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HomeMy WebLinkAbout0178 CAMELBACK ROAD - Health 1718Camelback Road Marstons Mills A= 047-148 ncue- I"1 DD 04-02-2014 12:00 BARNSTABLE LAND COURT REGISTRY DEED RESTRICTION WHEREAS, rc��nlcF l�« as �..� ��- O V\d 1of (owkees name) MA (address) is the owner of l 7-8 CcxvY.=-A located (address) at IrYla.�S}o.ns YY� \\S MA (hereinafter referred to as and being shown on a plan entitled "Subdivision of Land in MA, Property of et al, duly recorded in Barnstable County Registry of Deeds in Plan Book- , Page Or on Land Court Plan Number 3`� WHEREAS, �:ranJtA oad llcd&owner of said lot has (owner's me) agreed with the Town of Barnstable Board of Health to a restriction as to the number of.bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of.Sanitary Sewage; WHEREAS,the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal.of Sanitary Sewage, and authorzin g '.. the issuance of a building permit for the construction of a single family home on this property, is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the :, `. 2 • Barnstable County Registry of Deeds by recording this document, dw& D 9. *+ NOW, THEREFORE, te-tp-vx does ereby place the owners name) following restriction on his above-referenced land in accordance with his I agreement with the Town of Barnstable Board of Health which restriction shall �+ run with the land and be binding upon all successors in title: 1. t��3 Ca well oL�� 1Zd �s v�s 'M�kV a have constructed (address) upon the lot a house containing no more than-F4\rce (3 ) bedrooms. t-rav►1% Ack \eev�Qk\e_ ad1A_- agrees that this shall be permanent deed ,-I Nrc4jiI04 (owner's name) restriction affecting located on MA, and being shown on the plan recorded in Plan Book , Paged Or on Land Court Plan L.&*ya , pta,� 3�'1 t a-$ For title of see the following deed: Book , Page Or Land Court Certificate of Title Number ���_.; � tg,)83q Executed.as a sealed instrument Z*day of �` v Ow is ignature ' Owner's signature D Owner's signature 1 COMMONWEALTH OF MASSACHUSETTS 3 . 31 MCI ss 20 l 4 Then personally appeared the above-named 4 " NI F,_) (L ANb CL NI U nu IL known to me to be the person who executed the foregoing instrument and acknowledged the same to be ✓ free a nr d r dee , efore me, f , BARNSTABLE COUryry��yy�� Notary REGISTRY OF DEEUr5�bl1 A TRUE COPY,ATTEST My Commission expires: JOHN F.MEADE REGI TEA`,, ANGELA RAE PHI;I.BROOK (date) Notary Public COMMONWEALTH OF MASSACHUSETTS �. My Commission Expires deedr March 19, 2015 BARNSTABLE REGISTRY OF DEEDS af" of Rs TO ti do rn, SHED LOT 49 O26,497 SFf EXISTING S.A.S. ® EXIST. DWELL. Q 0 20.0' PROPOSED .ADDITION Q' `O ON SONO TUBES. (DECK IN AREA TO BE REMOVED) `1 Q Q PLOT PLAN ( SHOWING PROPOSED ADDITION ) DCE #14=067 PREPARED EXCLUSIVELY FOR THE PURPOSE OF OBTAINING A BUILDING PERMIT, NOT FOR ANY OTHER USE 178 CAMELBACK ROAD LOCATION! MARSTONS MILLS, MASS. PREPARED FOR: SCALE : 1 " = 40' DATE : MARCH 31 , 2014 FRANK NIEJADLIK, JR. REFERENCE ASSESS. MAP PCL. 148 ��bOf+MgS I HEREBY CERTIFY THAT THE STRUCTURE SHOWN ON THIS PLAN IS LOCATED ON THE 02 DANIEL ys GROUND AS SHOWN HEREON. o A. OJALA off 508-362-4541 ,a No.40980 v ' fax 508 362-9880 �OPFS5.10y� p$�� down cape en gin e erin g, inc. Cl VIL ENGINEERS LAND SURVEYORS 939 Main Street — YARMOUTHPORT, MASS DATE REG. LAND SURVEYOR TOWN OF BARNSTABLE LOCATION f?,Z' _SEWAGE# —)40 1 — 1 VILLAGE I`�� ('1-11 ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. "7%1—1�427 SEPTIC TANK CAPACITY W/o 0 � o LEACHING FACILITY:(type) 'ei Asize) �. .r. 0.2o �X NO.OF BEDROOMS it:i OWNER PERMIT DATE: ems-�• �.�— COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) N .',-- Feet FURNISHED 13Y P 164 y,7 6 67( " No. r' ! �V f Fee THE COMMONWEALTH-OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOVIli": OF.BARNSTABLE, MASSACHUSETTS ftphLation for Mispo9al *pstpm Construction 3permit Application for a Permit to Construct( ) Repair/ Upgrade( ) Abandon( ) ❑Complete System [.,Individual Components Location Address or Lot No. )-7'8 &mel6a4k 11W Owner's Name,Address,and Tel.No. 15�9 7 Assessor'sMap/Parcel L/7 jq mfsfs o zs- �16 �U ")9 'Gctyytc,2�,� fl o Installer's N � e ddr9ss,an"d Tel.No. � '`7`�i�9'391 I)Asigner' Name,Address,a%d Tel.No. ;(jor'`fDC.7e �5a'► �r�>��s'fry�2• n ������� /� Type of Building: ,Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3(j gpd Design flow provided 3(41 gpd Plan Dated�1, )$,"a0)1 Number of sheets/ �� Revision Date Title- j aL�� AA-1 6J 1-13 Size of Septic Tank 1;9 Type of S.A.S. y -&9e; Description of Soil6u-affa- 49 Nature of Repairs or Alterations(Answer when applicable) QQn�e�`� `lo r ln". r io as w )( .36.it L x --,a ;D i gamekita Rea- A �►.