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0090 BRACKEN FERN ROAD - Health
qu-Bracken Fern Road Marstons Mills F/R A = 043 006002 YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $40.00 for 4 years. A Business Certificate ONLY REGISTERS THE BUSINESS NAME in town (which you must do by M.G.L.- it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St,Hyannis. Take the completed form to the Town Clerk's Office, 15'•FL., 367 Main Street, Hyannis, MA 02601 (Town.Hall) and get the Business Certificate that is required by law. ,k Fill in please: Date: APPLICANT'S NAME: YOUR HOME ADDRESS: ( rrc�.�i.cr�rll�de�✓ . a45 Y BUSINESS TELEPHONE # HOME TELELPHONE #: EIN _ NAME OF CORPORATION: . S- C :6 FID # 0 0 7 NAME OF NEW BUSINESS TYPE OF BUSINESS G IS THIS A HOME OCCUPATION? NO -W2 ADDRESS OF BUSINESS -. vac �cii Wlai-,,r :: h�i��s, MAP/PARCEL NUMBER (Assessing) When starting a new business there are several things you must do to be in compliance with the rules and regulations of the Town of Barnstable. This form is to assist you in .obtaining the information you may need. You MUST GO TO „ Main St. (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in town. 1.� BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. f � Authorized Signature** „ -r COMMENTS: t 2. BOARD OF HEALTH This individual has be informed of the permit requirements that. pertain to this type of business: Authorized Signature** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING'AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** Town of Barnstable �p iME Tpw " o Regulatory Services Thomas F. Geiler,Director * BARNSTABLE, MASS. Public Health Division ATFp �A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 6 4 Designer: 4:�k Pnot�\ Installer: Address: •®, S�C.g Address: u M On �`� 5Fg��C was issued a permit to install a date) r (installer) septic system at� C;Cn� M-M�\�� based on a design drawn by (address) U� dated I p designer) C5 . 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. 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. e� V AR staller's Signature) U SHI ey o (Designer's Signature) (Affix Desi _ 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:Health/Septic/Desiper Certification Form TOWN OF BARNSTABLE LOCATION O SEWAGE # VILLAGE ASS OR'S MAP & LOT z 3-60'6'd7-- INSTALLER'S NAME&PHONE NO. S SEPTIC TANK CAPACITY ®. LEACHING FACILITY:.(type) . C, N p�=Ti � (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: a COMPLIANCE DATE: Separation Distance Between the-.- Maximum Adjusted GroundwaterTable 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 0 o � yam/ �, � , , ` �� l'V Sey - 20-01 13 . 54 BARNSTABLE HEALTH OEPT 5087906304 • S rZS/0 I NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM E_E"W_, hereby certify that the engineered plan signed by me ue;eC conceerring the property located at j meets all of the ict'ow;ng c;�tetla: • This failed system is connected to a residential dwelling only. There are no _omrn--rzia.! or business uses associated with the dwelling, • 'F�e soil is ciass;fed as.CLASS l and the percolation rave is less than or equai !o -%nut:s der inch. The applicant may use histoncal data to conclude this f3c: or may ;z)nduct pre:trr-wary tests at the site without a health agent present • The r: :s no ;ncr.—ase to flow and/or change. in use proposed • I here are no variances requested or needed. • The bottom of the proposed (caching facility will not be located less than fourteen 'ee: aoove the maximum adjusted groundwater table elevation. radjust the nundwater table using the Frimptor method when applicable) Please complete the following: fop of Ground Surface E!zvanon (using GIS informs!ton) _$^00 5; G W Elevat:or, � I. .d;us(men( for.-iigh F1-TRE�t F. BETWEEN -\ and B •QO PS:(3VED DATE; NOTICE 3asec j,OR the above :r.formacion, a repair permit will be issued for �zdr^ores ravirnum.. :`+^ :ddiuc)n3t bedrooms ue authorized to t`te future wi-.hout engtneerec :ept+c sy.tem plans. _— — �i.-Hh!r,:Oc, ;ic,cc.%MP T (o 1•. Permit Number, Date: Completed by: HIGH GROUNDWATER LEVEL COMPUTATION Site Location: C)C) Lot No. 3� Owner: f� yS,N _e Address:_ Contractor: AI cS1) S• Address: Notes: l �� S\4lll STEP 1 Measure depth to water table to nearest 1/10 ft. ..................:........... Date mo dth day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OA Appropriate index well.................................................... AD OWater-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well 150 month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 26) determine water level adjustment STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) .. 41. J; Figure 13,--Re—Reproducible computation putatlon form, 15 I 3 TOWN OF BARNSTABLE L:OCw1f'IOD e G SEWAGE # `V9LLAGE l�l ''— ' ASSESSOR'S MAP &LOT o INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNERCO-PC�'t cG� PERMTTDATE: 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 Ord y ..LM �A g � y a� �C S® ' TOWN OF BARNSTABLE �. OCATrnN 90 SEWAGE 0 i' ASS OR'S MAP & LOT V3�6 a JII.LAGE INSTALLER'S NAME&PHONE NO. � ` -�✓ r SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �YLS i6� size) � • NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: IL t. 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 ,6gl L7 . 6 { U y 5��� `� � �M s, No. �/ FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repaix Upgrade( ) Abandon( ) - O Complete System,)Vndividual Components Location qo 7 Owner's Name Sus Map/Parcel# 4 3 1 Address Lot# Telephone# Installer's Name C Designer's Name V ics. Address (7 tAF, Address ,). Telephone# . 5 d� Telephone# _ 5 Type of Building � S\,���1CLN ` Lot Size 12(aq sq.ft. Dwelling-No.of Bedrooms Garbage grinder Other-Type of Building N Oct No.of persons Showers (6)/,Cafeteria (7 Other Fixtures' L.A.,aTt:eY laxA--)6&A- Design Flow (min.required) '.4440 gpd Calculated design flow Design flow provided 443.