED MAIL # 7012 1010 0000 2851 3542 May 14, 2014 George K. &Nancy Peterson 28 Blueberry Lane Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 28 Blueberry Lane, Marstons Mills, MA, was last inspected on 3/25/2014, by Reid C. Ellis, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system" Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: ® System in hydraulic failure. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system with the deadline period will result in future enforcement action. PER ORDER OF TH ARD OF HEALTH tThomas McKean, R.S. C O Agent of the Board of Health • QASEPTIOSample Failure Ltr\28 Blueberry Ln MM may 2014.doc Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=5835 APl v 61A5$ �kl-' q Q �%/'f�'j�/ R` O�! 7/C/.�L'' G Logged In As: Parcel Detail Tuesday, May 6 2014 Parcel Lookup Parcel Info Parcel 102-122 1 Developer[LOT 107 T ID Lot Location 28 BLUEBERRY LANE � Pri Frontage Sec Sec F — -- Road Frontage Village MARSTONS MILLS ( Distrre ict(C-O-MM Town sewer exists at this Road -- address(No Index 0140 Asbuilt Septic Scan: Interactive 102122_1 Maps - Owner Info Owner IPETERSON, GEORGE K&NANCY - Owneor Streetl 128 BLUEBERRY LN Street2 City FMARSTONS MILLS � State F Zip 02648 Country Land Info Acres 10.23 Use Single Fam MDL-01 Zoning RF Nghbd(0105 Topography Level Road Paved Utilities JSepi c,Gas,Public Water Location Construction Info Building 1 of 1 Boat� Ext 1960 _ S Ru0t Gable/Hip Wall Wood Shingle LArea 812 �) Cover Asph/F GIs/Cmp � TYpe;None Wall Rooms ` Style Ranch � Wall Brt/Wood I 12 Bedrooms Int r W_.._._. Bath i _. Model residential Floor Hardwood Rooms 11 Full 1 .._ Total Grade Below Average I TYpe Hot Air Rooms E4 Rooms ' Heat Gas Found- Stories 1 Story Typical �� Fuel ation Gross http://issgl2/intranet/propdata/Parce]Detail.aspx?ID=5835 5/6/2014 ���a �, II ___ _ _I_�f�� Commonwealth of Massachusetts Title 5 official Inspection (dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 28 Blueberry Lane, Marstons Mills , MA Property Address George K. &Nancy C. Peterson Owner Owner's Name information is required for every Marstons Mills MA 02648 03/25/2014 page. Cityrrown 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. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not REID C. ELLIS use the return key. Name of Inspector ELLIS BROTHERS CONSTRUCTION Company Name C-7 . 23 ENTERPRISE ROAD Company Address r YARMOUTH PORT MA "' r1 02675 City/Town State ""'° Zip Code k-n" 508-362-6237 S121891 Telephone Number - License NumberCo -= € r B. Certification 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 the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature t 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 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 DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,-and the approving authority. ****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. t5ins-3113 - Tine 5 Offidal Insp 'o nn:Subsurface Sewage Disposal System•Page 1 of 17 I Commonwealth of Massachusetts AM Tile 5 Official Inspection F rm Subsurface Sewage Disposal System Form-Not for Voluntary issessments ;M 28 Blueberry Lane, Marstons Mills MA Property Address i George K. & Nancy C. Peterson Owner Owner's Name information is Marstons Mills MA 02648 03/25/2014 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete'all of Section D A) System Passes: //o I 1 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: OUY�e, el B) System Conditionally Passes: i ❑ One or more system components as descr ed in the"Conditional Pass" section need to be replaced or repaired. The system, upon coi ipletion of the eplacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determine " (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 exfill ration 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): I t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 Blueberry Lane, Marstons Mills , MA Property Address I George K. & Nancy C. Peterson Owner Owner's Name information is i required for every Marstons Mills MA 02648 