HomeMy WebLinkAbout0120 CEDAR TREE NECK ROAD - Health 120 Cedartree Neck Road,
_ Marstons Mills M to � ,
TOWN OF BARNST LE _
LOCATION / � &ACID'-es J�� 19C SEWAGE#:T 75P
VILLAGE t ,IS ASSESSOR'S MAP&PARCEL
'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 000
LEACHING FACILITY:(type y rochrSSo :s (size)
NO.OF BEDROOMS
.OWNER rodV 1—
PERMITDATE: C® ��DAThSP. 11 �
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
k C ,
23 ?Driveway .:,
\109
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•. 120 Cedar Tree Neck Road_
Property Address
Deborah Broduer
Owner Owner's Name —
information is
required for Marstons Mills__ _ MA 02648
every page. cityrrown — --- September 23, 2008
State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Impo
When filling
A. General Information
When filling out
forms the
computer,
r,use 1. Inspector: ✓ � �p
only the tab key
to move your Patrick M. O'Connell
cursor-do not -------------- ... ----.. --------.-.----- --
use the return Name of Inspector --
key. Septic Inspection Services Co.
Company Name — -- -------- --
rea 189 Cammett Road--
_o_ad
Company Address --
Marstons Mills MA 02648
rerten — -- -------- — --
City/Town -----_------ -�-�`- State Zip Code
508-428-1779 - - SI 12855
Telephone Number — ---- License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and thaT.�te
information reported below is true, accurate and complete as of the time of the inspection. Tinspction
was performed based on my training and experience in the proper function and main-tio -ce-c�f on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1�40 of
Title 5 (310 CMR 15.000). The system: ca
70
® Passes
❑ Conditionally Passes ❑ Fads � cn
tv
❑ Needs Further Evaluation by the Local Approving Authority
t
September 23, 2008
In ector's Signature -
Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system 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.
08-245 Broduer.doc•08106
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Cedar Tree Neck Road
'roperty Address
Deborah Brod_uer _
Owner Owner's Name
information is
required for Marstons Mills _ _ _MA 02648 September 23, 2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cons.)
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.
Tank is in good condition, leaching field was probed and no signs of saturation were found.
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 exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
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
08-245 Broduer.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 120 Cedar Tree Neck Road_ _
Property Address
Deborah Broduer _
Owner Owner's Name
information is
required for Marstons Mills MA_ 02648 September 23, 2008
-------- __-----._.-.._..----------
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ 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:
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.
08-245 Broduer.doc•08/06 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
'Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Cedar Tree_ Neck Road_
Property Address
Deborah Broduer
Owner Owner's Name
information is
required for Marstons Mills___ _ _ — _ MA 02648 September 23, 2008
every page. City/Town State Zip Code
Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than_ 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.
08-245 Broduer.doc•08/O6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection
coon Fo
rm
orm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°�M a,•°'• 120 Cedar Tree Neck Road
Property Address---_-_---------_._--- -- —
Deborah Broduer
Owner Owner's Name
information is
required for Miarstons Mills MA 02648 September 23, 2008
- ----- __------ ------ -...-.-.. -- - — - -
every page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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
i
❑ 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.
08-245 Broduer.doc•08106
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 i
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurfac
e Sewa
ge Disposal System Form Not for Voluntary Assessments
°«a,.•'� 120 Cedar Tree Neck_ Road__
Property Address
Deborah Broduer _
Owner Owner's Name
information is
required for Marstons Mills _ _ MA 02648 September 23 2008
every page. City/ own 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)]
08.245 Broduer.doc•08/C6
Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 6 of 15
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 120 Cedar Tree Neck Road
Property Address
Deborah Brodr
Owner --- u e
--------------- ----------
Owner's Name
information is required for fnarstons Mills _ MA__ 02648 September 23, 2008
- __ _
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
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: 1
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 ears usage d 334,000 gal. w/
g ( y g (gpd)): irrigation syst.
Sump pump?
❑ Yes ® No
Last date of occupancy: Currently
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:
Last date of occupancy/use: Date
Other(describe):
08-245 8roduer.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 120 Cedar Tree Neck Road
Property Address
Deborah Broduer
Owner Owner's Name
information is
required for Marstons Mills MA 02648 September 23, 2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Tank pumped one year ago.
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 j
❑ 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:
Leaching system permitted 3/25/05
Were sewage odors detected when arriving at the site? ❑ Yes ® No
08-245 Broduer.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 120 Cedar Tree Ne_c_k__R_oad_____ __
Property Address
De
borah Br oduer
Owner Owner's Name
information is
required for Marstons Mills _ __ MA 02648 September 23, 2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer (locate on site plan):
Depth below grade: 1
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
------------- -------- - ------------ -.
Septic Tank (locate on site plan):
16"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 8.5' long x 5.2'wide- 1000 gal.