� gpd Plan: Date A Number of sheets Revision Date Title \\ t► Description of Soil(s) tr Soil Evaluator Form No. --' Name of Soil Evaluator C&RIMS)J SM Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS SIC-1 1311. The unde igned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a51: e to of to plac tem' operation until a Certificate Comp'anc has been issued by the Board of Health. Signed to 4 \:Y..�.�,t.r..,,,,-."�,;.1'` ,�«.��� -.-+...,,t,�,�.-.w.^�-M..—.!.�+r""„^-+{.,r'vr+i^!m7"'j`:"�r.,'r'f"KVH/`y� ,7.r...+N.Sri.�ylri'y+"�,fi./`rtls('��'"r7r```+s'`�`��`'�r"f'ri"`'+icF".3"^""^"'.*A++-.ryy_f-•.-v+-^til ;No. �.C�,(� ja[ f,�.9 r r a t' FEE COMMONWEALTH OF MASSACHUSETTS y. d r Board of Health, APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT '^-Application for a Pernift to Construct( ) Repair Upgrade( ) Abandon( ❑Complete System Individual Components Location 'y�a 1 f M.A c, Owner's Name IS US�,J t c�e z_,r`, w Map/Parcel# Address r Lot# Telephone# t Installer's Name U �� t J 1 C'E' Designer's Name C()U Cd S'hS2ll G\ �'7dC S. Address r� �^ Address �^ t' ®• �X� (o . C ��Yt �?4l� N1(� 21Q, l Z', F *A NIA Telephone# �(� C5 L`a�� Telephone# Sd4 --C'1 60�5 Type of Building 'Cl[a�;tCA 1^� Ca,� - Lot Size I?(A I sq.ft. Dwelling-No.of Bedroomsw .C1Q�� Garbage grinder Other-Type of Building 1 V C)C)R No.of persons Showers ( 0-!Cafeteria ( y/ Other Fixtures k t -�rr ho c-, Design Flow(min.required) A 40 gpd Calculated design flow 4A0 Design flow provided 4 -7-,."+b gpd Plan: Date ' ' , Number of sheets , Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator CAA Q-M r'�-A Sw oYDate of Evaluation 411410+ DESCRIPTION OF REPAIRS OR ALTERATIONS _aeeC" 1 A The unde"signed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a es to of to place the/R tem' operation until a Certificate Comp'anc has been issued by the Board of Health. Signed J T x D to Q t/-1 V- -Ins, oction's' _/ .�. �Y/ ` �I v u w MMONWEALT14 OF MA C14USETTS FEE �2e�2 } Board of Healthr�/ jY__ , MA. CERTIFICATE OF COMPLIANCE Description of Work: Individual Component(s) ❑Complete System The undeme-L4- ' ed hereby certify that the Sewage Disposal System; Constructed ( ),Repaired),Upgraded ( ),Abandoned ( ) by: l� 44L,at am Shit ts has been installed in aaccordaanj� ,with the prvisio s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to T. application �l��o �l"�9)b dated ���d KI0 til Approved Desi • Flow (gpd) r ) Installer. Pthat Designer: Inspector: r / �nl Date: �The issuance of this permit shall not be construed as a guarant the system will`function as designed. No✓ t/[/Z/ ZJ6 FEE l C®MM®NW �H OF MASSACHUSETTS Board of Health,l kk MA. DISPOSAL SYSTEM[ CONSTRUCTION PERMIT Permission is hereby ranted to; Cons uct( ) air(4 Upgrade( ) Abandon('j) a individual sewage disposal system at ro t � Pa �1 ' t ll a`s`-escribed in the application for Disposal System Construction Permit No. "dated r � Provided: Construction shall be completed tiQn ,reLe years of the date of this p rmit/A� /o�cal conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date Board of Health 7 tl � COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL P OT CTIQISL.— RECANND FAILED INSPECTION OCT 0 2 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 90 Bracken Fern Road Marstons Mills, MA 02648 Owner's Name: Susan Ricketson MAR' r«' Owner's Address: PARCEL • �jo O0 Date of Inspection: September 27, 2003 SOT Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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 Needs Further Evaluation by the Local Approving Authority 4subm) a F ils Ins ctor's Si nature:pe g Date: September 30, 2003 The system inspector shallf 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 90 Bracken Fern Road Marstons Mills. MA Owner: Susan Ricketson Date of Inspection: September 27, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the 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"filtration 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 90 Bracken Fern Road Marston Mills, AM Owner: Susan Ricketson Date of Inspection: September 27. 2003 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 90 Bracken Fern Road Marstons Mills, AM Owner: Susan Ricketson Date of Inspection: September 27, 2003 D. System Failure Criteria applicable to all systems: You must indicate either`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 %day flow ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 90 Bracken Fern Road Marston Mills, MA Owner: Susan Ricketson Date of Inspection: September 27, 2003 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ _ 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? ✓ _ 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 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? ✓ 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: Yes No ✓ 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(3)(b)]. i 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 90 Bracken Fern Road _Marstons Mills, MA Owner: Susan Ricketson Date of Inspection: September 27, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present wes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 2 years ago-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Sep. 23190-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 90 Bracken Fern Road Marstons Mills, MA Owner: Susan Ricketson Date of Inspection: September 27, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 32" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 6" Distance from top of sum to top of outlet tee or bale: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid was even with the outlet invert There did not appear to be any signs of leakage The outlet cover was 8"below grade. GREASE TRAP: None locate on siteplan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 90 Bracken Fern Road Marston Mills, MA Owner: Susan Ricketson Date of Inspection: September 27, 2003 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: izallons Design Flow: Gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 90 Bracken Fern Road Marstons Mills, MA Owner: Susan Ricketson Date of Inspection: September 27, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits;number: 1 - 6'x 6'- 1000 Qal. w/4'stone(per as built card) leaching chambers,number: 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.): There pit was full Liquid was up to inlet pipe There nit appeared to be in hydraulic failure The cover was 8"below,grade CESSPOOLS: None (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 or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 90 Bracken Fern Road Marstons Mills, MA Owner: Susan Ricketson Date of Inspection: September 27, 2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. 