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HomeMy WebLinkAbout0025 BOG BERRY LANE - Health 25 ROG BERRY A= 044.007.004 f r� 1 Commonwealth of Massachusetts _ F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form:- Not for Voluntary Assessments 25 Bog Berry Lane Property Address . William A Kelly Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-1.-14 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 fillingiout forms A. General Information - - - on the computer, use cri the tab key to move your -1. Inspector: cursor-do not Matthew F.:Gilfoy use the return: y Name of Inspector B&B Excavation Company Name - -14 Teaberry Lane Company Address. Sandwich _ Ma. :. 02644. _. _. Ci /Town tY State Zip Code (508)477-0653 S134640 Telephone Number License.Number 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15000). The system: ® Passes ❑ Conditionally Passes ❑ .Fails El Needs Further Evaluation by the Local Approving Authority 5-1-14 Inspector's Sign ure- - 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. / I t5ins•3/1& Title 5 Offi"doo' bsurface Sewage;Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments <,M 25 Bog Berry Lane Property Address William A Kell Owner Owners Name information is required for every Marstons Mills Ma. 02648 5-1-14 page. &W-Town 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: ® 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: B) System Conditionally Passes: ❑ One or mores stem comp onents ponents 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. p System will ass Y 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): l5ins•3/12: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M 25 Bog Berry Lane Property Address William A Kelly Owner Owners Name information is required for every Marstons Mills Ma. 02648 5-1-14 page. CitylTown 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.): ❑ 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): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 public health, safety or the environment. 1. 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: ❑ 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 l5ins•3/1:3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 25 Bog Berry Lane Property Address William A Kelly Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-1-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 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 co of the analysis must 99 co py Y be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 1/ day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 25 Bog Berry Lane Property Address William A Kelly Owner Owners Name information is required for every Marstons Mills Ma. 02648 5-1-14 page. City/Town State Zip Code Da te of Ins pection 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. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® 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.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® 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. E) Large Systems: To be considered a large system 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"yes"or"no"to each of the following, in addition to the questions in Section D. 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 If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of"Massachusetts .. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form:- Not for Voluntary Assessments �M ,`°• 25 Bog Berry Lane Property Address. William A Kelly Owner Owners Name information is required for every. Marstons Mills Ma. 02648 5-1.-14 page. City/Town::. 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 EJ 1Z Pumping information was provided by the owner, occupant, or Board of Health ❑ Were:any of the system components pumped out in the previous two weeks? 1Z El "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? l � Were:as built pans of the system obtained and examined If the❑ . ( ywere not. available note as N/A) 1Z El Was the facility or dwelling inspected for signs of sewage back up? 1Z El Was the site inspected for signs of breakout? ® ❑ Were all system components, excluding the SAS, located on site?. . ® ❑ 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? ® ❑ 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: ® ❑ 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 El ® approximation of distance is:unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design):: 3 Number of bedrooms(actual):: 3 . DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): . 341 — 15ins•3/13... 