Sludge depth:
3"
Distance from top of sludge to bottom of outlet tee or baffle
27"
Scum thickness 2
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
12"
How were dimensions determined? Measured
08-245 Broduer.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Cedar Tree Neck Road _
Property Address
Deborah Broduer _ _
Owner Owner's Name
information is required for Marstons Mills _M_A_ 02648 September 23, 2008
every page. citylTown 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.):
Liquid level was found at bottom of outlet invert, tees are intact and clear. Recommend annual
pumping with use of garbage grinder.
Grease Trap (locate on site plan).
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain):
08-245 Broduer.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
f
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
120 Cedar Tree Neck Road
Property Address
Deborah Broduer
Owner Owner's Name
information is
required for Marstons Mills MA_ _ 02648 September 23, 2008
City/To
every page. wn State Zip Code Date of Inspection
D. System Information (Cont.)
Tight or Holding Tank (cont.)
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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber (locate on site plan):
Pumps in working order. ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
I
08-245 Broduer.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 120 Cedar Tree Neck Road
Property Address ----— —
Deborah Broduer_ _
Owner Owner's Name
information is Marstons Mills
required for ___.__._______.._______.__ ____ MA 02648 September 23, 2008
every page. Ci:y/Town State Zip Code Date of Inspection
D. System Information (cont.)
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:
Type:
❑ leaching pits number:
® leaching chambers number: FourFlowdifussors.
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number.-
El 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.):
Area of SAS was probed, soils and stone surrounding leaching system show no signs of saturation or
surcharge.
08-245 Broduer.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w„ 120 Cedar Tree_Neck_Road
Property Address
Deborah Broduer
Owner Owners Name
information is RI arstons Mills MA 02648 September 23, 2008
required for _ p
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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
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.):
----------------
08-245 8roduer.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
f
'• Commonwealth of Massachusetts -
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
9 p Y Y
120 Cedar Tree Neck Road
Property Address
Deborah Broduer
Owner Owner's Name
- _...............
information is required for Marstons Mills MA 02648 September 23, 2008
-- _ .........._--._.. _._.._..----_.--------
every page City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.
2
33
109
118
I }ys IMF
.3;�u�w�4
I
' Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�. 120 Cedar Tree Neck Road
Property Add ress ----------------—------------
Deborah Broduer
Owner Owner's Name --- ---
information is Marstons Mills _MA 02648 September 23, 2008
required for p
every page. CityFown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to ground water: 20
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:
USGS topo map and town GIS_
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water at el. 5 and topo map shows property at el. 30.
08-245 Broduer.doc•O8iO6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
f
,
Town of BalrnstAle
" - Regulatory Services
Thomas F.Geiler,Director
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
rmit# 24065'-100 Assessor's Map\Parcel VK&P A. PU 63
Date: (0065 Sewage Pe
Designer: Si!!,Vb►ch A. Wi IsaM PE Installer: 13orfe to Hi C Kst,
Address: Q&x ITT Lla1 wa rlr^ _ Address: A U . ►3x 7 6 Y
8► uric�•. S t r Os ,rv�I Lc 'IMa rs ky.a Wl i l IS
on 3123 LOS Bor-61.4i Cast was issued a permit to install a
(date) (installer)
septic system at l ZO Ccdor Tre hieek 120a cP based on a design drawn by
(address)
Siy--pticn A W: Isar► dated S-12- 2.00r
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
X_ 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
certifi d as-built by designer to follow.
N OF Mqs�
i
STEPHEN CyG
ALLYN
o WILSON -+
(Installer's Signature) " No.30218
9RGISTEP�� Q
�SSIONAL
esigner's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU..
Q:Health/Septic/Designer Certification Form 3-26-04.doc
TOWN OF BARNSTABLE
:.00A't1rly .�Zo C'Actyi, �u.Luk y =r SEWAGE #
VILLAGE b j% l.( t A VIA 1 I, ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY i a
LEACHING FACILITY: (type) _®tr (size) t-X
NO.OF BEDROOMS 3
BUILDER OR OWNER L QC0au`!�C--:>
+E%VIMDATE: A\A o%� COMPLIANCE DATE:'
Separation Distance Between the:
Maximum Adjusted Groundwater Table — 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 C..��
*tab _
_ a
0
TOWN OF BARNSTABLE 14
LOCATION ,ZO C �'/'� /�'�e •SEWAGE #
VILLAGE {ZIP' 2�9_�-5,-elOf1_ ASSE OR S MAP & LOT 3
INSTALLER'S NAME&PHONE NO. Aar ID!4lel1
SEPTIC TANK CAPACITY ® J a
LEACHING FACILITY: (type) /V f10 em irs (size)
NO.OF BEDROOMS y
BUILDER OR(!O�
PERMITDATE: 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
l o
231
�Z = /of
lb
�1 j j, 3
TOWN OF BARNSTABLE `
L CAr1UN ��b �POIOtT 4/cck 2W SEWAGE # Arcs--loo
VILj;.,G.. r-114, M� I�S ASSESSOR'S MAP & LOT 0 7A`0 6
INS TALLER'S NAME&PHONE NO. 6014&
SEPTIC TANK CAPACITY `-
LEACHING FACILITY: (type) (size) yD Xl) lk"
NO.OF BEDROOMS
BUILDER OR OWNER r-,ale V,-
PERMITDATE• s 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) J Feet
Fii nished by /1
ce r 'Q tt-j �,� /m C D� e
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a im
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t� , rs•ra i're' �
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`8 A;�� •a E'Ba
No. '2by.5- U U Fee v
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
;Z
Yes
PUBLIC HEALTH DIV'ISiON -TOWN OF BARNSTABLE, MASSACHUSETTS
01ppiication for Migool bpotem Con!Wurtion Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System ICKIndividual Components
Location Address or Lot No. I Z.o (fc_d cLrr 1 me- MCX 1�r VZJ, Owner's Name,Address and Tel.No.