3 a ALi B y 6 3 a� 40 6 6 y 3� So 10 Page 1 I of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 90 Bracken Fern Road Marston Mills, MA Owner: Susan Ricketson Date of Inspection: September 27, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 40 +/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain:_topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USJS database-explain: You roust describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 40'+/-to ground water at this site. This report has been prepared and the system inspected and failed of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, ?ither expressed, written or implied, relating to the system, the inspection and/or this report. 11 TOWN OF BARN�STABLE LOC Tl^::r <© �G �1i�yl fat SEWAGE # ?�l�-l�7 /VILLAGE /� /� ASSESSOR'S MAP & LOT04/3,aa.�VZ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY y Uua e�-PVL LEACHING FACILITY: (type) r' (size) >e- NO. OF BEDROOM_ S 3 BUILDER O O R PERMIT DATE: COMPLIANCE DATE: —Z 3'd I 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 A' 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 Our- Y la yN�b - No. _Z&V /r! (� 7 Fee Jy I / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippfication for Mig o aY *pftem Con.5truction 30ermtt Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System 'Individual Components Location Address or Lot No. �ele Owner's Name,Address and Tel No. Assessor's Map/Parcel 'V1119P1fJ 10115 j/JS Installer's Name,Address,and Tel.No. //! Designer's Name,Address and Tel.No. Ber&,�01i ce0,1t 4 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( � Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) I_L° A � ®C�' f A ✓a Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b is B ar f H lth. Signed Date h 91 Application Approved by Date o Application Disapproved for the following reasons Permit No. ZejV — 1 6 -1 Date Issued am 3 Zv cr ——————————————————————————————————————— Gl/3 No. -&v 16 7 Fee + / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pprication for Dizponf *pztem Congtructdon permit Application for a Permit to Construct( )Repair( )'Upgrade( )Abandon( ) El Complete System ©Individual Components Location Address or Lot No. � � t wner's Name,Address and Tel.N'o. l Assessor's Map/Parcel 'r'Q 49 er-5 A,115 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type lof Building: Dwelling No.of Bedrooms 3 Lot Size sq.Xft. Garbage Grinder( �6' Other Type of Building _5 ✓IIP..No.of Persons r A Showers( ) Cafeteria( ) Other Fixtures h, Design Flow gallons per day. Calculated daily flow gallons. Plan Date t Number of sheets Revision Date Title ' Size of Septic Tank ? Type of S.A S. Description of Soil r, ' 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 Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B ar e Hea th. Signed 2 Date lv� Application Approved by Date Application Disapproved for the following reasons Permit No. Z, fo I _ 6 1 Date Issued 3 Zd v l THE COMMONWEALTH OF MASSACHUSETTS 0 / 3 BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CER IFY, that the On-site Se _gge Disposal System Constructed( )Repaired (Upgraded( ) Abandoned,( ) y G?l` �4 % & - at �/'Ct !�l �L� JW. constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7,ey I-16 7 dated 3 ' Za-Of Installer Designer The issuance of this permitf hall not be construed as a guarantee that the syst w'll fun c}�on tesignedd Date Z3 /0 I Inspector� - `- / /,� 0�] ——————————————————————————————————————— No. C�V r�t9 O'—1 —dliv,OdZ Fee ''� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpogai *p5tem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) located,System Y � P and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio must be completed within three years of the date of this a it. ` Date: 1 ; Approved by-, U TOWN OF BARN/STABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & /19 INSTALLER'S NAME&PHONE NO. film SEPTIC TANK CAPACITY G-ei(- LEACHING FACILITY: (type) -71 (size) )4- 1,2 NO. OF BEDROOMS BUILDER OJ�6 R -O��COMPLIAN�CEDATE -Z3 PERMIT DATE.��?-��7 Separation Distance Between the: Maximum Adjusted Groundwater.Table and Bottom of Leaching Facility Feet Private:Water Supply WeH and Leaching Facility (Ifany wells exist on site or within 200 feet of leaching facility) Feet. Edge of Wetland and Leaching Facility(If any wetlands ex ist within 300 feet of leacbin�.facility) Feet Furnished by F. 'W Wj qq 3-7 1,,, r / 9 '� 1 � ✓ � �_ p-�- - - �®,�' ' �'ePlgce ��'�-� 0 � �� �n� 0 � �� ��ac��� ���,� f 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) GCS©f 'iereby certify that the application for disposal works construction permit signed by me dated �/ 1�� , concerning the property located at �� � �!