�. XA?rjjcllaI �S Date last'inspected: Agreement: The undersigned agrees to ensure the construction and m ' ce of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environm Code d not to place the system in operation until a Certificate of Compliance has been issued by-this Board of Healt Signed Date Application Approved by Date 3 Application Disapproved by Date for the following reasons Permit No. � �� Date Issued I- ---------------- -------------------- - - ----- -- ----------------------------------------------------- ------------------- fI 0s No. C/ r' / �` �. Fee ::THE''COMMONWEALTH-4F-MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOW!R-~LFF�BARNSTABLE, MASSACHUSETTS Yes 01pplication for Misposal *pstetn Construction i3ermit r , Application for a Permit to Construct( ) Repair(4"Upgrade( ) Abandon( ) El Complete System []Individual Components Location Address or Lot No. (r}� n1R� ,to Owner's Name,Address,and Tel.No. 76/-;4/$- IM�i rSfvvtS 1°Vl���S ���-i�'rc(v�r�. ���Cce.✓tutC�.rc✓t.1i Assessor's Map/Parcel y7 /�($ nva1`/1 .4. o�4 ya Installer's N e Addr ss7 and Tel.No. '�'?1"� 19 Designer' Name Address,arld Tel.No. /, v fvlCix�ia= �/5?r �/ry cr rs oAlAt Type of Building: Dwelling• No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(mina required) 3-3(> gpd Design flow provided 30 gpd Plan Date ( , 09,'a0I day- Number of sheets � Revision Date Title j r/�¢ 5:S► � RIM 10 1'15s �tt k1l?P- lx2de /V /slon S vy I>>S r,• Size of Septic Tank e )':S4 (Xjd � Type of S.A.S. q -liao .3cs� i�t k�,rS s}r,h �t WY Description of Soil ¢ , ;) 1 r,4 y Nature of Repairs or Alterations(Answer when applicable) r:o�t sc 14.in 111�7�'l/1FCJ1..� f r' 1o•1S U.� �[ �•�l rL �l � ;c..-' ) =eGic:lt[.:+e �Pl.� S�,c.vlrx.ei��G�Ic� �1 Sr'�7c.x f 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 Environmen al Code d not to place the system in operation until a Certific to e`of—' Compliance has been issued by-this Board of Healt . Signed Date Application Approved by ✓ Date 3 Application Disapproved by t Date for the following reasons p' )f Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(.1 Upgraded( ) Abandoned( )by &r--tp/c,&e- ,, -. r75,LruGfi;,' 4- ,4nc- at 17$ Ca mewA 'M A(S� c ns M;J I5 has been constructed in accordance with the provisions of Ti t(he for(Disposal System Construction Permit No! '' 4~/" dated Installer oA ff[ 1 Designer k60n ,R(j•(I Ln to r;Q -at-,C. #bedrooms 3 Approved design flow gpd The issuance of this permit shall n f be constt'ued as a guarantee that the system wilYfunction desig d. Date � /V Inspector - - - -------- No. _ e - - F - - (�' off e THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal bpstem Construction permit Permission is hereby granted to Construct ) Repair(� Upgrade( ) ` Abandon( ) System located at r72 0 gip ' , Kra, Mn S and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must b 'comp)Feted within three years of the date of this perrmit.' t 1 Date • ` � Approved by,-,,_ { III MAY-14-2012 08:27 From:BORTOLOTTI CONST 5084289399 To:15087906504 P.1/1 FROM :down capc engineering ink FAX NO. :1SM3629880 May, 14 2012 Oe:19AM Pi i ..' tau (I,l Bwei �Ftg k,- ,Wu -v Services pboYfllAlD?. dFc?IPeti',7yaueett,r �� >uaH}•��neu,�a ��nu i 1'kt)uab+�1VII� Pmnr,t' ametor ?.fi0'Wajin Strcet,Upinni®yMA U ra: �t18•lf2 A6fd t'n;:: 5;18-7911 63A4 Y�se�P: ;1�t 1 Scwa�e Fe���ari .W7d►��=L.z 1��ea®mr,"aa PvIlolPamd.�k ! IB $DaP.W� t�t•s '"'if�+.,.� � f�.. - ,..����� ��aj,�lt��: fin,-t��; L.�xa..� ��.�..,-. Ll �ait�rPr�ta: �y Yyic�a:.__,___^_^-���, ......� "'' "►d�r�s; ti .q Ir1,, 1�� wu i3oned itpes[mit It)iuFl All it f ate) (irWgller; Sc�iiu Ry�catxt n P t�� � .('G��.� �(.•r� _i�u; tl 4�a do iga draw.i aY ( cgs} Y""I ceylily tlwz tho,soptip above wuW WMi llt:d MhNU'Ulil) Y 1101:9yidjng tc+ rb.e desig l wllitl awy )z ularia Min n k1pT avved chwi3t^.3 Alt on Intprdl�o Incudou Of"tisc: dlst'ibu�m box atcl/or,�eX'riir.;t9tlh, L cctrtiry tit tha avpLC yt= it.m-enced nbuvc ww ,uotOlad W lh .LL70joT. alLWAA (ir. Fg(-fltr;c tbau 10, 1fjtertil r tor,µGon of fhr 30 ol-LIUy YcAirltl eelc=60tt Or any C'OL:t.n"Ut nrtIle Scpti.c sy'Stcrn)but in eMordttuct,tiv►"�� tiluin& 1_,acftl Raon(F.io=. PlAn Tev19if►o oT Ger+a,i•t:r �� 1� 1)y dmimrT UP fnllmv �IM1 OF A4q BANISL L OJA•{ xtstrill yr' Alr�aturn.) NI W�502 (L�c Z�X�6r's£�i.t,namF¢1.) �ra T(mix 17e:r�ign� nm N�rc; rrt—jo rum, (10MIMtrot �ML 1+lf b:'�, . 