Mc-rc}yjd, Yh,'1(s 7'ohn C 12e_6m �rvdlcVr
Assessor's Map/Parcel 12 5 C",Q, 1✓�cc GVc�+c 2�
1►'Ic� ? tqc-( (03 Wlor dah i'YI l OZlo 9,
Installer's Name,Address,4nd Tel.No. Designer's Name,Address and Tel.No.(509)gZls i13/; e-xf /3
A. w, Isvh,?,F,,
/y 7�y1pX}r/ IJje-4 Hr,I r►�ea fLN
17 Y►'I�GJIv� ScF 1 OS�c✓di/Lt l�'1/d- C32�S�
Type of Building:
Dwelling No.of Bedrooms ::o or Lot Size /Z sq.ft. Garbage Grinder
Other Type of Building L' �o.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow //0 ec gallons per day. Calculated daily flow Z/ ® gallons.
Plan Date /f �Z Number of sheets Revision Date -3�Z2�OS _
Title Sev dzc 5 4 s h.-.; L5 rao,..x�cL1Q
Size of Septic Tank /000 gUllc Type of S.A.S. 1-c-Ji''j 6kaWthers YD�xIL�z 2'hf
Description of Soil f2e �r 4, go 1 f o 5 5 12(a v► P 10 `7 Z Z
Nature of Repairs or Alterations(Answer when applicable) ►2e-p(Qip onc_Gr-ail cC0 lemck 42+ to ice,
�Cs..C� •�- L(�4vhh �5
Date last inspected:
Agreement:
The undersigned agrees to ensure the constructioji 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 s o f It � / �
i
Signed Date /
Application Approved by Date T 3 U �
Application Disapproved or the following reasons U
Permit No. UUs—_ d 0 „ Date Issued o� S'
V
W
No. ,Cr7(J !tJU 4, - -'" ft " _. Fee U —
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
7i�
Yes
PUBLIC HEALT i Of
-D1V1� 0I'tOWN OF BARNSTABLE, MASSACHUSETTS
r ricat on for,30(goo5al *p9tem Congtru; iott hermit
Application for a Permit to Construct( . )Repair( )Upgrade(x )Abandon( ) O Complete System . Individual Components
Location Address or Lot No. 12.0 Trce Me e Fr VZJ. Owner's Name,Address and Tel.No.
M vc-zIvis Yh,'I(S Sohn F i�cbrk �iraGOcVr
Assessor's Map/Parcel 12 5 Ce dc.^ t✓-cc PVcc+e I?�/
Ma 1�c.1 �3 or tvn in oz4 0
Installer's Name,Address,,and Tel.No. Designer's Name,Address and Tel.No j_570, 5Y3/;ex� /3
'7 ` 7'j7 Sd I z r►'la,.� 5}v��! Oshrdi/la knti- OZ&SS
' Type of Building:
Dwelling No.of Bedrooms =au r Lot Size l �1/2 sq.ft. Garbage Grinder
Other Type of Building of Persons Showers( ) Cafeteria
Other Fixtures -
6
Design Flow //0 gallons per day. Calculated daily flow yz10 gallons.
Plan Date Number of sheets .0 n Revision Date T 21oS y
Title Se i» S il s-,k w; y p e,,?, r-Qo
Size of Septic Tank as o gne /� Type of S.A.S.I.,cac17i!j Ghani►xrs
Description of Soil R �� e=m (a n ( P-10,-7 22_
t
Nature of Repairs or Alterations(Answer when applicable) r „eJr rr iz ca0 Ic&ek ,o� - ea i
�Gr�CI�,� Gfilc.w:b�✓5
r
4
.Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system T nq
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 BoardoflHealth.
Signed '��IP / "' Date
Application Approved by Date
Application Disapproved Yor the following reasons
r
Permit No. UUS� /U y Date Issued a
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
i 'THIS IS TO CERTIFY, that the On-site S wage Disposal System Constructed(, )Repaired (�Upgraded( )
Abandoned( )by r
at ) :211 C erlfl�.r 1 V Pr_ A)"c�' ,� /fit_ has been constructed i accordance
with the provisions of Title.5 and the for Disposal System Construction Permit No. 2 0 u = /d dated 2 �
Installer Designer
The issuance of this perrryt sh 1 not be construed as a guarantee that the system wi ctt n as designed.