/' �%( . meets all of the following criteria: t//This failed system is connected to a residential dwelling only. There are no commercial or business / �u es associated with the dwelling. Y he soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system here are no private wells within 150 feet of the proposed septic system YThere is no increase in flow and/or change in use proposed There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the maximum /ad'.sted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when icable] e S.A.S.will be located with 250 feet of any vegetated.wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation +the MAX.High G.W.Adjustment. _ DIFFERENCE BETWEEN A and B SIGNED : A DATE: �/�g o [Please Sketch proposed of system on back]. NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert S i CN 1 ' l�j 0orlb o 4 �,COMMONWEALTH OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS �� �14, DEPARTMENT OF ENVIRONMENTAL PROTECTION - T ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor' -; Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION aa Property Address: 90 BRACKEN FERN MARSTONS MILLS, MA 02648 M43 L6-2 Name of Owner SUSAN RICKETSON Address of Owner: 90 BRACKEN FERN MARSTONS MILLS,MA 02648 Date of Inspection: 10/10/00 Name of Inspector: JOHN GRACI l am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes _ Conditionally Passes Needs Further Evaluat' n By the Local Approving Authority Fails Inspector's Signature: / Date: 10111/00 The System Inspector shall sibmit a copy ofithis inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a•shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS s., O�, 'The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.M,. inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEN PUMPING SYSTEM NOW AND EVERY YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE.THE LEACH PIT HAD 6"OF LEACHING LEFT AT THE TIME OF INSPECTION.THE PIT HAD SOME SOLID CARRYOVER, RECOMMEND RAISING COVER TO PIT. revised 9/2/98 Paoe 1 of 11 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 90 BRACKEN FERN MARSTONS MILLS, MA 02648 M43 1-6-2 Name of Owner SUSAN RICKETSON Date of Inspection: 10/10/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion o the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y, N,or ND).Describe basis of determination in all instances. If"not determined",explain why not. n1a The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. t. nla Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced nla The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed i it S G, revised 9/2/98 Paoe 2 of 11 P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 90 BRACKEN FERN MARSTONS MILLS, MA 02648 M43 1-6-2 Name of Owner SUSAN RICKETSON Cate of Inspection: 10/10/00 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD'OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM I.- NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy'is withiri 5O feet of surface water Cesspool or privy is.within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nla (approximation not valid). f 3) OTHER nla s s. I L revised 912198 Paoe 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 90 BRACKEN FERN MARSTONS MILLS, MA 02648 M43 L6-2 Name of Owner SUSAN RICKETSON Date of Inspection: 10/10100 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nla. r X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. g X Any portion of a cesspool or privy is within 50 feet of a private water supply we;l, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. i E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply 1F X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of the Department for further information., '' PT revised 9/2/98 Paae 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 90 BRACKEN FERN MARSTONS MILLS, MA 02648 M43 L6-2 Name of Owner: SUSAN RICKETSON Date of Inspection: 10/10/00 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health. X _ None of the system components have,been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A. X - The facility or dwelling was inspected for signs of sewage back-up. X _ The system does not receive non-sanitary or industrial waste flow. X - The site was inspected for signs of breakout. X _ All system components,excluding the Soil Absorption System,have been located on the site. X _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X - Existing information,For example,Plan at B4O,H, X - Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)) X - The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Pape 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 90 BRACKEN FERN MARSTONS MILLS, MA 02648 M43 L6-2 Name of Owner SUSAN RICKETSON Date of Inspection: 10/10/00 FLOW CONDITIONS RESIDENTIAL; i. Design flow: 110 g.p.d./bedroom 3F°.i Number of bedrooms(design): 3 Number of bedrooms(actual):n/a Total DESIGN flow: 330 gpd Number of current residents:2 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): NO Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) nla ,S GENERAL INFORMATION PUMPING RECORDS and source of information: 6l1/00 BY BORTOLOTTI System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a TYPE OF SYSTEM X 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) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1990 Sewage odors detected when arriving at the site:(yes or no): NO revised 9/2/98 Pape 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 90 BRACKEN FERN MARSTONS MILLS, MA 02648 M43 1-6-2 Name of Owner SUSAN RICKETSON Date of Inspection: 10110/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 42" Material of construction: _ cast iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: n/a Diameter: n/a Comments: (condition of joints,venting,evidence of leakage,etc.) TOWN WATER SEPTIC TANK: X (locate on site plan) Depth below grade: 36" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 5'7"W 4'10"" Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND EVERY ONE YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle nla Date of last pumping: n/a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) nla i � revised 9/2198 Paoe 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 90 BRACKEN FERN MARSTONS MILLS, MA 02648 M43 1-6-2 Name