4 i.Qk.j-t:u, AoTC,LMtq Ft2HK A, , w (A MI � �t�� vrrcr) .� r� A•fif,W:pv z,la:A :�►r,�-rAZ .A�aa�ILI Pi•7Tnn�th/R�'fi�J17�!pt�ICi C'n+Ff•wtion,rem+3 2b q�dn�s I � I, '� l � ' I j ! • 111 � iT l it a� Town of rustable, �itt�rya Departmo'It of Regulatory ,Services f�- BAMUTABLE, ° Public Health DivisA®Al Dime 200 Nlain Street,Hyanuis MA 02601 c 7 � `§ pate Scheduled h lt�— Tinie )ELe Pdl. `D a" Soil Suitability A sse snie>fi> o>rr° S L4 , .�e Disposal Pcrronned Oy: Witnessed By.: LOCATION & G ENE RAIL J[Nl[ORIWA7 ION Location Address //`7 f camelba I� �g Owner's Name r/uza V. t4arz 77 n, M/ r`f Address `J ` Assessor's Map/Parcel: '�; 1� engineer's Naiuc I w-, NEW CONSTRUCI'lOrd REPAIR / TeIcphoneIt (� �d 3� :_.and Use, Slopes(°/n) is"L Surface Stones s ' Distance's Fran: Open'Water Body ''�� It Possible WEL.Area Il Drinking Water Well F[ t Drainage Way ~ Ft Property Line ' G Ft Other �' rt a SKETCH., (Street name,dimensions of lot,exact locations o stE Boles Bc per tests, locale svetlands'In pro)cinuly to Boles) J � \ ` `0 �a Parent material(geologic) �ttvAS� Depth LU Bedrock t Depth to Groundwater: Standing Water in Hole: N/\ Weeplhg fl'um Pit ptloe L'stimated Seasonal High Groundwater ]DE,TEl[.iMNA7C]LON l[t'OR SEASO.NAIL HIGH WA.7 E1,1[k TABLE, E, Method Used: Depth Observed standing in obs.hole: In, Depth to 5Q11 nluWn; Depth to weeping From side of obs.hole: Itl, CIYI)ulldWutar Adf uslhtent„_����ft'. Index Well✓# Rcading Date: Index Well levnl _ Adi,1NCtAr mm_ AtJ,C7npundwner Uvt l JC'JC+RCO L,ATI.ON 'II,'EST [Dr;'ptli bservation c fP Tints!ll 9"of Pcrc J� TIIriG 4t G" Star(?re-soak Time @ V y _ Time(9`4') EndFrc-soak Ratc Min./Incli -2 ' Site Suitability Assessmunt: Site Passed Sits-Failed: Additional Testing Necded(Y/N) Origh al: Public Fledth Division Observation Host;Data To Be Completed on Flack--� -- *It percolation test is to be conducted vvltiAn 100' of vveilland, you must first UoUry the, Barnstable Conservatioll T)tvis1011 it least one (1) week prior to begian ug. QAS GPT1C\PI:RCPORM.DOC -n)EI EP-ORSR_RI7_AT ON]F1IOL' f ]LOG Depth Cron, Sell Iforizo" SoilTexture Hole #Surface(in.) Soil Color (USDA). Soil• Other (Munsell) Mottling (Structure,Stones; Boulders. Con iste c °a' ra et 140 D]EICp OER-�gV'�7I'1[Oiv ROLE, ]LOG Soil Horizon Depth from Surface(in.) Soil Texture SO1I Color Soil(USDA) —�"'- -� (Mlmse!I) V°ttlin Other g (Structure,Stones, Boulders. (,(M t�, , — Sig e c %0 Rvel /el YA? i Depth from DEEP O-E v]ERVA7[ION FIOLE ]LOG Soil Horizon ] ole # Surface(in.} Soil Tcxture ol°r Soil C -----_ (USDA) Soil ) (Munsgll) Other Mottling (,!structure,Stones,Doulderg. C 90sistaneV 4a Orwell Depth From RVf�TIOjO T IIOL�E LOG. �H ole # Soil Horizon S Soil Texture Surface(in.) Sail Color 5011 (USDA) .• (Munsell) Moltlln Other g (Structure,Slonv.7,, Boulders, .• Conslstancy �,6 O�a��1� ---- L1190 1l Insurance Rate Majj: Above Soo yearflood boundary No yes "(Rhin 500 year boundnry No Yes ' %Vithin 100year nood boundary No� Yes De 1hoaf1Lytulrej➢ly/ Occuarring7poyiollsMaterial V Does 'It Icasf four feet of naturally occurring pervious M�teflal exist in all areas,nhserved tl±l'aughcut the . a;Pa s—c.a a�._.r_.. prcpo �„c soil absorptio-1**1 system? f At not, svhat is the depth of naturally occurring pervious marofial� Ce�'�ll�g�at�lt]f➢ . A cert�_— i;fy that on Qe-I_ (date)I nave passed the soil evaluator examination approved by the Department ofEnvaronmental pl,otection and that the above 9171a1Y2is was performed by me consistent with Glae megtaired training, expertise and experience described in CIO CI\dR 15.017, Signature s c Q:\SEI.PTICTERcrCRM.DOC i r Commonwealth of Massachusetts fo Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for-Voluntary Assessments 178 Camelback Road Property Address Slusarz Owner Owner's Name information is Marstons Mills MA 02648 March 5, 2012 required for State Zip Code -Date of Inspection every page. Cityrrown 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: A. General Information When filling out I forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services-Co. Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 renmr City/Town State Zip Code 508-428-1779 S1 12855. Telephone Number License,Number _ f O B. Certification `' v C� N ,y 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. T,�e inspection was performed based on my training and experience in the proper function and maintenance of l t sewage disposal systems. I am a DEP approved system inspector pursuant to Sectior>,$5.34f § Title 5(310 CMR 15.000). The system: i 5 rn ❑ Passes ❑ Conditionally Passes ® Fails i ❑ Needs Further Evaluation by the Local Approving Authority q March 5, 2012 Job# 12-36 Zlllrh!spector4St tur 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 t5ins•11110 r /�� Zell Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 178 Camelback Road Property Address Slusarz Owner Owner's Name information is Marstons Mills MA 02648 March 5, 2012 required for every page. City/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: ❑ 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. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System Will pass inspection if`he existing tank.i 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): 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 178 Camelback Road — Property Address Slusarz Owner Owner's Name information is Marstons Mills MA 02648 March 5, 2012 required for State Zip Code Date of Inspection every page. Cityrrown B. Certification (cont.) 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 t5ins•11110 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 178 Camelback Road Property Address Slusarz Owner Owner's Name information is required for Marstons Mills MA 02648 March 5, 2012 every 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 p;pm, provided that no other failure criteria are triggered. A copy of the analysis must 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than _day flow l5ins•11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Camelback Road Property Address Slusarz Owner Owner's Name information is Marstons Mills MA 02648 March 5, 2012 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® 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- 10,000gpd. ® ❑ 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-11/10 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 178 Camelback Road Property Address Slusarz — Owner Owner's Name information is Marstons Mills MA 02648 March 5, 2012 required for every page. Cityrrown 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 ® ❑ 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: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 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): 330 t5ins•11110 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 M 178 Camelback Road Property Address Slusarz Owner Owner's Name information is Marstons Mills MA 02648 March 5, 2012 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: i 2 I Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Currently Last date of occupancy: Occupied. 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: 15ins•11/10 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 w 178 Camelback Road Property Address Slusarz Owner Owner's Name information is Marstons Mills MA 02648 March 5, 2012 required for every 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: Tank pumped Sept 2011 Was system pumped as part of the inspection? ❑ Yes ® 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) 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Camelback Road _ Property Address Slusarz Owner Owner's Name information is required for Marstons Mills MA 02648 March 5, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance issued 12/1/86 _ Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer :locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on ccndition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5' long x 5.2'wide - 1000 gal _ 1" Sludge depth: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 178 Camelback Road Property Address Slusarz Owner Owner's Name information is Marstons Mills MA 02648 March 5, 2012 required for every 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 29 Scum thickness Trace 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 14" 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.): Liquid level was at bottom of outlet invert, baffles intact. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ 178 Camelback Road' Property Address SlusarZ Owner Owner's Name information is required for Marstons Mills MA 02648 March 5, 2012 - every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 ❑ 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 178 Camelback Road Property Address Slusarz Owner Owner's Name information is required for Marstons Mills MA 02648 March 5, 2012 every page. Citylrown 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 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.): 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 178 Camelback Road Property Address Slusarz Owner Owner's Name information is required for Marstons Mills MA 02648 March 5, 2012 every page. CityRbwn State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: One 6x6 pit. ❑ leaching chambers number: i ❑ 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.): Liquid level was 4-5" below inlet pipe with staining to top of pit, pit is in hydraulic failure. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Camelback Road Property Address Slusarz Owner Owner's Name information is required for Marstons Mills MA 02648 March 5, 2012 every 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 Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 178 Camelback Road Property Address Slusarz Owner Owner's Name information is required for Marstons Mills MA 02648 March 5, 2012 ---- --- - ---- every page. Cityfrown 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: ® hand-sketch in the area below ❑ drawing attached separately n J 7 Vriaa 33 r .>. 26 4 \/\J♦/♦/♦/♦/\'\/\/\/\/\r\/\/\/\/\J\/\J\r\/\/\/ Water Service Camelback Road I . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Camelback Road — Property Address Slusarz — Owner Owner's Name information is Marstons Mills MA 02648 March 5, 2012 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water Check cellar ® Shallow wells N/A Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. (Sins•11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 178 Camelback Road — Property Address SlusarZ Owner Owner's Name information is Marstons Mills MA 02648 March 5, 2012 required for every page. City/Town 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 WN O -BARNSTABLE LOCATION�d �1°% rk!/ r �ISEWAGE # VIL•LAGE� ASSESSOR'S MAP & LOTi d'i% `W INSTALLER'S NAME & PHONE NO. 5 O 7�di,�V �I�r' - � SEPTIC TANK CAPACITY �It LEACHING FACILITY:(type) (size) /Q 60 Kfa ,NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 51 • ,7�� DATE PERMIT ISSUED: Am/ C-2 DATE . COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No !✓ �� p� �� ,� .A/ � � . h �� � � � �.��� �� �� ��� �� c t I THE COMMONWEALTH OF MASSACHUSETTS BOARD ®F HEA H C ....OF.-.- j� . ........ ........ Appiiratiun for Ui ip aii al Worka Tonstratrtiun Urrutit Application is hereby made for a Permit to Construct 41 or Repair ( ) an Individual Sewage Disposal System at• i (� �p Loc io -Add ess Q Lot o. ...49- �6+•..s�.. ^- ,`�P -.._mil/ 14 .......... �Gl. .....................•. Owner Add ess ----... ..- Installer Address U Type of Building Size Lot..X /.6j..Sq. feet �-, Dwelling—No. of Bedrooms.........., •...........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ,�lyrf No. of persons........6--------------- Showers ) — Cafeteria ( ) Other fixtures -------------- --------- --------- ---- ---------- ------- W Q� T} Design Flow.•......•..........................gallons er person e}^da�. Total dilly ...................._.... 16 WSeptic Tank—Liquid capacity 9OMgallons Length__d". ._.. Width././O... Diameter________________ Depth... f�--- xDisposal Trench—No. .................... Width--..._.............. Total`Length.................... Total leaching area_____.}..._......--.sq. ft. Seepage Pit No.--_-_____/-------- Diameter......... Depth below inlet......... Total leaching ar;a4_ Z'_-sq. ft. Z Other Distribution box (/) Dosing tank ( ) p•� / aPercolation Test Results Performed by._ ;#_ ._,/���/i/!/����..__. Date.....l.'��_......D.-� Test Pit No. I................minutes per inch Depth of Test Pit....:............... Depth to ground water.___ - --- -- }- --- -- (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water _.a UYy�T ' a ••--.. ..... -............ --•---------------- 0 Description of Soil..----•- Q L.(,l�'1 0 ... ••----AY1 ,r U •••••••••••••••................•••--••--•---••-....•••-•••••---•-••-•-•--•--•--••.............. W x ------------•-----------------------------------------------------------------------•-•...