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 Voluntary Assessments 25 Bog Berry Lane Property Address William A Kelly Owner Owners Name information is requi-ed for every Marstons Mills Ma. 02648 5-1-14 page Cltylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): n/a Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ 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 Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 25 Bog Berry Lane Property Address William A Kelly Owner Owners Name information is required for every Marstons Mills Ma. 02648 5-1-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pump driver Was system pumped as part of the inspection? ® Yes ❑ No If es volume pumped: 1500 y p p gallons How was quantity pumped determined? tank size Reason for pumping: Maintenance Type of System: i ® 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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts N v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Bog Y Berr Lane Property Address William A Kell Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-1-14 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 32" feet Material of construction: ❑cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10 feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank(locate on site plan): Depth below grade: 26" feet Material of construction: ® concrete ❑ metal ❑fiberglass 9 El polyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal. Sludge depth: NS l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Bog Berry Lane Property Address William A Kelly Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-1-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle NS Scum thickness NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle NS How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order,Tees present no sign of back- up.Liquid level equal with outlet invert. Tank pumped for maintenance after inspection. Grease Trap (locate on site plan): 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 25 Bog Berry Lane Property Address William A Kelly Owner Owners Name information is required for every Marstons Mills Ma. 02648 5-1-14 page. City/Town 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.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 25 Bog Berry Lane Property Address William A Kelly Owner Owners Name information is required for every Marstons Mills Ma. 02648 5-1-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 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.): At time of inspection d-box appears to in working order no sign of deteration. So carry over present in D-box. 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.): * 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Bog Berry Lane Property Address William A Kelly Owner Owner's Name information is Marstons Mills Ma. 02648 5-1-14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gal ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ 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.): At time of Inspection leaching appears to In working order no sign of hydraulic fallure.Water level was 1' below invert at time of inspection. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Bog Berry Lane Property Address William A Kelly Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-1-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions i Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts - Title 5 Official Inspection Form Slubsurface Sewage Disposal System Form Not for Voluntary Assessments 25-Bog.`Berry Lane Property Address William.A Kelly Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-1-14 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 where public water supply enters the building. Check one of the boxes below: 0 hand=sketch in the.area below ❑ drawing attached separately A i 5 _ t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 25 Bog Berry Lane Property Address William A Kelly Owner Owner's Name information is required for every Marstons Mills Ma. 02648 5-1-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: no GW @ 10' 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: 2-7-98 Date ❑ 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) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan on file Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 25 Bog Berry Lane Property Address William A Kelly Owner Owners Name information is required for every Marstons Mills Ma. 02648 5-1-14 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® 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 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF ADDRESS LOT �� PERMIT# ��P INSTALLER yACrA 140si.