of Owner SUSAN RICKETSON Date of Inspection: 10/10/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) s Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:N/A Alarm in working order: NO Date of previous pumping: nla Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:_ (locate on site plan) ; Depth of liquid level above outlet invert: n/a Comments: (note if level and distribution is equal,1evidence of solids carryover,evidence of leakage into or out of box,etc.) DID NOT EXPOSE-UNDER POOL PUMP CHAMBER: _ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2/98 Paoe 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 90 BRACKEN FERN MARSTONS MILLS, MA 02648 M43 L6-2 Name of Owner SUSAN RICKETSON Date of Inspection: 10/10/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(1)1000 GAL 6'X 6' leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Alternative system: n/a Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD 6"OF LEACHING LEFT AT THE TIME OF THE INSPECTION.THE PIT HAD SOLID CARRYOVER.RECOMMEND RAISING COVER. CESSPOOLS: _ r. (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a L f tt Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a 'c revised 9/2/98 Paae 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 90 BRACKEN FERN MARSTONS MILLS, MA 02648 M43 1-6-2 Name of Owner SUSAN RICKETSON Date of Inspection: 10/10/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at'least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) 6NC 6 peg oq ne A�3a` Ac 36 C 4 �Ba7� gc 50 revised 9/2/98 Paoe 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 90 BRACKEN FERN MARSTONS MILLS, MA 02648 M43 1-6-2 Name of Owner SUSAN RICKETSON Date of Inspection: 10/10/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ 'SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet+ Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers x Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12 FEET revised 9/2/98 Paoe 11 of 11 CERTIFIED SEPTIC SY TEM REPORT RECEIVED CD LOCATION MAY 1995 HEALTH DEPT. 90 BRACKEN FERN RD MWN OF BARNSTABLE MARSTONS MILLS MA 02648 MAP 043 PARCEL 006 002 LOT 38 PREPARED FOR MR. & MRS . CHESTER SLIVINSKI 209 CROSS AVE DOVER, PA 17135 BUYER MS . SUSAN RICKETSON 284 POPPONESSETT RD COTUIT, MA 02635 LEE BY HILLIARD HILLER, JR . 41 MAPLE AVE CENTERVILLE, MA 02601 508-778-1472 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property Owner 's name 1,74 tAr4s crrEsr�,� s��v�vsri Date of Inspection y�a o PART A CHECKLIST Check if the following have .been done: r/ Pumping information was requested of the owner, occupant, and Board of Health. _ None of the system components have been pumped for at least two weeks, --ai;dt � —�ce e peril � Large volumes of water have not been introduced into the system recently or as part of this inspection. e-e_X5 _ram As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. t/ The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site . The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _✓ The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 3 number of bedrooms o number of current residents �o garbage grinder, yes or no yfS laundry connected to system, yes or no ,r/o GJ/s'Sf1E�lQ/�y,�iP �/�LSE.�T seasonal use, yes or no If nonresidential , calculated flow: Water meter readings, if available: /0/�ly 3, G�9C �y93 9y� GEC /yS a IS7- e, //,, /7/ 9, Last date of occupancy GENERAL INFORMATION Pumping records and source of information: System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping : ,5c'Li,05 w/TNiy /a" Type of system 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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: //l5. O�!%� CGa¢iPG✓fl�/GL /S$�/E,�J - 9�Z 22 ram/ Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B - SYSTEM INFORMATION continued SEPTIC TANK: y (locate on site plan) depth below grade: 3',V material of construction: ._concrete metal FRP other(explain) dimensions:_Y9' D,G�<' rF�G' z y- 1/�' 4i< /ao GAL /--> sludge depth $" distance from top of sludge to bottom of outlet tee or baffle 7" scum thickness distance from top of scum to top of outlet tee or baffle 9" distance from bottom of scum to bottom of outlet tee or baffle Comments: (:recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level i-n relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) Al _i fH E DJ.STRIBUTION BOX: !� ( locate on site plan) depth of liquid level above outlet invert Comments : (note if level and distribution is equal , evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER: ( locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, :-ccummendations for maintenance or repairs, etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : Z--' (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number J 417- GfIC �ivST�7GG.E/C leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) �o SiG y of 09C211_� CESSPOOLS (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 (cesspool must be pumped as part of inspection) Comments": . (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) 111'_ V y : (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil , . signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) - 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' FC'e,-/ "I"o I I o I I _ 1 60 DEPTH TO GROUNDWATER `�3 depth to groundwater o` �y method of determination or approximation: SATE P,,,,�? 9 v a o'� /��.t,_✓f, j,r,.y U,� G•4ov���lC ��� .C��Pl1tioT.rl�3GE i`7/�i� " �/35,C/1lid�i IdATE/1 _ ✓s G� Co��� 'C/ice,t/_�-S Ow 3 �cav� C = 9-3 ----�=fir'-�-T�_�oTla�`z"'O�-�� IT ',v�r ly �31� /a' now-v l'-��-i �✓�.�y' i . 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) _ Backup of sewage into facility? J,/ Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is .any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? I✓ within. 