Date r%n _� Inspector
n
No. U U S -i U U - Fee l 00 �
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migonf *p!5tem Con5truttiott hermit
Permission is hereby granted to Construct( )Repair ' )Upgrade( )Abandon( )
System located at 1�u C P C/'„,- _7`i� Ale c%. ,r/Ir, 1z4
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: Cons uctio must be completed within three years of the date of thie 7
Date: 3 a u.S Approved by \\ � io r
1 O 12/ 7/6
L O,C v
ON SEVAGE PE ACHT E30•
T. .�
VELLACE
INSTALLER'S AfAE 8 ADDRESS
a4
'16M &-V�
Sa.
6 UILDEA 0
pjjwrt�
DATE PERMIT ISSUED
DATE COMPLIANCE ISS-UE-D
CPO
1J,
rioX
1
No..$. ..�/.f.. Fis....J .. ...
THE COMMONWEALTH OF MASSACHUSETTS
.� BOAR OE HEALTH
.......... �.)...............0F........... r1 Cj
Appliration for Disposal Workii Tonstrurtiun Frrutit
Application is hereby made for a Permit to Construct (S4) or Repair ( ) an Individual Sewage Disposal
System at
.......... .. ... ......f.JVF.rX -------------------- ............................................ "--------&.-----------------------
.oc do - re o
Oynr
......... � .....--•--••--------- -------�.J �-�.-, --LS.�:�aa�... .....----•------- •------------.-.--
Inser Address YjPQ
Type of Building Size Lot...-(___00---
U Dwelling—No. of Bedrooms.................:3--•-____-_-__.___-__--Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Otherfixtures ------------------------------------------------------•••••-•••••-•------••••-----•--•----••-•••......--•••--•-•-
Design Flow.................��5._.__.___.....:...gallons per person per day. Total daily flow.....................
WSeptic Tank—Liquid'capacity_ gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No----------1---------- Diameter........ .... Depth below inlet.......4........ Total leaching area.... 3...sq. ft.
Z Other Distribution box (K) Dosing tank ( ) (�
'-4 Percolation Test Results Performed by J `t' �� .._... ..._rC?_... Date.__.I�........-8 __.___....
Test Pit No. 1................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........................
----------------------------------•-----------......------------.....-----------........--•-----_•-•.........................................................
0 Description of Soil....... ........................
--- •--........ --------------
x �-
U .....-----•-•••-•-•--•-•-•-•••••••••.
::...--' .. ?..__ S�.............c !J --- .-------- --------------- .-----..........---------...------•-------------------
w
VNature of Repairs er nswer when lic � .'
Agreement:
The undersigned agrees to install t e a o escribed Individual Sewage Disposal System in accordance with
the provisions of iITI,;=. 5 of the State d The u signed further agrees not to place the system in
operation until a Certificate of Compliance e i t e b and of health.
Sign ....... ••- -- --• - p•-................................................. 4D... �~ �
Date
Application Approved By... .... /2 `_t�'.� .1'
Date
Application Disapproved for the following reasons-----------------------------•------.._...---------------------...-------------------------------•----••...------
...............•--•••••-••-••••••----•......-•-•-•-••--••----------••-•••••--••-•-•••--•-••--••-•••-••---•••--•--•---•••-•••-•-••--------•-----•-•••-••••-•--•-••------••-----•••••------•••••••.......
Date
PermitNo......................................................... Issued.......................................................
Date
Fxs... S.. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Off` HEALTH
._.._.... ........Qlf ............_OF.... .....! T...... ..................................................
Appliration for Bitipas al Vorkg (foustxnrtiun "anti#
Application is hereby made for a Permit to Construct (,4.) or Repair ( ) an Individual Sewage Disposal
System at:
.............................................../ .............................................w�....... '- .......----
o tion- reIVA .7 \
r No.
gin. . .
W Ow r tt �.. Address
Inst Iler Address �J
L 00 f'G_ Sq-#eet-
d Type of Building r Size Lot_________________________
U Dwelling—No. of Bedrooms________________._.......................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building ersons____________________________ Showers
G� YP g -------••----•-•--------=-__ No. of P ( ) — Cafeteria ( )
P4 Other fixtures ___________________________________ ______ _ `
--------------------------
W Design Flow...............n�'?_....................gallons per person per day. Total daily flow... ?. ..........gallons.
WSeptic Tank—Liquid capadty_c_!,k_)_gallons Length................. Width................ Diameter................ Depth................
x Disposal Trench—No. ................... Width.................... Total Length._._.__._..._._____ Total leaching area_____ _...`.__..sq. ft.
Seepage Pit No.........1---------- Diameter....... Depth below inlet_.__..-___..... Total leaching area_._L!....�...sq. ft.