----•• 1r. U Nature of Repairs or Alterations—Answer when applicable.......................................:....................................................... ............................................................................................................-.......................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI I-E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been sued by the board o Ith.' 1 Signed•••• • •--•-- . Dat Ca Application Approved B _ : �_________ •_ _ Date Application Disapproved for the following reasons----------------•----•-------•-----------------------------------•-------------------------.........--•-....---- --.....•--•-••.........-••----•-•--••---•-••-•-••-••--•--•••--•--••....••••-----•-•---•----•...•••••----•-•••-•-•--•-••••-•---•••••-•-•••---•-•_..•••-••••-•-•-•••-••----•---•••-•--•---•-••••••......._ Date PermitNo......... --------—.1 ------- Issued........................................... .--.------ Date .. ..-. No................-.....-- Flcs.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD-OF HEALTH . .. f . ApplirFatiun for DispirS al Works Toustratrtiun rranit . f Application is hereby made for a Permit to Construct '(7`) or Repair ( ) an Individual Sewage Disposal System at 1 Y �• !� t (� Location-Address or" Lot No 1 fGd rCl�a................. .............................. .. r fs'`-1 ;.. i fl 'tll- /' f '................ ._ ""�.. Owner �^ { _ sF fJfti'S (-� t� lj........�`l '`� Ad/Ssl/.'.. ... _r__... -•-) — --------- M Installer Address U Type of Building f - feet Dwelling—No. of Bedrooms_________________....______________________Expansion Attic ( ) Garbage Grinder ( ) 4 Other—T e of Building 1� l - f1+ YP g ;-G- '---! '-!�` No. of persons___-___/_________________ Showers,(�" — Cafeteria ( ) Q' Other fixtures ' ----------•-- •;•--•-------•--...-•-••-••-------•----- W Design Flow__________________J.___.......___.____.__;_gallons per person per day. Total daily flow.... :_ :_ .....gallons. WSeptic Tank—Liquid capacity]�gallons Length__- Width__.._._.'_..._ Diameter________________ Depth................ x Disposal Trench—No. .................... Width.................... Total Length........:___..._.___ Total leaching area....................sq. ft. Seepage Pit No__________ _________ Diameter.___... `._._.___ Depth below inlet____._..l..___.__ Total leaching area:_�!; ....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ' _ ' a Percolation Test Results Performed by_________________________________________, _ Date..._.'_._ -._ ______..+... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..-,.............. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water:''/_-_- r'_''._:'_C��' Description of Soil......... - .......... !fi/� , ---•-•••- -=., ,tom- ._1 V .....•-•-••-•-••--•-.......••--•-••.._...---•-••••-----•---......•------•--••----•_.. . ...... ------------------- ---------------------- - - 7 =' ts" . . U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ••-•------•-•-----------•--•-----------•--------------------------------------------------------------------•----------------•---------------------_-•-•-...•--.....••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of-health. I ApplicationApproved BY............................... ......j�_--...---......... ----•..................... ---------•---------- Date Application Disapproved for the following reasons:-----•--------------•------•----------------------.............................................................. .................................................... .. --+--•---•••----••---•--------•••-•--••-•-•----....-------------- -••-----•----••-•--------•••-•---•••••--•-......•------•--•--- Date Permit No-------------------•_----._......l.P... ................................................... Issued-------------------------------------------....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r ,� --) r / �j....:.:......".."'...........OF....... w................�......................... ............ ............ (Irrtifiratr of TontViinnrr THIS;IS TO CE.,RTIEN, That the Individual S agre Disposal System constructed or Repaired r y{ r Installer r / at ... fly /'.'� e% 'di£ �Zs��C � f�� ' .a ' 1 p \ � r^ J, ,/f i has been installed in accordance with the provisions of TIf TEW.At Sanitary C de �W4 the application for Disposal Works Construction Permit NTo......................................... dated................