� DATE OF ISSUE DESIGNER. C—AgL �- (��` LICENSE# I CERTIFY THE SYSTEM WAS INSTALLED ACCORDING TO THE PLAN SUBMITTED WITH THE PERMIT. I CERTIFY THE SYSTEM WAS INSTALLED ACCORDING TO CHANGES APPROVED BY THE DESIGNER,REVISED PLAN FROM THE DESIGNER WILL BE SUBMITTED TO THE HEALTH DEPT. S. 13. 98 DATE INSTALLED INSTALLERS SIGNATURE HEALTH CERTIFICATION S-BUILT"DIAGRAM ON REVERSE DESIGNER'S CERTIFICATION a/B- Cps TALK _ Al Ala -p %n A353 ,o 4 A f 67 4,,, Ar �So 0 t 8S 44- m -O BXATABLE (� LOCATION f[�7`T L7C?t@ /s]d/��, n�� SEWAGE # VILLAGE h� �.+�a ,;_ j , 1/ ASSESSOR'S MAP & LOT 6 ,- INSTALLER'S NAME&PHONE NO. rePl�a�r- �- SEPTIC TANK CAPACITY 4 J�®0 's LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER btu , PERMITDATE: 19 F COMPLIANCE DATE:_ ^ I°3 -`/f 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 No. / O , F Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes APPIication for Zi!6poml *p.5tem Construction Vertu Application for a Permit to Construct( pair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Lo..cZatio�ddress or�Lot o. � � Owner' ameQAddr�ess�a�Te1RN'o. Assessor's Map/Parcel ' � ��f `°2 Z '3 Installer's Name,Addre s,and Tel.No. Designer's N e,Address and Tel.N to fjV� Type of Building: Dwelling V No.of Bedrooms Lot Size 2� b�O sq.ft. Garbage Grinder 61d) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow S J J gallons per day. Calculated daily flow 3 3� gallons. Plan Date Number of sheets R vision Date ,S Title kxrAg} D)S Pos A L S y S T''31N o-43 1 l d P6 7 G Q � ZS' 3v(, $q�X L Q Size of Septic Tank /�5� �P�5 Type of S.A.S. Description ofSoil�i �"6 SD►1i®b CtAsa e-* C )St t_ ►VW4 Gdl�7-Lo�,M' z1 -Ioa Mub , 'w SIi'�cO o Gb' re- ;P� CILhM Ga' S /4(oY 4et Nature of Repairs or Alterations(Answer when applicable) N Q Date last inspected: � (� Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss1ked by this Boaz f Health. Signed Date 2_11-1 8 Application Approved by Date Z -70-°J Application Disapproved for the following reasons Permit No. ,! /f/ Date Issued 2-Z 0 - No. T d'I/� #* `` Fee Idle. 0 THE COMMONWEALTH.OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for -Migpool *p5tern Construction Permit Application for a Permit to Construct(L/<Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No.4,c Owner' Name,Address and Tel.No.� �. / � ^�_ _ AssZessorS's M /Parcel !�� •^�t�/I �. t�l W 'Z G o7 - 1bQ 22 a;tee ' 02 SG 20-2$ qV Installer's Name,Add ,and Tel.No. Designer's Name,Address and Tel.No. .TAYVNES ress e.L6_K., G n k) rly ).,S'sb t ?,a. 5ji Type of Building: 6 o Dwelling J No.of Bedrooms 3 Lot Size ) sq.ft. Garbage Grinder NO) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 41) gallons per day. Calculated daily flow 3� gallons. Plan Date 2 Number of sheets f Rivision Date .A Tit1e� �iA T D IS�vCi1� SyST�1� A�SI�IJ �� Lo' ZS' �0(, 3L1� LIJ Size of Septic Tank 49*0 C ALS Type of S.A.S. Description of Soil O"b� S O y C 4 •4JA h" L-4 S '0QN CiA I-Con M' 71�-100 MOO - lsr o — 'J V61 JiCS' �' " 4h .LDA i � ,� S oY C�A9 - o N yh% • C.t`)d Sb{ T 0.y S h1(,\,1, Sr w lr Nature of Repairs o�,Alterations(Answer when applicable) N n Date last inspected: Agreement: � r ;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 thelinvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is ed by this Boar f Health. Signed Date 2 Application A roved b N PP PPS Y Date 2 —7-0 9 ' Application Disapproved for the following reasons Permit No. g -�,(�' Date Issued Z 0 — THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( Repaired (',--w )Upgraded( ) Abandoned( )by j2!&(e at 2 [3 0& 13 622 Y has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated "Z ZO gr Installer Designer r1UC T��(,. •d- The issuance of this permit shall not be construed as a guarantee that the system will fu ction as designed. Date_ - �1 CV Inspector Fee BQ. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lizpogal * ztem Con5truction hermit Permission is hereby granted to Co struct Repair( )Upgrade( )Aba don( System located at Z � 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. I Provided:Construction must be completed within three years o the date of this p i . Date: 2 Z d_q Y_ Approved by ` Department of Health,safety,and Environmental Services V Public Health Division Date o+� 367 Main Street,Hyannis MA 01601 &ARMANA XM °J Date Scheduled Time L o'o. Fee Pd. Suitability Assessment for Sewage Dis osal Soil Sui ty `I ��cs;Z-Z� Performed By: Ln d'/r3l/y �'" Witnessed By: � LOCATION & GENERAE'INF+ORMATIO Loc A resT"Z S� �O(0 � (, Owner's Name .