Z Other Distribution box Dosing tank ( )
'—' Percolation Test Result Performed b . :_... .�'_._...............� ........f t E_`� 1't% Date._:: '``}`-" '
a y �' v
Test Pit No. 1________________mmutes per inch Depth of Test Plt.._.__._______.___.. Depth to ground water.......
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
¢'+ --•••••••-•----•••--------••..............•---•--••--•••--•......-•-•••.....-•-•----••••------•--••--•••--•-------••----••---•--•-••••--............._....--
ODescription of Soil-------`•'••--•-•-----••••••--••. ....................f!� •--...•-•-•--•-------••••---•-••••-•--••••••••--•••-•-•••--•-•-•-•••-•••--•••••••.....--•-••-•---
x _..
w
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---...-•-....._.
P U Nature of Reairster when lic k�1 ". -----------•--------------------------------------------------------------------------
� nswer ���
.............�••••--••-••- ------------------------------••----------------.......................................
Agreement:
The undersigned agrees to install e a o escribed Individual Sewage Disposal System in accordance with
the provisions of TTTL g g P Y
5 of the State a d The u signed further agrees not to lace the system in
operation until a Certificate of Compliance s e i t e b and of health.
Siga ••-•• - •• _•--••• - ••-•-••-------------•-•••-•-••-•--.--._...__ !. 7" �not
Date
Application Approved By..__�! -.t_ � �c�
PP PP -- .._... ._e -
�K --••-•-•-•--•••--•----•---•-••••-•-••-•-------•-•••-•-------------Date•••...........
Application Disapproved for the following reasons___________________________
.............••---••.........••-•--••••----•••••--....---•••-•--.._..._..-----••-•••---••-•-••-------••--I---••-•----••-••-•-••••-•--•••••••••••-...••-•••••---•-•-••-•--•••----••-•----•---••-•••-•••---
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............................
(Irdifirtttr of fannipliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( k1l'or Repaired ( )
by............ _.........
.........................................................................................................................................
Installer .40
has been installed in accordance with the provisions of TITLE' j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit ....... dated_._...........:................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATI FACTORY.
DATE..............................................6 r: .1��.......... Inspector............... ............................................
. _ -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............OF.........,. .
No. -.. /t' FEE........................
Dispniial Works Tnnptrnrtuan anti#
Permissio is ereby granted_.... .......... __----_----•-----___----_................................................
to Construct ( - ) or Repair ( ) an Individual Sewage DisDoosal stem ,✓
atNo.......... :�.:-...... G1 ---------� .................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated ...
Board a O-alt
DATE............. -------------------------
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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CO\IMONNVEALTH OF NLkSSACHUSETTS
-- y, EIECLTIVE OFFICE OF E.\VIRONMENTkL AFF.MRS
= = DEPARTMENT OF ENVIRONMENTAL PROTECTION
O\E WINTER STREET. BOSTO\ \L�, 02108 1617J 292-5500
TRUDY CORE
8 Secretary
ARGEO PAUL CELLtiCCI 'hb STRUHS
sio er
Governor o
q� p SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A i!J 4�,lv
,VV>CERTIFICATION111
�- le
_ a. Q O
Property Address ?-� C s c = L i C"`,C-�_�t1 Name of Owner i `�rriatil L�C`j �-' � �
9
t-�1t Address of Owner: tr 4� 9
Date of Inspection:(-!tkXI�01 1 // , ,/ :l to c ==� i 77 i-1� � 9
Name of Inspector:(Please Print)H a Q C.I �%��ELI�U ` �b
I am a DEP approved system inspector pursuant to Section 15.340 of True 5 (310 CMR 15.0001
Nam: �
Company Na : �r r'r Lc✓`�}�G u. 1%,% C
Maaing Address:-?a 2.,a y��f+-- H is N, - /�/`r UZC�t"c
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
J ) r 1 {�1�
Inspector's SignaWrft� A!t\/ J�) Date:
The System Inspectcr shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 page iorn
-`= Printed on Recycled Paper •
C
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
'roperty Address:
Jwrw:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, of D:
I + t.`�
A. SYSTEM PASSES:.
xI have not found,any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
{{++crate not evaluated a
MENTS re indicated below.
COM :
B. SYSTEM CONI j,ATIONALLY1PASSES:
_ _ t
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion oil 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.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection: or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health)•
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ 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
e..
revised 9/2/98 Page 2orIll
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order t determine if the system is failing to protect the
public health, safety and the environment.
11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORD NCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC EALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated w tland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH( ND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE P BLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil abs rption 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 6sorption system and the SAS is within a tone I of a public water supply well.
_ The system has a septic tank and soil bsorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and s absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a ell water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from th t facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to de ermine distance (approximation not valid).
31 OTHER
revised /9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
property Address:
Owner:
Date of Inspection:
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 contact d to determine what will be necessary to corre:t the failure.