100 feet of a surface water supply or tributary to a surface water supply? /l-) within a Zone I of a public well? .t-/ within 50 feet of a bor dering vegetated wetland, or salt marsh (cesspools .and privies only, not the SAS) ? within 50 feet of a private water supply well? .'V' less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION `jy=> l3�'%�C:< f/./ ,�L:.-.�/✓ sC'� �'>�/c's%c�i.� r-7,GGs- 'mil/� N a n e of Inspector Company Name Company Address Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Cher.k one: L I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. o Tnspector' s Signature ;3% ' Date original to system owner Copies to: Buyer. ( i f appl icabl.e) Approving authority I l KEY NUMBER <10321 > NAME <SLIVINSKI, CHESTER > B-C 1 B-C 2 B-C 3 B-C 4 STREET 90 BRACKEN FERN ROAD CITY MARSTONS MILLS ST MA ZIP 02648-1743 REF 1 REF 2 PHONE ( ) - REF 3 REF 4 METER NO. < 9981> DATE READING CONS STREET <BRACKEN FERN RD NO. 90> 12/31/94 512 55 CITY MM H L38 ST LOC 06/30/94 457 68 PHONE ( ) 428-3258 12/31/93 389 --6� 06/30/93 327 y 32 ROUTE NUMBER 06 12/31/92 295 71 SERVICE DATE 08/18/90 06/30/92 224 " 7 46 METER DATE 08/22/90 12/31/91 178 CAPACITY 7 06/30/91 79 �y 41 STYLE T10 SIZE 1 RATE SCHEDULE KEY PIT PLASTIC X NOTE RR LEFT SIDE ADDITIONAL CONS 0 ALTERNATE MIN 0 r TOWN OF BARNSTABLE LOCATIONI-f J? �f�r,;� �t ��,�,J ���� �'�� 9D SEWAGE # yR VILLAGE ,g�{ ,ff ASSESSOR'S MAP & LOTS INSTALLER'S NAME PHONE NO. ! )�rv�l T Devi/ f,'cq0a L SEPTIC TANK CAPACITY �� p LEACHING FACILITY:(type) �l (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: �--f ;�c� O DATE , COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No BAR OF 0. , TOWN NS�TABL t_ , S1 � -LOCATIO'NZ174�� ���!eG.�� "^, tEWAGE # M-YR VILLAGE A il' /�l�f ASSESSOR'S MAP & LOT® w INSTALLER'S NAME & PHONE NO. T At'yc'/�C SEPTIC TANK CAPACITY J®® 0 LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER }A��C SSr�• 71h DATE PERMIT ISSUED: /�°� ��� 00 DATE COMPLIANCE ISSUED: 771 VARIANCE GRANTED: Yes No . ( _ l �f ��r .3 �^I®® � t O .�r��_4 �� �q �� 3� . �'�� . 5--� ,y .. � '..ti THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH t13 1.o.wn.......................OF........&ZWJ a.b<..------............................................ Allp irtt#ion fur. i a �a1 nxk Cann #rnr#'tun ernti# Application is hereby made for a Permit to Construct ( x) or Repair ( ) an Individual Sewage Disposal System at 0..:.... ....... ..........Z.....36........................................................................ _ Location-Address 2 or Lot No. —sl�!h19r1� ....�' S 4- C Ji^?c%fin• `crrl..-.. Owner Address W Installer Address UType of Building Size Lot----13: .4-5.1........Sq. feet U Dwelling—No. of Bedrooms......... ________________Expansion Attic Garbage Grinder VJO) Other—T e of Building No. of persons---------------------------- Showers — Cafeteria Q' Other fixtures ____________________________ W Design Flow...................................S .gallons per person per day. Total daily flow.............................-330....gallons. WSeptic Tank—Liquid capacity.1650-gallons Length._3.t(,a`.... Width.4,-14.'... Diameter................ Depth._5..�-.. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit ...... Diameter.......U5........ Depth below inlet......(G._........ Total leaching area._e? ...sq. ft. Z Other Distribution box (X ) Dosing tank ( ) Percolation Test Results Performed by..... .......................�_._......._......... Date_ /_q/q_..._...._..... Test Pit No. I......�......minutes per inch Depth of Test Pit------cS..._..... Depth to ground wat r- (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground ,��,�N Mq O s......• ........•-----•--•-•••--•••-•..........--••••.....-----•-•-----••-•---..._.._•-----........................ •-•--•---•-....... �� .•g�Ei�ht� Description of Soil....... .::2--j------pp...l a m-.t..S- k) --1.............................................................. Z--------ALLYN------- (xj 3 .. 1 �/�Gcfiux2P?[ . ILSON. i UNature of Repairs or Alterations—Answer when applicable.............................................................. .o ..--•-------••-----•-•................•--•-----•-•----•------•------•-------•--•---••--•-----•-------......-----...------------•-----------------•---••-•••-••-•-•-.. MA Agreement: a The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in ccordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in opera it n a ertificate of Compliance has been issued by the board of he th. Signedx-: .... ............... ......��---�--- Date Application Approved By -------- r ..-� ............................................................. ............ ..... .................. Date Application Disapproved for the following reasons: -- ..... . .......... ... .. ........................................................................................ ------------------------------------------------------------------------------------------------ --- -------------------------------------------------------- ----- ---------------- ----------- ---------------------------------------- Date Permit No- ---------- -- - Cl.-'��- �-�--- --- ----------- - Issued .....:-------------------------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................OF........, !-,.1�-//G......._...................._......_..._.... ...__... Apli iration for 11ispnstt1 Works Tonstrnrtion runfit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: • ? � -.� �✓ / 1•/ i Lam: ._..... ..... ..... ............... ....••-••...... ------••--••-••---•-••-•......••-••_.----- •••. .•-- .... _t Location-Address !r� t or Loot No. ...................3 C.r'LQ:4....`1:.. " 1 .1.......................-•.........--... R.//�G/�... IG/'rT /'tGI.•......................................... ....... ......... ..._..._.............,........ ,-^ Owner / Address ..:........................ ....�.. �.♦^� r1s... 11..er...............----•-............--•---.............