03/25/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.) i ❑ Observation of sewage backup or break o it or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled for uneven distribution box. System will pass inspection if(with approval of Board f Health): { ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): i ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or repla ed ❑ Y I I I N ❑ ND (Explain below): i i i i ❑ The system required pumping more than I times a year due to broken or obstructed pipe(s). The system will pass inspection if(with appro al of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑I N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑I N ❑ ND (Explain below): { i I i I C) Further Evaluation is Required by the Bo d of Health:; El Conditions exist which require further evalua on by the Board of Health in order to determine if the system is failing to protect public health, afety or the environment. I 1. System will pass unless Board of Heall h determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioi iing in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of 3 surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh !Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Tile 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments { ,. 28 Blueberry Lane, Marstons Mills , MA I Property Address George K. & Nancy C. Peterson j Owner Owner's Name i information is required for every Marstons Mills MA 02648 03/25/2014 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) j 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, 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 surfacelwater 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 anc the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: i **This system passes if the well water analysi I, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the pres Bnce 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. , 3. Other: i i I i i i I i , D) System Failure Criteria Applicable to All Systems: i You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ElBackup of sewage into facility or system component due to overloaded or / clogged SAS or cesspool Ell—�/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or!cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow i t5ins-3113 Title 5 Official Inspedion Form:Subsurface Sewage Disposal System.Page 4 of 17 Commonwealth of Massachusetts Tile 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary!Assessments i M 28 Blueberry Lane, Marstons Mills , MA Property Address 1 George K. & Nancy C. Peterson Owner Owner's Name information is required for every Marstons Mills MA 02648 03/25/2014 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ [ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. i ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. I ❑ 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 lindicates 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.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. i ❑ 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 fa* re. E) Large Systems: To be considered a largeystem the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"y s"or"no"to each of the following, in addition to the questions in Section D. Yes No i I ❑ ❑ the system is within 400 eet of a surface drinking water supply El Elthe system is within 200 eet of a tributary to a surface drinking water supply I ❑ ❑ the system is located in nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapp ad Zone II of a public water supply well If you have answered"yes"to any question in 3ection E the system is considered a significant threat, or answered"yes" in Section D above the larg system has failed. The owner or operator of any large system considered a significant threat under c4taction E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. he system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 or 17 Commonwealth of Massachusetts Tile 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for VoluntarylAssessments 28 Blueberry Lane, Marstons Mills MA ? Property Address George K. & Nancy C. Peterson Owner Owners Name information is required for every Marstons Mills MA 02648 03/25/2014 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No j M/ ❑ Pumping Information was provided by the?owner, occupant, or Board of Health El 10/ Were any of the system components pum I ped out in the previous two weeks? I ❑ V❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of / this inspection? ❑ Were as built plans of the system obtained and examined?