Yes No
Backup of sewage into facility or system component due to n overloaded or clogged SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the gro nd or surface waters due to an overloaded or clogged SAS or
cesspool
Static liquid level in the distribution box above outlet nvert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below inv t or available volume is less than 1/2 day flow.
_ Required pumping more than 4 times in the las year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is wit in 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is rthin a Zone I of a public well.
Any portion of a cesspool or privy i within 50 feet of a private water supply well.
_ Any portion of a cesspool or priv is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality an.lys" . If the well has been analyzed to be acceptable, attach copy of well water analysis for
,coliform bacteria, volatile orga is compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes" or "No" to a ch of the following:
The following criteria apply to lar systems in addition to the criteria above:
The system serves a facility wit 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 envir nment because one or more of the following conditions exist:
Yes No
the system is wi in 400 feet of a surface drinking water supply
the system is ithin 200 feet of a tributary to a surface drinking water supply
the system i located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone If of a public
water suppl well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for urther information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: c.
Owner: P . CuouG—n
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Y@s No
_ Pumping information was provided by the owner, occupant, or Board of Health.
_ 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.
As-milt plans have been obtained and examined. Note if they are not available with N;A.
_ Tne facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, 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.Soil Absorption System on the site has been determined based on:
� 1 Existing information. For example, Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
�! 115.302(3)(b)1
el 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 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM..
PART C
nSYSTEM INFORMATION
rroperty Address: CC CL,G n
Owner: P . L-V p N Cj o
Date of Inspection:
4/ cjq
FLOW CONDITIONS
RESIDENTIAL:
Design flow: i-' g.p.d./bedroom.
Number of bedrooms (design):C_5 Number of bedrooms (actual):r�-�
Total DESIGN flow`-�3 C)
Number of current residents:
Garbage grinder (yes or no):_-3
Laundry(separate system) ( es or no):� : If yes, separate inspection required
Laundry system inspected ye�or no)
Seasonal use (yes or no): l�
Water meter readings, if available (last two year's usage (gpd):
Sump Pump(yes or no): lU
Last date of occupancy:S 11-\
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: qpd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes 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:
OTHER:(Describe)
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: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
revised 9/2/98 Page 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continuedl
'roperty Address:
Owner: )q , L V O ti ri"O
Date of Inspection: 4 / I c,c�
BUILDING SEWER: / ! (.
(Locate on site plan)
Depth below grade:
Material of construction:_cast iron 40 PVC_other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, eyidence of leakage,-etc.)
�a i '•TS TjC V\� I d d del li U-.. ..wi!t {
SEPTIC TANK:
(locate on site p and
Depth below grade: lz
Material of construction: `concrete_metal_Fiberglass _Polyethylene_otherlexplain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: Ul C ci%4 i
Sludge depth: 4151,
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 0
Distance from top of scum to top of outlet tee or baffle: l I
Distance from bottom of scum to bottom of outlet tee or baffle: 1
How dimensions were determined:
comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, str�cturel iratelily,
� C�,. `.�C � (1 s X
11-9
GREASE TRAP: 1
(locate on site plan)
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:
(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.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
pro yAddress: L�'ac .� � �� i7 - /-"l / l "S HuLIS
C' `�- ��
Owner:
Date of Inspection:
4//r 1 "I `7
TIGHT OR HOLDING TANK: '01�(Tank must be pumped prior to, or 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/day
Alarm present
Alarm level: Alarm in working order: Yes — No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_Lk.�,
(locate on site plan)
Depth of liquid level above outlet invert:
Comments: _
oli
(note if vel and distrib4tion ismqual, evidence of Ads carryover, evidence ofleakage into or out of box, etc.)
0, ILa-c,
PUMP CHAMBER:4FLo
(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.)
revised 9/2/98 page sorn
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Owner: /7 - Lv o Gcq
Date of Inspection: I 4C
SOIL ABSORPTION SYSTEM(SAS):t> .�
(locate on site plan, if possible; excav ion not required, location may be approximated by non-intrusive methods)
Knot located, explain:
Type:
leaching pits, number:\(,Xk
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:---
Alternative system:
Name of Technology:
Comments:
(note conditi n of soil, signs of hydraulic failure, level of ponding., damp`s}oil, condition of vegetation, etc.) t _a
�� ` - �'y ��+. �� b(Vj �)� �`]xr1 r4;i �l'� E X \ iLZ �� v�4�1e•�c of r �2- SSZ`tYr ;( T'i
CESSPOOLS: ti`I,1
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
)epth 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, 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.)
revised 9/2/98 Page 9orU
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address: \-'�` City R- E',,'i�-( (_�. 0 - I ``^�"�SY 0 .-_S �S
)weer: � t-uo uo-C)
Date of Inspection:
per/ << � C7 `7-
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or bencF;marks
locate all wells within 100' (Locate where public water supply comes into house)
y
e
C.