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM MILL FUNCTION SATISFACTORY. DATE........... �'`�� ( ' -- .......................................... Inspector.........-----•---- --- ........................ THE G� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f, r (� ....... .......L ".... .............................�.....OF.. ....:.............. ••-• f N .. FEE...................•-•-- Disvin tl Works Tonotrwtion Vrrutit Permission fis hereby granted. ---------'--••••..---••---•-•-......---f--'•------•--•--••--•--••---=•......--•••.....••-•-•--•-.........•...............__•-•••• to Construc (f ) or Repair ( ) an Individual Sewage Disposal System .& , i l....... •-•--. �' / Street �.• „/r7/4it = t �as shown the application for Disposal Works Constructton Per ---- -•--'-.....---•---•---•---•--•--- 2 G _ ( S (D Board of Health DATE FORM 1255 A. M. SULKIN, INC., BOSTON _ �i2 • l2 tT4�;i Ki'fG-4�1. LIV1 N C1 o R4AIV ,1WY. 411 P" . Lu _ 0,00 .......... _........... _ - m 1748 F V .. 1y I ++ r w, %V& + IQ$tea.raw. kl.41j" -" 0 Ofz -1*,/ pAAOC. eA4C! N a (low ,,+ , low`� �.. �/7'R nv ,, ..................... f, W ............ Af .,�0 ��,�'R'gL�_ ' .. � M' � •3 t Li.per�M � .. .r � - A i w Al r _,`.r •y w Von i• - „fir 1. �r'�'�"' L000 *Yl r.r ■...��.. c.d ,/ ` An. ITIOV 178 0 AN A446 1971 00 low ia1*�!c LiNI� zo C) A' /78 A440 - - - _ -4- 7 w 00 V4 f 1 'G a J 178 A444� ELMI ..._LLUI .......... .t . f E v . + , , a 178 x A14 w y�0� . - A - t i tip- ' �- . j 4 i sill I � j � ... 1,00.0 .. p n 178 ROAO *M*N= f n Mot r Pof*109 4044UA94 i9f rW.Aloof '/`1,+'�, vy/SN�NSCAACT .02 mac.V9, � r M c*jA&.*r , 5 ,,DIX* � � �. t +.. � l A . .. �� I � ) [� (/ Y �1 J i t i {I f /713 vr AA4* I 1�j L A - tz T4-V,� 00 IV�V` l _I N O c ALL SYSTE LL SYSTEM PROFILE MARKED WITHC MAGNETIC TTAPEAOR BE PROVIDE MIN. 20" DIAM WATERTIGHT (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. NOTES ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 1. DATUM IS NAVD a P s �P PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE C) TOP FOUND. EL. 105.4' 2. MUNICIPAL WATER IS EXISTING MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED VER SYSTEM 104.5' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. ` PRECAST H-10 Rcc [one i .' RISERS (nP.) 4. DESIGN LOADING FOR ALL PROPOSED PRECAST c• .'.• 2'0 103.2' 4"0SCH40 PVC 2" DOUBLE WASHED,PEASTONE UNITS TO BE AASHO H-]Q PIPES LEVEL 1ST 2' OR GEOTEXTILE FAC3EjIC� 5. PIPE JOINTS TO BE MADE WATERTIGHT. . I I 101.5' o EXISTING , 10" 14" 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE Ps TEE SEPTIC TANK** TEE 101.8'f*� o WITH 310 CMR 15.000 (TITLE 5.) �c 08 GAS BAFFLE '40 00°0°0- 0 101.0' 0 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND 101 .17' 101 .0 80 2' . NOT TO BE USED FOR LOT LINE STAKING OR ANY ono ,$ 000 99.0 OTHER PURPOSE. \ \R ,.,,.. 7 a 6" MIN. SUMP H-20 3050 INFILTRATORS " 0\ 12" MIN INT. DIM. 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. Sc 00I 6" CRUSHED STONE OR MECHANICAL 3 4" TO 1 1 2" DOUBLE WASHED STONE 9. COMPONENTS NOT TO BE BACKFILLED OR COMPACTION. (15.221 [2]) CONCEALED WITHOUT INSPECTION BY BOARD OF ' OVERALL DIMENSIONS TO OUTSIDE: OF STONE: 30.4' X 10.25' HEALTH AND PERMISSION OBTAINb FROM BOARD 4.6' OF HEALTH. (3•9% SLOPE) ( 1 % SLOPE) K 49'f 10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS MAP CALLING DIGSAFE (1-888-344-7233) AND NOT TO SCALE FOUNDATION- EXIST. SEPTIC TANK 16' D' BOX 2' LEACHING VERIFYING THE LOCATION OF ALL UNDERGROUND & FACILITY OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF BOTTOM TH-1 & TH-2 WORK. ASSESSORS MAP 47 PARCEL 148 NO GROUNDWATER FOUND 94.4' 11. ANY UNSUITABLE MATERIAL ENCOUNTERED **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT G-W ESTIMATED AT EL. 50't SHALL BE REMOVED 5' BENEATH AND AROUND THE *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL AS PER TOWN MAP PROPOSED LEACHING FACILITY. UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE WITH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE CONDITIONS IF NOT SUITABLE AN EXISTING LEACHING FACILITY SHALL BE PUMPED PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM AND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. �b RAISED SHED x 104.85 CV BENCHMARK �� GARDE 1o4.s9 104.50 COR CONC BULKHEAD= 104.10 1014�14 �8 EL. 104.7' 104� r� 4.5\ r SYSTEM DESIGN: f r�3.8 ' �41 f{` 70 f{� gg TH 2 �x� 4f ` �'o GARBAGE DISPOSER IS NOT ALLOWED .1ix 104.96 DESIGN FLOW: 3 BEDROOMS ® f10 GPD = 330 GPD 2 (•1 - 1 09 x 10 2 USE A 330 GPD DESIGN FLOW G CATV & ,TEi _ r:; 104.71_._ . Xt AT HSE �9 104.70 ,�� SEPTIC TANK: 330 GPD (2) = 660 04.50 x 10,3.20 k� ____ PIT POSSIBLE RE-USE EXISTING SEPTIC TANK*# " � 4..4-7 105.37 ��,, LEACHING: TEST HOLE LOGS \100.65 EC METERS lxp 104.26 f YJ434� SIDES: 2 (30.4 + 10.25) 1.85 (.74) = 111 GPD CATV �1 44.P5 ARNE H. OJALA PE, SE RISER \ 1 .70 EXISTING BOTTOM 30.4 x 10.25 (.74) = 230 GPD ENGINEER: 8 : 02 88 DWELLING 104.26 04.20 TOTAL: 462 S.F., 341 GPD J WITNESS: D. DESMARAIS, IRS ELEC.