(If they were not f available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ElWere all system components, :occluding the SAS, located on site? i ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles o1r tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the pro bsurface sewage disposal The size and location of the Soil Absor p4tion System (SAS)on the site has been determined based on: ❑ Existing information. For example, a plan 'at the Board of Health. ❑ 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)] I D. System Information f Residential Flow Conditions: k Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 for example: 110c ( p gpd x#of bedrooms): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for VoluntarylAssessments yM 3 28 Blueberry Lane, Marstons Mills MA y Property Address George K. & Nancy C. .Peterson � Owner Owner's Name information is required for every Marstons Mills MA 02648 03/25/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information I Description: 1 Number of current residents: �Jv Does residence have a garbage grinder? ❑ Yes M/"No Is laundry on a separate sewage system? (include laundry system inspection El Yes [�No information in this report.) Laundry system inspected? ❑ Yes M No Seasonal use? ❑ Yes 8"'No Water meter readings, if available (last 2 years usage (gpd)): Detail: r, 45 �.5 p pump? •� Sum ! � �N4�t ❑ Yes No �l Last date of occupancy: f �7 Date Commercial/Industrial Flow Conditions: A0 Type of Establishment: Design flow(based'on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): I Grease trap present? I ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 syste ? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fol rm Subsurface Sewage Disposal System Form-Not for Voluntary,Assessments I 28 Blueberry Lane, Marstons Mills MA Property Address George K. & Nancy C. Peterson i Owner ; Owner's Name I information is required for every Marstons Mills MA 02648 03/25/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i Last date of occupancy/use: Date Other(describe below): i I i General information Pumping Records: Source of information: ������� Was system pumped as part of the inspection? I � ❑ Yes No If yes, volume pumped: �� gallons How was quantit y y pumped determined? � Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy t ❑ 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 i ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): j i I t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary lAssessments °M 28 Blueberry Lane, Marstons Mills , MA Property Address George K. & Nancy C. Peterson Owner Owner's Name information is required for every Marstons Mills MA 02648 03/25/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) # Approximate age of all components, date installed (if known)and source of information: Were sewage otl6rs detected when arriving at the site? ❑ Yes [h"O'No Building Sewer(locate on site plan): Depth below grade: `s i feet Material of construction: i 1 cast iron 40 PVC ❑other(explain): r Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): p e:/,ct y-�4— �� jtw!P ril I Septic Tank(locate on site plan): � t<� Depth below grade: feet Material of construction: I concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank 2nfi ' tage: Is age ed by a Certificate of Compliance?