I i
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
;operty Address:
Owner: A - L v o ev G-,
Date of Inspection:
p[ -/ // / 7 `I r
NRCS Report name - —
Soil Type_ — ------— -
Typical depth to groundwater_ __
USGS Date website visited V-6
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope 1ACS
Surface water ,-c✓
Check Cella. � —,
Shallow wells -jZ;
Estimated Depth to Groundwater ifFeet
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
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
revised 9/2/98 Page 11of11
N/F DELANEY
N/F KILEY WOODED LEGEND
N/F PITEIRA EXISTING PROPOSED
41.4-- S 731 V41 E -325.00' M
L
C.B. XN- t T- L - 47.72'
100.00' 0 t 225.00' -------
FND.\\ 04 X IQ") Stake & Toc Set/Found
x 39- Mag Nail Set/Found
0. 39.6 M Concrete Bound
36.8 0 Gas Gate
X 39.1 n 46 - Electric Meter
35.7 38.3 6,0 ------------- - Catch Basin
6.2 35,9 40 04 Water Gate
6.0 0 Water Meter
0 WOODED 3 4.57 62 36.1 41 Telephone Riser
0 62 cur J�,,e 40.1 -0- Utility Pole
0 cly
371- 200
32,3 32,7 J> Contours
.N r- 305 5 3- 11 IN 20000 Spot Grade
o
-i CH
T 3 Test Pit
N/F BURKE 36,
32, �cj S Conc. Concrete
33, ap-Y j
EP Edge of Pavement
32.8 ♦ 9110,
32.8 ljq BCC Bottom of Concrete Curb
36.Q kv
29.9 362 3 P2 010 39,0 CA C.B. F.F.E Finish Floor Elevation
32, 4 fA z RAGEt,
IV04z, FND.OFF
X Iron Pipe
IP
LOCUS MAP 0- 0. CONIC. APRON
&�* 36.
1 2000'
C.B. 400 32 7
36.5
FND. 23.5 ' 7- 36.838
30,0 3 7,6
ZONING DISTRICT. RF LS q,2 8, 34.8 q
X 36
36.7
OVERLAY DISTRICTS: REMOVE
AP (AQUIFER PROTECTION) 23.8 X D-BOX 36P- TEST PIT
37.0 36J-
X PUMP AND FILL
36.1 MNG LEACH PIT 36 9/
RPOD (RESOURCE PROTECTION) 4 LS Septic Permit #2005.100
r 35 WITH CLEAN SAND
MINIMUM LOT AREA: 2 ACRES (RPOD) -2 26.5 L79 27.3�2 4,0 "1 0 1 , 36,8 X X 9
MINIMUM FRONTAGE. 150' 225 2G 2 6 6 -CONCREE&t 36.1
GENERAL NOTES
0
FRONT SETBACK = 30' SIDE & REAR SETBACK 15' X 2.3 25.. ACH PIT X
8 35.8
'25 1- PRIMARY BENCHMARK DATUM: NGVD
361
LOCUS PROPERTY IS SHOWN AS: WOODED 25.4 2 6 X 26 BL-E� EDGE TBM: HYDRANT #1316 SPINDLE ELEVATION 47.72'
ASSESSOR'S MAP 76 - PARCEL 63 (rYFI.)
35.7 1
.6 -)T PIP-twopLub �5. 36,-,7 ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE WITH
a
DEED REFERENCE. 22.0 ASKET BALLH 22.7 X 23.1 25,2 OUTL2ET 0 SEPTIC'-TAW U 7T V OF THE STATE SANITARY CODE DATED MARCH 31,1995
DEED BOOK 12,317 PAGE 233 2 4.6 31.4 X 0 31.8 ANY LOCAL, RULES APPLICABLE.
LS
38,0
j 36.5
PLAN REFERENCES: 0 X30.11 39,0 I f%'�%
24.7 6.1 AM CHANGE TO THIS PLAN MUST BE APPROVED IN WRITING
1* 21
PLAN BOOK 272 PAGES 29 & 30 LAWN I BY DESIGNING ENGINEER
CONCRETE PAD x 2 6.6 36.2
24.8, 36,1
0 3.7
COMMUNITY PANEL NUMBER 250001 0018 D W 22.7 22.9 1/261 -35.9 WHEN CONSTRUCTION IS COMPLETED, PRIOR TO BACKFIWNG,
-7,7
THE FLOOD INSURANCE RATE MAP DEFINES THIS AREA AS ZONE C, N/F KELLEY X-. NOTIFY THE ENGINEER & BOARD OF HEALTH AGENT
AN AREA OF MINIMAL FLOODING 124 1 35 7
STONE DRIVE
3O 5 ,_ - __ / ADJUST INVERT ELEVATIONS OF SOIL ABSORBTION SYSTEM AS NEEDED
24.1
22.6 TO ACCOMODATE EXISTING SEPTIC TANK.
PROPERTY OWNERS: z 30.4 3A1
24 9 ?7e
7. D. OF EXISTING LEACH PIT TO BE PUMPED AND FILLED WITH SAND.
MARSTONS MILLS, MA 02648
JOHN E. & DEBRA BRODEUR 21.2 7 C.B.