�> Addres_+p J46::)q Ti-)­rk,. Assessor's Map/Parcel: � ezr) 00+ Engineer's Name N j�lg S��e� �y-�• / �/r V REPAIR Telephone# NEW CONSTRUCTION 0 Land Use L'd`3— 0 fin/��,J tAt Slopes(%) 5 6 Surface Stones . it Possible Drinking Water r Possible Wet Area W Well< 7ft\7 Distances from: Open Water Body t r d �✓`1 �Z6� p- 130�- 2�a R J706 Drainage Way 2 2. a � 6 ft Property Line _ ft Other 1i SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) i } L 1/ k.. i e s; , Parent material(geologieR'*?D LYE Depth to Bedrock O tJ Ls Weeping from Pit Face � C/J Ls Depth to Groundwater: Standing Water in Hole: � p g Estimated Seasonal High Groundwater i DETERMINATION FOR SEASONAL HIGH WATER TABLE'' Method Used: In, De to soil mottles: in. Depth Observed standing in obs.hole: p ft Depth to weenine from side of obs.hole: in. Groundwater Adjustment ,.... Index Well!f_ ,-,_ •Reading Date:_ Index Well level Adj.iacior Adj.v.v�='aM•`^Ve'-- PERCOLATION TEST' Observation 1 .time nt 9" Hole p / a • "i ;$ . 3 Depth of Pere a Time at 6" Start Pre-soak Time Q End Pre-soakf 1 tt +�rss�x „ 7I Rate Min./Inch 'tn� WAR Cams J xoiJ J S Site Suitability Assessment: Site Passed V1. Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Comple(4on Back Copy: Applicant iluie# L ,— ` I)h.CP,OIZ5E1iVA'I'IUN 1tOLE Lou Soii �,,,�, �. L(USDA) ture Soil Color Structure,Stones,Ilouldercs. Depth from Soil I lorizon (Munsell) Moilling Surface(in.) 1 t C5 " '' f�a/�a1�.sJ SahAu STa^1C 4, l , '� too' � 40e,ZD e-co'wc- s�Ne EItV 'I'ION tIOLE LOB'' Nollz# DEE�tjnBS Soil other Soil Texture Soil Color structure,Slones,noulderes. Soul I lorizon , .(Munsell) Mottling ( • Depth from (USDA) MAWL— Surface(in.) rOW �4R�©` 61l.. 0 f�0l�12t'A+� S� ID Z +_ �o r+ A rJ CiN� Lr)AM� i 5P'#jM 6 C?'A -u��M /D +P �.Ydf✓�' Itole# _ I;p 01ISri RVATION HOLE T Lture Soil Color O+G soil ocher Soil ex Structure,Stones,nouldetes. I)cptlr from Soil Ilorizon (Munsell) Mottling ( • (USDA) . Surface(in.) r A, Hole llEE 1;ItVI' OBS TION MOLE LUG soil other Soul Texture Soil Color Simcture,Stones,noulderes. Ucplh frnm Soil Ilorizon (USDA) (Munsell) . Mottling ( • y I�1 Surfnce(in.) ri I &►�1VIan1 car flood boundary No Yes - �Above S00 y ,. , Within 500 year boundary No 7. Yes c Yes Wilhln 100 year flood boundary No— — e ( 'aturall Oc urrin Pervious Mate ial -` .' u�feet naturally occurring pervious material exist in all areas observed throughout the Does at least fo area proposed for the soil absorption system? s material? � If not,what is the depth of naturally occurring perviou s r,; - f-. i . I certify that on (date)i have passed the soil evaluator examination by me consistent whit Y Department of Environmental Protection and that the above analysis performed the required training, )crtise and e��,icrience described in 310 CMR 15.017. L F(N_ FLunR i 7e 8p � 84 8`l 8r FJ N-GR�L- 3'DEX�S, ING GR.E1 �t3 .o 74- 76 i 7. G EL�4.o \ ? Xxx�c l� orE ; PEE M0VE ALL IMoEW uj o LOTS / 1�1/�T L ► FiL S S �0� z\ IN - 7 4 7 L � I INS 8o-5 GAL_ ; �t 8 80 \ Cc-LLARFr-oor` 10 MIN, p fleCor`c y,N-79.? � �`,'z .� mil' 1 � 3Q' EL, -rC.s T SC�L 20 M i rk. ,�- 0 B t L O-yj � v rr;. )•'= 42 PPLn- LE D1SP0SAL SYSTEM �' \�� 6—JL � W LOT s _ o E 'I,pLSPOSt\;. SYST"EM, To B� CONS -f�VCTED IN STR�cT Vs i s Q Ccoao Am c.E o C oM M. oi= J` AS S. F-n' v rRo t-i. C ooE-Ti-r 41*5. Z. GO1U T OVR Q.M- FROM TOWN T-OPO 65.5 a 1N7E \ St Li or BOG, 64.4 ` I�Tr� \1 Lt4 _ A N b IZI\/ ET-k TZ0Y\2� - I qjq -Dp�S'VM_ SUi?V��I rZoJ� n t-'LX►J ? ITLED` t3oCs T31=. '��I k'NOLL" D T'E III-J - I9rc37 TEST P► rs fRC T1:Sf A 3D-8 r-t�V 11 - -1 . R GoRDE-t� az- i3 X1�NSA31..£ -Ptf1N aK 944 PG, 15 ' L o-T 5 / 2 5 a 0 6 FSERRY L N. MXRS-kW S MIllS A SSI: SSOR M IMP G 4 4- r---E x r T JNG 2610� - PC_ 25 / 007- O64ti W-1 \ 0 RHbE 7 sLt�:���. O-A -SANDY B.5 — I CLAY - 0L- S1GN SI -FF PLAN i 76 Lan-- ! SCALE: )" 4p J I Lit 57T))A1+ I — 80:1 Ztoe/iw. i I SINGLE I=AiAl� _Y DWELLIrIG W/ 3 Rt=DuootlS Z r � ,9� NO 3Av\-sA(3 -= I = 33o G: o, D. ��P�jt\ oF�y gSsy I � -SF- W�6E (�)SPOSAt SYSTEM OE5)GI /�AIL`t FL a W = / ) a X 3 oz rl /1L HARRY � i S� ?-Tic -7Aril<. (� Cam. R`.. CQ EARL ri !�1F7 - i - 7�J.� E)-�7 i 6 C 0 GAL-S, LANTERY, JR. D .o .p No.26575 O o`er 1 , 500 GA L , At`JY, O . k'- °.��G18TE����v i s , r �� S�c�C I P.O. ��ox 15 Ji i SIONAL EN L2ACISIN � fin/ ' JJiNs L _C_ + 4S)01;c L D 1 5 / z5 FLOG (3ERF\� N. \ � /a SSA SSoR M1P 0=I,4 PC.o>7-L�4 [ >`r E CT I V- pr�', - 2 _� iZ�Q � I-\\. -S � 1�1C1. . 0_74 = I i3x24 o."T4 = 231 _ �q 3_— I—� )Jo)l�o �ol�Zu — — 74.oi ASS OCR TECH_ �ERVACES i ��-��` CAi�>^:. ' - 341 GALS . TtSn_v: 2 ? 0 ®b