('ttach a copy of certificate) ❑ Yes ❑ No Dimensions: Ii Sludge depth: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 - t Commonwealth of Massachusetts Title 5 Official Inspection Fol r m Subsurface Sewage Disposal System Form-Not for Voluntaryl Assessments 28 Blueberry Lane, Marstons Mills MA ? Property Address George K. & Nancy C. Peterson Owner Owner's Name information is ; required for every Marstons Mills MA 0264$ 03/25/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i 1 Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle I Scum thickness v Distance from top of scum to top of outlet tee or baffle j Distance from bottom of scum to bottom of outlet tee or baffle, How were dimensions determined? -"2 I-- Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t�.s tsv ' 4-Aa� AV - �� _ E I Grease Trap(locate on site plan): 4 Depth below grade: j feet A Material of construction: ❑concrete ❑ metal fiberglass ❑ polyethylene ❑ other(explain): i I Dimensions: I Scum thickness ? i Distance from top of scum to top of outlet ee or baffle Distance from bottom of scum to bottom outlet tee or baffle Date of last pumping: � Date t5ins-3113 Tille 5 Official Inspection i Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Igo',rm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ; 28 Blueberry Lane, Marstons Mills MA Property Address George K. & Nancy C. Peterson j Owner Owner's Name information is Marstons Mills MA 02648 required for every 03/25/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i Tight or Holding Tank(tank must be pumpe at time of inspection) (locate on site plan): Depth below grade: Material of construction: i ❑ concrete ❑ metal ❑f berglass ❑ polyethylene ❑ other(explain): i i Dimensions: Capacity: I gallons ; Design Flow: gallons per day Alarm present: ❑ Yes j ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of.last pumping: Date Comments (condition of alarm and float switches, etc.): i I i i *Attach copy of current pumping contract(req ired). Is copy attached? El Yes ❑ No I t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary!Assessments 28 Blueberry Lane, Marstons Mills MA Property Address George K. & Nancy C. Peterson Owner Owner's Name information is required for every Marstons Mills MA 02648 03/25/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on i e plan). Depth of liquid level above outlet invert AM Comments(note if box is level and distribution to outlets equal, any evidence of soZsrryover, any evidence of leakage into or out of box, etc.): I Pump Chamber(locate on site plan): �/, i Pumps in working order: I ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* I Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): i i i t i i i i *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: j it i i t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 28 Blueberry Lane, Marstons Mills , MA , Property Address George K. & Nancy C. Peterson Owner Owner's Name information is i required for every Marstons Mills MA 02648 03/25/2014 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) CV/v Type: leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: i ❑ leaching fields number, dimensions: El overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc_ ®a '9 I I I Cesspools (cess ool must be pumped as pa of inspection) (locate on site plan): F Number and configuration C F Depth—top of liquid to inlet invert Depth of solids layer I Depth of scum layer i Dimensions of cesspool Materials of construction Indication of groundwater inflow i' 1 ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 • n Commonwealth of Massachusetts Title 5 Official Inspection (dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 Blueberry Lane, Marstons Mills , MA Property Address George K. & Nancy C. Peterson Owner information is Owners Name required for every Marstons Mills MA 02648 03/25/2014 page. 6-t-Yrrown State Zip Code Date of inspection D. System Information (cont.) I Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): , i I I Privy(locate on site plan): Materials of construction.