--- Installer Address QType of Building '/ Size Lot....e A, .1........Sq. feet U Dwelling—No. of Bedrooms-__,.....1.11t^c .....................Expansion Attic (/�) Garbage Grinder (/�) 4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ----•---------•................................................. W Design Flow...................................�FS gallons per person per day. Totalai`®dflow__._....................._...--.aO.....gallons. WSeptic Tank—Liquid capacity.l O.O.gallons Length.J! ..-�..... Width.-_.•: -:•... Diameter------------ Depth.----_`•----_.. x Disposal Trench—No. .................... Width.................... Total Length__..r_-------e.....I Total leaching area--------------------sq. ft. Seepage Pit No.....C0 �______ Diameter-------J.0-------- Depth below inlet......1........... Total leaching area.. ---sq. ft. Z Other Distribution box (K Dosing tank ( ) Percolation Test Results Performed by...... ___7c�ce..?.t.......................�_................... Date. Z� _ ........... Test Pit No. I......5.._...minutes per inch Depth of Test Pit______ _________ Depth to ground ® . . ..... f3;q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to grou.- r............ STEP HEN a+ ............... .......••............._............: ..........................•........................ .....• •----•-..... . O Description of Soil.......+' .-.:a'...j..Tod.,. ? ?_ .?�l 2 ALSCr ..... ••-•---•-•------------------•-•-----••-•-----...---...-•---•---•••-•-•------•----...---•------.........----•-•-•------•-----•..................................•. U Nature of Repairs or Alterations—Answer when applicable.......................................................... FS Q v ......................................................•......................................................................................r............ •... ••---• Agreement: a o f C- 8'9 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance th the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operati I a rti -�'� ficate of Compliance has been issued by the board of health p Signed - --- - -- ....` �.....:r-�--' '�- ................. - ------------ ----------------- Dace-----'---- Application Approved By ......... --. -. - f_ Dace Application Disapproved for the following reasons: ................................................................................................ .................................. ...................................... .... .. .•-- . .....----- ------ ---------------------------------------- ............. .-.-.........-..------------------------.....---------'----....-......... � Dace PermitNo. -------- _ ...� . ----------------------- Issued ------------- ................---------------- ---------- Dare t �1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................... OF ...................................................3 ` Cer#ifira e d (141umpXianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ''' ) or Repaired ( ) by--------------C '---------- ----------.................................--------------------------------------------------------------------------------------- • - Imraller at •&rr--� = er -- - 2.. ----- ....................... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ......v C'---*..6.�.. ......... dated ----------------------------------------------- THE ISSUANCE OF THIS CERTIFICATE $HAIL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIFU ON SATaACT ORY.� � 7'0 DATE...................................... ................................................... ... Inspector.L................... . _...."-.................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No......d ....... .._ FEE... ....... Disposal Workii Tnnstr MOM -. � , Permission is hereby granted....._....: . _.�.'�,.. .:....___.. . ...... to Construct ( or Re air ( ) a ndavidual Sewage Disposal stem Street as shown on the application for Disposal Works Construction Permit No.F�:l4_17.. Dated.......................................... Q ............................. .:.._, .b1.--------------------------.....--------...------•-•--._ DATE. /Q _-q0 Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS j f^i 1'ii s iN� 47 ,V/L I , ' �T31406 8 / MMoX 3' 330 6.`/?i.�•: L Ywit- S%DE t�/tlLL Q,P /7S.;S',A. I tv ,77 2 4142 t OF 19 OF; $ STEPHEN yG �0� 6i0CF1ARD ix ALLYN ? ��A�s �• � ® �I � � i6` �'y i S • WILSON ' IBP�MR .��No.30216,Q � No.24045. I � y �l i I1 ,� Ins ,a�-� �•�� A/ 2 .�-Esrsra�.E /?-7oyZ f3�Z`�S$ '.4-LL UNSU/1�i3� MgTE121gLT� P i3,sc,• 4o 3Ibe /u�E c 1.c/4 Cof3/ -�i�/G/�/&Ei2 �2Etit A�✓EG �� be I o w racle 3 `7 ♦I N c�Ay 30 3 L /` BoX /Vil � fw. 0 g �. /.vti /.vr/ �J `,VO r iv�TG •• % 0b. � ] G'.E.2T/F/EO PG OT pL4�V 4 _� SsylO . , �---c" ,E'"' ,: . L oGQT/o.Y M�STb,�✓S �I/[z,�5 Ga� 3S 4/0 6a�¢T� No W4� )�� / CE2T/F}� Tf/.4T 7,-V FotJ�/o ,yE,c�Eov c0�lP�•Y�S W�rx/T,s��,Si��,ciit/E � Baxr�,e �',c/%E /.vc, .4�t/�.fETl�AGf' .e�Ql�/,��',y�Nr.S d� T�`►'� �2.E6/ST�.P�=1�,lf1NO.SU,er/��Q�S ToYfv aFigq,2n/Sr.�BCE �1N1� /S iVOT ,-- G�ST�.GYfLGc' a- �-/Qrr, ' V J4.�.Lfc.4.t�T-• cf'�ES � r'f� - , I i ; 1 SECTION A -A Nrxnra>rrla�uty ; *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. VENT PIPE (O Least 24 Inches toll ALL Ou1LET PIPES FROM THE 10' min. from PROFILE VIEW OF ADDITION TO LEACHING SYSTEM DISIRIBUTK711 Sox sNAl1 eE Schedule PVC w Charcod Odor Filter ae Ex4sefip Foundation house t0 septic tank / : SET LEVEL FOR AT LEAST 2 Fr... 12' CONCRETE COVER �`seY TOP Or FOUNDATION = ELE'V. 100.00 (Assumed) Septsn tank coven must 6s _ grade (Rods ow Septic Tank- 97.00 Grade over D-Box- 96.00 over SAS - 96 00 3 of 1/8" -1/2" Washed Peoeton 3-5'OUTLET ♦ ' ! ,, �' �' 3/4' to 1/2 "_Washed Crushed Stone KNocxoul5 r aoA�a II n -- 5.5' OUTLET j 12' MET Ad A m"aF yaM pfi �, S 0.02 - 3 HOLE H-10 - - 4'PVC(CAPPED)INSPECTION FORT To BE s. q 3' Ma irnum Cover T Load -Ebv. -93.08 INSTALLED AND M BE WTHNN C OF GRADE - o [MST.Box w / 10, EXIST. 