\\ TOP FNDN. DECK 19 12 HAN (�X 104.23 4 DATE: / / 1 EL.= 105.4 104.15 x 10 42 II USE (4) H-20 3050 INFILTRATORS PERC. RATE _ < 2 MIN/INCH 10 TEL C) WATER ' 11 I WITH 1'. STONE AT ENDS AND 3' AT SIDES RISER 101.19 GAS METER QQ104.59 CLASS I SOILS P# 13612 \ METER 3.90 �-'s G GARAGE `L� ff�fJ'! 04.56 ELEV. ELEV. \\ G 65 87 SLAB 104.00 �1 �-� l04.59 \ 03.17 103.6ax 1 �P �, \ o" 4 104.4' o" 104.4' rn �� G / ` �\ GI VL 585 x 3.93 x)104.53 APPROVED DATE BOARD OF HEALTH MA yam\ 78 PAVED 0 ' FILL FILL � \ i 4-PJ2.66 DRIVE \ 1 13 " v x� 8 x-��g '�103 71 � TITLE 5 SITE PLAN n 78 1 \ 91 04.68 OF A/B A/B LS LS \\ 99pGE�'%�� 10YR 2/1 10YR 2/1 \ _ 0� 178 CAMELBACK ROAD 10" 10" x 1.87 / X 1�0430 MARSTONS MILLS B B � � �f 10 3 SL SL 10YR 5/6 01 4, 10YR 5/6 101.4' I o PREPARED FOR 36 36 Ih C BORTOLOTTI CONSTRUCTION/ x 02.09 PERC B. SLUSARZ C C APRIL 19, 2012 CS CS �ZN of Mgs �-SN OF ygs off 508-362-4541 �� fax 508-362-9880 �� DANIELA. yes DANIEL y`N I downcape.com 10YR 7/4 10YR 7/4 ' , A. , 120 94.4' 120" 94.4 �� OJA,A `� � OJALA � � � � ' Scale: 1"- 20' No.46502 o No. ALA down cope engineering, I/IC. NO GROUNDWATER ENCOUNTERED - �o�Fs cisTe� o���M tq o� civil engineers �.s �� 'oNA ,. R E� land surveyors 0 10 20 30 40 50 FEET I� )Z r' t f 939 Main Street ( Rte 6A) DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 >2-087 T , g, c- X i t Q': i ': -, •},fit � A'`'..�.�L{M E-r.�' •UA-(�'t_..t i-'I ox. �vaail g 1 .e, f?f TCH ,4 44, 4 llVE'S .'f ts9//1r'Ik' 0 O a0 O 1rN4Ess OTHERk sPEC1, .3. A.� 4 10110,'. 7-O ANP fN 79E S Y6i _ - 3,E c4srF IRON OR ,5CH69ME 40 ;.,. t 0 ( 00 0 0 @ 0 4 444 SE.-TIC TANleS, PISTRIBUTION e0A' ,. ANP 4 Er4Cf-!I!t/O 1�>>T+�' �'JY�c'41r3 G"�Eu/.f�',R,,� 0 m O DO f OR AI-ZO f'V,41E, '1, t Q.(PINC-S t't IYW—Al Q (D (D 0 0 G ( I1N Fx' IcWINc�. 67 R4 '•W°Ot/,E .�`4,1, t/NSU/T,�#Sk� 5' ,�ATE•R'IA 4, s � � C-ff :' - C� ® O O C� C� ENEAT,- TEE /lE. E ,E . rro 1 r 1 r?� r� r� cl1 Q (D � 0 0 O LU (D 0 49f rH,5 Pl c�rllS'0R,5 FORA P1-5 T ANC E OF /0- (4-z"rQ C!. 54NITA " iC4. ; , , � =o O Q O C➢ /� ANP SAC FI ,�. r °/TV CkAY-F,�EE TYPICAL I-�/S'��'/t�11T/C�/1l B #�� � ,�A.�r�-.�,�rP �,�A V�'�. �.�1lrV6 A PEl�CO�;.4rlO1V BOX � ��� RA'TE Or Z MINL/T675 1:16W INCH OR�. uo -�. r� > a3CoUuT NOT rO sC, .E �_�_ _ _A� .._ .,._._�. u.. 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NOTE ACC;E55 M A1901.,E5 TO ,5EPT/C TANK A ND L EACH ING'PI TS TO 54 E34)ILT LIP TD Fives / GRAG'E F/NlSH GfrAI�E OVER NfC ,$'H GR.4f� G OVER „ FIN1514 6,2ADE OVE,Q EGEVfo E.GEt! 47� 464EV -•ter ' 8 - 4 - . /Nt!> hl moca o pg t2 of3 12 G,4 N-k- 5 ° O OM 4SX5 ' 4REtp C,QU5REO STO NE'T43ELEFE 0 CDOI � aCI,B E� o 10 0 C? O (7' y a u� 47h p /NY f7 ,° L=-----=_=-`�� -�� aOTTOMof Per -� 7 (roE �,EV�� sr,a���� --- c,EU = z N 46ar 7 v " 4,EACHIA/G F'/T (-ro ISE 4,EVEC. 4 5TA.6 t.E) TYPICAL OEMAGFE SYSTEM PAO,0)c7 L.E N No7' TO 5eAL� Lod � � fl N p 1c� r 47k7 -44 \Ov n l�SEPT C- . Per kk. _._ ..- . ... -_ 1 7 96 5 t 'ON/NG a/STPr'/CT X-400P 1-1,"Z49P .Z-ON�f 4Tk z 49,E&6N CRITERIA �'ROPOSER L 0C4 ION OF R E�.1INS' �t OF ,a+q _._ -- �� `� SEA l P YS� 47 a Nl1rNE3ER OF BEOr4QOiNS 3 . ',./ST. CCJ�`r TOUR' 8 I�� ��� F 2 f OP0' 5ER CONTOUR .f- w F'E'/`s'SC7fYS PER ®�'G'ROOrtf _ - a R �..�,w...._ � taAY�ON+� � p� OA d,LONS PER PERSON PER PAY-_�5 CX I,5 r SPOT �"/,EVA7`10N 8-0 �; too.21583 Q � J��-� 4`D ��� E-L ES AC� Fad.+41.�> C EACNlN!i REQUIRED' _ f'R4PC�S P LSPOT EI ENAT/ON r tQ ��ev CIST R�`�y4 �C,y F 2 A 4EACNING PROVIP�EL� .42 PERCOLATION TEST M ac Q ,4PP,G/CAI T' ' ENGINEEfi No PlSPOSA/.. � OBSE:R'VATION PST � : � ,: 4RROPY ENGINFERING INC 111 25 t2 t��- 1b DL. D� U SIDE I VAS C, 2, c-V Y RA rE � 2 4: ` = �R L5 7 T - x 4 �. b ! a tc�,rn 7 �t1C2; Is-PPt ate►. foti.1Ic� : �- 7 3'�: O Cl - ►.o . >d u6 N0776e; y' /S rip�?6 TO 7",4 t? C w • . - Pls'.44�'!1/ tY' 1"h� ' �k' ' 'B�' A 'f' f3 Y'= f' A , Asp , A - I