- Dimensions i Depth of solids Comments(note condition of soil, signs of I iydraulic failure, level of ponding, condition of vegetation, etc.): 1 I i i t5ins-3f13 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 28 Blueberry Lane, Marstons Mills , MA Property Address George K. & Nancy C. Peterson Owner Owner's Name information is required for every Marstons Mills MA 02648 03/25/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 ti where public water supply enters the building. Check one of the boxes below: (/hand-sketch in the area below ❑ drawing attached separately i I 1 G' i i ee I i i a 1 I ! d 1 i t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of!Massachusetts Title 5 Official Inspection F®rM Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i M 28 Blueberry Lane, Marstons Mills MA Property Address ) 4 George K. & Nancy C. Peterson Owner f information is Owner's Name 1 required for every Marstons Mills MA 02646 03/25/2014 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope Iel—e-'--1 ❑ Surface water /V,- ❑ Check cellar ,/�it� ❑ Shallow wells1l-i Estimated depth to high ground water: i feet Please indicate all methods used to determine the high ground i water elevation: ❑ Obtained from system design plans on record { If checked, date of design plan reviewed: I Date I ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: i ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation- <a' j I d Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 28 Blueberry Lane, Marstons Mills MA Property Address i — George K. & Nancy C. Peterson Owner Owner's Name information is required for every Marstons Mills MA 02648 03/25/2014 page. Cltyrrown State Zip Code Date of Inspection E. Report Completeness Checklist ' E MInspection Summary: A, B, C, D, or E checked LJ Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page j15 or attached in separate file t5ins•3113 Title 5 Official Insp ection'Form:Subsurface Sewage Disposal System•Page 17 of 17 1 Cxrr-- V000, TOWN OF BARNSTABLE LOCATION o7$ Bluebe-Rfiig IAA SEWAGE # g2__�Xf ., AZ�lee VILLAGE ASSESSOR'S MAP & LOTI �- INSTALLER'S NAME & PHONE NO. Ellis Bgof CgNjS :3G-2_-&Z T7 SEPTIC TANK CAPACITY ► 000 LEACHING FACILITY:(type)�7�1 000 r�e� (size) LIJ,N&ji le"AN,/A/-(.A _ NO. OF BEDROOMS 2 PRIVATE WELL OR P(HLIC WATER Btffl;OeR O OWNER G�o2o, DATE PERMIT ISSUED: j DATE COMPLIANCE ISSUED:j;L,/;2,x 19Z VARIANCE GRANTED: Yes No ;/ �3iuE��2�ey �Pwo& A ii No.? Fim.... ... ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD. OF HEALTH aMOVED TOWN OF BARNSTABLE Ba 3 Comometia� _ Appliration for Di�ipwial Wuriz,i C omi x , n 0= Applica *on is hereby made or a Permit to Construct ( epair ( ) an In-1 ' 'ewage Disposal System at .................................................. -- .......................... _. -••--E3 . . . ..... - -- Location- \ Lot o. �_ /-------- --•-- ------------ - ��':.... ... �..__ A -ress r a Installer L� . Address t Type of Building Size Lot.................._.........Sq. feet .� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 0`4 Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity-------------gallons Length---------------- Width.._.._-_-_-__-_- Diameter---............. Depth................ x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area__..................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by....... .................................................................. Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water......................... 44 Test Pit No. 2................minutes oer inch Depth of Test Pit.................... Depth to ground water........................ x ...---•••-•-----------------•--------•--•---•--•-•••--•--••----•--••--•••--••------•---._._.........----•••-----------------------•-•----.._...--------•----• 0 Description of Soil...................................................................................... ...---------------------------------------------------._.......--•----------_--•-. x U .....------•------------------------•--------•----------------.----------------------.--•....._......------•-----------------------------------------------•---------.._._....._......---•---....._...