5-0.01 or Greotr Top of SAS-Ek m -92.50 rem lal 'EXM, PIPE ►= 1,000 GAL. S- 0.01' Per foot or greater A 4" - SCH. 40 T 1.)S' FROM EX MST. TION w � SEPTIC TANK 40• Etfective Depth to H-10 PLAN SECTION CROSS-SECTION -` I + ono ( 2 Units a 6.25' � 44.00' CONCRETE FULL FOUNOA b N d D.83 10 inches) I s N S s• 4 3" 3 HOLE H-10 DISTRIBUTION BOX 6 in.of 3 4'-1 1 N SYSTEM PROFILE / /2' o �, �, compacted"taro _v o rn 0' NOT TO SCALE �o n Not to Scale - c u e i2eu1 NNr,Nry3r070e1Tectrbpts i 4 4• N Effective Length c c a 2' c SOIL ABSORPTION SYSTEM (SAS) GENERAL NOTES 6 M.of 3/4"-1 1/2' 'a Effective Vldih ,. - compocted stone INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GE❑RGE ❑'BRIEN NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6' BELOW GRADE v to 1. Contractor i3 responsible for DlgsQfe notification Bottom of Teel Hale I Bev.-MOO (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes. -- ' Obs. Groundwater - Test Hole 1 Elev.= NONE OBSERVED NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18' /EFFECTIVE HEIGHT IS 10' 2. The septic ptank an distribution box shall be set level on 6 of 3/4 --1 '1/2" stone. 3. Backfill should be clean sand or-gravel with no stones over 3 in size. 4. This system is subject to inspection during installation OPEN SPACE by Carmen E. Shay - Environmental Services, Inc. 5. The contractor shall install.this system in accordance PERCOLATION '' C CT with Title V of the Massachusetts state code, the approved plan LJ PL and Local Regulations. Date of Percolation Test APRIL 14, 2004 16.00' 6. If, during installation the contractor encounters any Test Performed By. CARMEN E. SHAY, R.S., C.S.E. soil conditions or site conditions that are different Results Witnessed By. WAIVER (per BARNSTABLE B.O.H.) from those shown on the soil log or i our design f Excavated By. SHAY ENVIRONMENTAL SERVICES, INC. installation must .halt & immediate notification be Percolation Rate: Less Than <2 MPI Vt - Environmental Services, Inc. PVC mode to Carmen E. Shay Vent Pipe 7. No vehicle or heavy machinery shall drive over the septic system unless noted as H-20 septic components. 8. Install Tuf-Tite gas baffles' or equals on all outlet tee ends. Test Hole 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. No. 1 " 10. All solid piping, tees & fittings shall be 4 diameter DEPTH SOILS ELEV. 1 1 2 Schedule 40 NSF PVC pipes with water tight joints. - O 96.00 , '�� _ »_ 11. Municipal Water is Connected to ALL OF The Residence and Abutting Sa ndy g Properties Within 150 Feet.` 10 1tt 3/2 ` ti-- e L 96 0'-6' A, s5so \ THE PROPERTY LINES ARE,APPROXIMATE AND COMPILED FROM THE SURVEY PLAN GENERATED BY Loamy Wf YANKEE SURVEY OF MARSTONS MILLS, MA Sand i; ENTITLED "COUNTRY SIDE, MARSTONS MILLS, MA 10 YR 5/6 :h • , DATED JULY 30, 1987, PLAN BOOK 448 PAGE 84 6'- Be 93.00 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN sae �\ t 01 IT SHOULD BE USED FOR NO PURPOSE OTHER THAN Z5 Y 0/e THE SEPTIC SYSTEM INSTALLATION. 91.85 LOT 39 `° yt '- # Co TEST HOLE #10 ' � EXISTING LEACH PIT TO BE PUMPED OUT AND s� 1 � OPEN SPACE FILLED IN PLACE OR REMOVED TO-FACILITATE INSTALLATION OF NEW SAS. z 7/4 50'- 132 .00 /-,• NOTE: ANY STRIPPED OUT 'SOIL CONTAINING LEACHATE ?� FROM THE EXISTING LEACH PIT TO BE DISPOSED OF AS PER BOARD OF HEALTH SPECIFICATIONS. _ ___ - -- _ --- _ - __ �O�j• � \\ 0 NO SANDS ARE PRESENT-,w-_I I HLN _200' �\ 1• NCH MARK `� Failed-•/ i ��\ ASSESSORS MAP 43, PARCEL 006-002 PROJECT BE NCH Leach Pit .' \ Perc art TOP OF FOUNDATION o � ExISi• 1000 ga. LEGEND Depth to Pere 50" to 68" ELEV. = 100.00 (Assumed) �� f Septic sank Perc Rate= Less Than 2 MPI ` 31.5' Observed ESHWTO - NONE OBS.- 132" Assumed �� \�� \ 1 44X1 DENOTES PROPOSED ADJUSTED H2O Elev. = NONE OBS. - 132" Assumed `� \ SPOT GRADE DECK X 104.46 DENOTES EXISTING SPOT GRADE �\\ HOUSE #90 PL DECK PROPERTY LINE r- _\ _ EXISTING 96P PROPOSED CONTOUR 4 BEDROOM HOUSE �� - - - - - -97 EXISTING CONTOUR ►� m _ �\ ® DEEP TEST HOLE & 2-16' DIAM. ACCESS MANHOLES i rl \�� ' �� PERCOLATION TEST LOCATION ----g .. ASPHALT \�•� < �� .---. 6 FOOT STOCKADE FENCE :;j�= F.`•-4: -:':_-;r•-. :�:. _ �j I DRIVEWAY LOT #38 � T ► ► .0 12,691 Square Feet OuTl ET or, P LOT P LAN 00 V V THE ACCESS COVERS FOR THE SEPTIC TANK. DISTRIBUTION Box AND LEACHING COMPONENT _ ,I ____ I L ` 0 F PROPOSED SEPTIC SYSTEM UPGRADE r- -c -� - r- •z ,� SE T DEEPER THAN 6 NNCHES BELOW FN4SFIED ---------.�...s,� . R ___10 SfY.0 b •'��'°''' r �• _: �:'=> GRADE SHALL BE RAISED TO "THIN 6'OF �_- STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE. 98.- PREPARED FOR PLAN VIEW INSTALL TUF_T17E GAS BAFFLES OR EOUALS MS. S U S A N RICKETS O N f-3-24" REMOVABLE COVERS� BRA G'KEN E'ER lAT R OA D AT J -• ..- _ - • • .r.,.. #90 BRACKEN FERN ROAD min. 3• mina FOOT RIG WAY) MARSTONS N S MILLS, MA 8' n. ?• nlet to outlet ".rat,. l ,3'' MET INLET mi � � r_� M - OUTLET '. '� �too (� 1 ' s -7- s' -r Design Calculatio Q Xr3 r / tH OF MA PREPARED BY: bo o.u.w. _ =. tla,rw depth _: Number of Bedrooms 3..E uivalent to 330 Gal./D 30 Gal./Day Min. per+ 12 Garbage Grinder. No r 1 N V e /�/�.�L�L ►' E. S l A Y .- Leaching Capacity Proposed: 440 Gal./Doy'Mini j lr� ;� i tic Se - USE NEW 1,500 GAL. Se 1•� �- z -_ -- p Tank 2 x 440 Gal. ay Septic Tank. 0 20 40 50 S 'ENVIRONAfENTAL SERVICES, INC. g_G• 4 -10' ' �, SOIL ABSORPTION AREA: Using percolo CROSS SECTION END---SECTION Bottom Area:. 0.74 ga1/sq. ft. x •50o sq. ft. _ 37o gallons „� P.O. BOAC 627 Sidewall`Area: 0.74 al. s ft. x 99.6 s . ft. = 73.7 ollons ti� g / q- q g a►s=,~4 EAST- FALMOUTH, MA 02536 Providing: - 443.70 gallons SgNlTAR1A 1000 'GALLON SEPTIC TANK SCALE 1 "=20' TEL/FAX 508-548-0796 TYPICAL Use: (7) INFILTRATOR HIGH CAPACITY H-2i) UNITS, HAVIrIG A 0.83' (10INCHES) EFFECTIVE DEPTH, NOT To SCALE SCALE: 1"=20' DRAWN BY: CES DATE: APRlL 23,' 2004 TO BE USED WITH 4.0 OF WASHED STONE ON THE SIDES, ANDS OF WASHED STONE ON THE ENDS. NO STONE UNDER: , PROJECT#SD562 FILENAME: SD562PP.DWG SHEET 1 OF 1 i