__. x -••••••----•-----------------•---.......---------------------------------------------••------------ U N re of Repairs or Alterations— nswer when applicable f .... _...�i 1.....5 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance e issued by the board of health. Signed .... �eLT% j ........................... �� -�� ApplicationApproved By --------------------------------------------------------------------------------- ------------------------------------------------------------ ........................................ Dire Application Disapproved for the foll'9wing rearonf: ................................ .... .. . ... ............. ...... ................-----.................. ............................................ Q......................................................................................................................................................... ........................................ Permit No. ...../.... ...�`��'�...�................ Issued ------ mac'' .....'"�2 Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Applirtt#iatt for Diripwial Works Tomitt'ur#tuxt Trutt# - Application is hereby made for a Permit to Construct ( ) or Repair ( V) an Individual Sewage Disposal System at•� �v� ............� �r9/�(:... r1 .............................. 2........... Q ... -_ .... Lorttion \ddriss /J 0 -P or"Lot No. ���,/� Address .............................. Installer Address t UType of Building Size Lot________________________;4q. feet .. Dwelling—No. of Bedrooms------------- ...........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) al Other fixtures _______________________________ _ _ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity------------gallons Length..........:..... Width---------------- Diameter................ Depth................ Disposal Trench—No_ ____________________ 'Xidth.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No_____________________ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1.4 Percolation Test Results Performed by.-........................................................................ Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.............._......... 9 -----------------------------------------------------------------------•-•-•-••-•--•---•-•--•-_.............................................................. 0 Description of Soil......................................................................................................................................................................... x x -----•••-••••--------------------•-••--••--••-•---•-----------•-•.--•---•••••----------••••-•-•--•-------•-•---•----------------•••-•--•--. . ......----•-•-•-•-........................................................ U Nature of Repairs or Alterations—Answer when applicable__/ t: __..Ci✓___��� .__ ._�.__!_!r Agreement: ✓ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h been issued by the board of health. Signed .....`. ... ... . ... .. 5........................... 2-- ApplicationApproved By .................................... ..... ... . ... . ................................................... ........................................ Dare Application Disapproved for the following reasons: ............. ................. ............................................................................................... .............. ............................................................. . . ...... . ..--............................ .............. ................................. ........................................ .."' / Date Permit No. .... ........G/............................... .. Issued ...-..-- �r f-.......". Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CIlPr#ifi ate of TompliartrP THIS l O. CERTI That the Individual Sewa e Dis o'al System constructed ( ) or Repaired ( Y) by ........_. ........�--- --- ..�.dif .g....... p - ......................................... J ns. . .� / at --------- .._ '�' � .- ! P,2.. ....................... ✓/�.' ................../...l..c................................ - has been installed in accordance with7t , provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. I -_ __ �--...-.- dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFAC ORY. DATE-'------------------- ../ --------�d Inspector .......... .--, .....-._................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE c� Noy.-_. K FEE..._.... �L........ �io�r,astt� or�ku �ott,�#rttr#uan rruti# Permission is hereby granted..-... f.77----........ .............................................. to Construct r( ) or Re air ( an Individual ewage Di'pos System, atNo..... - 1 /a................................... Street, / as shown on the application for Disposal Works Construction Permit PN�b Board of Health DATE--- � ....A -------------------•-- FORM 36508 HOBBS&WARREN,INC..PUBLISHERS AsBuilt Page 1 of 1 TOWN OF BARNSTABLE i LOCATION .?? (3ruE b,-R(x�A JAK SEWAGE # ci2: 2 ' VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. Ej :& 13acrj C s�, fo -'623� SEPTIC TANK CAPACITY 1 000 -r- LEACHING FACILITY:(type)T1. 000 (size) �IJi•V�ji QGLM�/L+�ef� NO.. OF BEDROOMS 2 PRIVATE WELL OR EUALIC WATER R O OWNER l�Fol�4� ��.�F2��t�3 DATE. PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No i http://issgl2/intranet/propdata/prebuilt.aspx?mappar=l02122&seq=1 4/22/2014 RACE LANE LOCUS DATA LAKES�pF DR z J CURRENT OWNER GEORGE PETERSON N NANCY PETERSON W 149 W LOCUS PLAN REFERENCE 138-25 z DEED REFERENCE 8345-14 ZONING DISTRICT RF GP L 0 7- 106 BENCHMARK LOT I I J CORNER OF CONCRETE 28 IRON PIPE I BULKHEAD. ELEV=75.29 LOCUS MAP FOUND FLOOD ZONE "C" I I S 87'00'00" E 100.00' IRON PIPE NOT TO SCALE: ASSESSORS MAP 102 FOUND 14-0107 s9 PARCEL 122 - — _ ` _ I I �� � 7p- - — _ OVERLAY DISTRICT ZONE II LOT �2 LOT AREA 10,200t S.F. I I / ' ��— _ _ ` 72_ SHED SITE 8c SEWAGE I / N I REPAIR PLAN I r%o �� 73_ - -- _ _ _ Li 8L UESERR Y L A NE ► I �`' ,�� �� M IN j � o / Z MARSTONS MILLS II ' ' I I ` I I ¢ I EXISTING Q T NG �\ DATE: APRIL 14, 2014 I GAS GA 2 BEDROOM EXISTING 1500 \ GALLON SEPTIC DWELLING 15 0- o ` TANK TO REMAIN OWNER/APPLICANT: �yy � _W BOX EXISTING BE GEORGE & NANCY I I 21.1' REPLACED PETERSON _ _ /� POSED , #28 BLUEBERRY LANE I LOT 107 PROPOSED 40MIL D #1H LEAOCHING FIELD 2' AR T N S MILLS 02648 POLY LINER AROUND I OF D.T.H. 0 10.0' M S 0 I I 10,200 f S.F. NORTHERLY END LEACHING FIELD (20") #2 o OBS OAK TREES TO BE _ REMOVED NEAR SHEET 1 OF 2 PROPOSED S.A.S. S 87'00'00" E 100.00' PREPARED BY: �\ IRON PIPE EXISTING LEACHING PIT TO FOUND E A S SURVEY, INC. ���� �� SSq�yG \\ LOT 1 08 BE PUMPED CRUSHED & o EDWARD s REMOVED FROM SITE IN 141 R T. 6 A A. \ ACCORDANCE WITH TITLE 5. L 0 T III � N o STONE 0 20 30 40 SANDWICH , MA 02563 N° 2 PH. (508) 888-3619 �o s 0 ON �75— LA CELL (508) 527-3600 /1Ar RAP1 GNCHHIC SCALE:0 FEET EAS.SURVEY©YAHOO.COM D' SYSTEM DESIGN RAISE COVERS TO WITHIN 6" OF FINISH GRADE OBSERVATION PORT TO EXISTING DESIGN FLOW TCF = 76.00 FINISH GRADE GRADE / SCREW ON CAP 2_ BEDROOMS AT100 GPB/D 220 GPD GRADE 75.30 ELEV. 73.8 FINISH GRADE ELEV. 73.7 REQUIRED SEPTIC TANK ELEV. 73.6 ELEVATION 73.5� GROUND TOP 72.9 220 x_2 _ __ __440 GAL. N TOP ELEV 71.0 N SEPTIC TANK PROVIDED = 1,000 GAL. EXISTING 4" PVC 3' (�S=0.34 6'®S=0.01 EXISTING TO REMAIN SCH 40 4' PVC SCH 40 - S=0.005 S AC .. 2 MIN-TOW MAX _.. -. TI E _ INV.= e e e e e° ° °e o.0 ° °°e°e °°e°,°,e*0 N E NDS SIZE OF LEACHING FACILITY REQUIRED ,• INV.- EXISTING --- 0000aop 00000a °°000000 0000 „ 71.84 10"TEE 14"TEE INV.= _ ° ° e e e , ° TO REMAIN INSTALL 71.67 6" o 0 0 0 0°° o o a o 0 0°°o 0 0 o e °a o 0 o a e DESIGN PERC RATE <_? MIN./INCH GAS BAFFLE 3 OUTLET ° ° ° ° ° ° ° ° e e e ° ° ° ° LONG TERM APPL. RATE_0.74_GPD/S.F. 4'-1" LIQUID LEVEL H-10 D83 14' x 22 LEACHING FIELD INV.=70.64 INV.=70.41 INV.-70.30 0 L69.80 SIZE OF LEACHING SYSTEM PROVIDED: DATUM: INV.=70.47 22' _I a 220 _ 0.74 SF/GPD = 300 S.F. MIN. REQ. 0 ° (3) 4" PIPES 5' ON CENTER � Lci VERTICAL DATUM: USING A 14 x 22 LEACHING FIELD EXISTING 1,000 GALLON PROPOSED 40 MIL 62•7 „ MSIf / BARNSTABLE GIS SEPTIC TANK TO REMAIN POLY LINER (20') OBSERVATION PORT TO WITH A MINIMUM OF 6 STONE UNDERNEATH BENCH MARK USED: TOP=71.0 GRADE / SCREW ON CAP CORNER OF CONC. BULKHEAD BOT=68.5 14' x 22' = 308 S.F. ELEVATION 75.29 CONSTRUCTION NOTES: 14-0107 FILTER FABRIC 308 x 0.74 G/SF = 228 GPD 1. CONTRACTORS / INSTALLERS SHALL VERIFY GRADES AND ° e e e °° a ° o °e°°° (-3 S.F. FOR D-BOX) ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING °°°°°°°°°$°8 $ 8°0 °° °8°0°0°0 "� 225 GPD PROV > 220 GPD REQ.= 5 GPD RES. ° ° e e ° °°°°°° e e °o°°°o°oe° SITE 8c SEWAGE WORK ON THE SITE. o°o°e°o°o°e°o°o°oo°o°o°O° o e o 0 0 0 o°e°°° O 2. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE °°°°°° °°o o a °°°° °°o ° ° NO (GARBAGE DISPOSAL / GRINDER ALLOWED) REPAIR PLAN WITH DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT 2' S' S' 2' IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. P#14323 , 28 3. VEHICULAR TRAFFIC, PARKING OF VEHICLES AND PLACING rj` v MATERIALS OVER THE SEPTIC TANK, DISTRIBUTION BOX AND �-- 14•0' D.T.H. #1 D.T.H. #2 BL UEBERR Y LANE S.A.S. AREA IS PROHIBITED END VIEW DATE: 4-8-2014 DATE: 4-8-2014 GROUND ELEV. 73.7 GROUND ELEV. 74.1 GENERAL NOTES: I CERTIFY THAT I AM CURRENTLY APPROVED BY THE NO GROUNDWATER NO GROUNDWATER IN 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. DEPARTMENT OF ENVIRONMENTAL PROTECTION TO CONDUCT M A R S TO N S MILLS TITLE V AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS SOIL EVALUATIONS AND THAT THE RESULTS OF MY SOIL A A FOR SUBSURFACE DISPOSAL OF SEWERAGE. EVALUATION AR ACC RA E WITH310 LOAMY SAND LOAMY SAND 2. AT LEAST ONE ACCESS POINT OVER TANK TEES SHALL BE CMR 15.100 UG 15 07. 10YR 4/3 10YR 4/3 DATE: APRIL 14, 2014 ACCESSIBLE WITHIN 3" OF FINISH GRADE, WITH ANY REMAINING 4" 6" ACCESS PORTS BROUGHT TO WITHIN 12" OF FINISH GRADE. _ _ ;ACCORDANCE g g 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE EDWARD STONE, CERTIFIED SOIL EVALUATOR LOAMY SAND LOAMY SAND OWNER APPLICANT: CAPABLE OF WITHSTANDING H-10 LOADING UNLESS OTHERWISE SPECIFIED. OF M 10YR 5/6 10YR 5/6 .�y�N qss� 26„ 24„ GEORGE & NANCY 4. THE EXCAVATION CONTRACTOR SHALL VERIFY THE LOCATION �� oy EL. = 71.5 5. ANY PRIOR TO ANY EXCAVATION. UNITS USEDTO BRING COVERS TO GRADE off° DAV N /f DTH #1 INDICATES HOLE SILT LOAM DEEP PETERS 0 N OR WITHIN 6" OF GRADE SHALL BE MORTARED IN PLACE. 1r HE R. // C 52" 10YR 6/8 #2 8 BLUEBERRY LANE 6. FINISH GRADE SHALL HAVE A MINIMUM OF 0.02 FEET PER No 21 INDICATES MEDIUM SAND EL. = 70.9 38 P-1 52 FOOT OVER THE S.A.S. AND DISTRIBUTION BOX. p " PERC TEST 2.5Y 7/4, 7. SEPTIC TANK SANITARY TEE'S SHALL BE CONSTRUCTED OF �GISTE M AR S TON S MILLS, 02648 R(G SCHEDULE 40 PVC AND SHALL EXTEND A MINIMUM OF 6" ABOVE S Nl AR\r SHEET 2 OF 2 THE FLUW LINE AND SHALL BE ON THE CENTERLINE AND NO MOTTLING C-2 LOCATED DIRECTLY UNDER THE CLEAN OUT MANHOLES. /j NO WEEPING MEDIUM SAND 8. THE INLET PIPE INVERT ELEVATION SHALL BE NO LESS THAN / 2.5Y 7/4 PREPARED BY: 2 INCHES NOR MORE THAN 3 INCHES ABOVE THE INVERT 132" INDICATES ADJ. GROUNDWATER ELEVATION OF THE OUTLET PIPE. NO G.WATER NO G.WATER „ E A S SURVEY INC. 9• THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 INCHES NO OBS. GROUNDWATER EL. = 62.7 132" EL. = 63.1 132 10. THE OUTLET SANITARY TEE SHALL BE EQUIPPED WITH A GAS 141 R T. 6 A BAFFLE, 4 INCHES IN DIAMETER AND CONSTRUCTED OF 4" PVC B.O.H. O.DONNA MIORANDI 11. ALL PIPES SHALL BE SCHEDULE 40 PVC SEWER PIPE AND NO-OBSERVED GROUNDWATER SANDWICH , M A 02563 SHALL BE SLOPED 1/4 INCH PER FOOT MIN. EXCEPT FOR THE DEPTH TO BOTTOM OF HOLE SOIL EVALUATOR FIRST TWO FEET OUT OF THE DISTRIBUTION BOX WHICH SHALL ED. STONE BE LEVEL VARIANCES REQUESTED BACKHOE OPERATOR. PH. (508) 888-3619 12. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION ELLIS BROTHERS, (KEVIN) CELL (508) 527-3600 TO EAS SURVEY INC. FOR B.O.H. AND DESIGN ENGINEERS REVIEW TO ALLOW THE PROPOSED S.A.S. TO BE SOIL TYPE: AND APPROVAL. 15' FROM A BULKHEAD IN LIEU OF 20' PERC RATE: <2 MIN. PER INCH EAS.SURVEY©YAHOO.COM 13. MAGNETIC TAPE ON ALL COMPONENTS. (LINER PROVIDED) LOADING RATE: 0_74 GAL/SF/MIN