318 ; /FN -F
125 CEDAR TREE NECK ROAD 0 P 0.5 I/ 1 t -* \ �v
C
of
THESE ELEVATIONS MUST NOT BE CHANGED WITHOUT WRITTEN
21 7 APPROVAL BY DESIGNING ENGINEER
C6
---ST PIT (#P-10,722)
20.6 WOODED ALL SANITARY DISPOSAL SYSTEM PIPING TO BE 4* PVC., SCH 40
D-BOX
1 EXCAVATE AND REPUTE ALL UNSUITABLE MATERIAL. SURROUNDING
t ISTMICE OF 5, PER
LOT 6 x 25 qI IRRnuNnING THE LEACHING FIELD FOR A DI
85.912 S.F.
310 CMR 15.255.
SOIL LOGS #P-10.722 DATE 0
SOIL LOGS DATE: 10/17/80 2-00 ACRES
EXISTING SEPTIC SYSTEM LOCATION PER INSTALLER'S CARD.
ENGINEER: Stephen A. Wilson,P.E. 31.3'X 37.0 PERMIT 181--716
ENGINEER : BOARD OF HEALTH AGENT: BOARD OF HEALTH AGENT:David Stanton
Alan Jones,P.E. Paul Murray
L LOCATION OF UNDERGROUND UTILITIES ARE APPROXIMATE AND
TEST PIT I TEST PIT I LOCATION OF LEACHING"SYSIV SHOULD BE VERIFIED IN THE FIELD BY THE APPROPRIATE
G.S.E. - 36± G.S.E. - 21.5± FROM INSTALLERS AS-13ULT CARD UTILITY COMPANY PRIOR TO ANY CONSTRUCTION.
0, 0: 0
Loom and Subsoil 0
* 2 2*
72 Sandy Loom, 10 YR 314 Ui
72A 510 Ap, So N/F GALLAGHER el
Medium to 5
Coarse Sand ;. B, Sandy Loom, 10 YR 5/8
144w 2
27w Finely Stratified 10 YR 7/4
�'��/ �/ /
NO WATER ENCOUNTERED RATE= <2 MIN/IN 126- Medium Sand
NO WATER ENCOUNTERED RATE- <2 MIN/IN
UNABLE TO SOAK UNABLE TO S6AX
Leaching Area Requirements
263.51' 0 120 Cedar Tree Neck Road
0) N 68e 4 BEDROOMS AT 110 GPD/BEDROOM = 440 GPD
*03 W -j Marstons Mills, Massachusetts
N/F RUGG C.B. NO GARBAGE GRINDER PREPARM MR
FND. PERC RATE = 2 /1 MIN. / INCH (CLASS I ) John & Debra Brodeur
NOTE. IF AREA OVER SEPTIC SYSTEM IS UNPAVED, MANHOLE COVER & DESIGN SCHEDULE ELEVATION 32' LTAR = 0.74 GPD/S.F. TITLE
FRAMES ARE NOT NEEDED. ADJUST CONCRETE COVERS TO 6' FINISHED FLOOR ELEVAT10N 38.4 4' MIN. LEACHING AREA OF SAS.
BELOW FINISHED GRADE SEWER INVERT AT FOUNDATION -33.3 1
SEWER INVERT INTO SEPTIC TANK -33.1 440 GPD/ 0.74 GPD/S.F. 595 S.F. MIN. Septic System Upg
F.F.E. 38.4 rade: Assbuilt
SEWER INVERT OUT OF SEPTIC TANK -32.9 PROPOSED SYSTEM
- -t-7T)
TYPICAL SY'�TEM PROFILE SEWER INVERT INTO DISTRIBUTION BOX 24.7 4 4' 12'
FINISHED GRADE - 36.2 SIDEWALL (12'+40)(2-)(2) 208 S.F.
• BA=R9 NYE & HOLMIGUN, INC.
NOT TC SCALE SEWER INVERT OUT OF DISTRIBUTION BOX 24.5
3OTTOM 12' X 40' 480 S.F.
.Af
SEWER INVERT INTO LEACHING SYSTEM 24.0
Af4
BOTTOM OF LEACHING SYSTEM 22.0 40 TOTAL 6W S.F. Registered Professional Of
WATER TABLE. NONE' OBSERVED AT EL 11.0 - Engineers and Land Surveyors S PHIF
FINISHED GRAM OVER TANK 36 0.+ 812 Main Street, 0stezville, Massachusetts 02655
FINISHED GRADE OVER D. 9OX 28.0± PLAN OF PRECAST LEACHING CHAMBERS co
FrMSHO GR4DE OVM 1.154CHK TROCH 26.01 Phone - (508) 428-9131 Fax - (508)428-3750 No.3021e
NO SCALE
COVER ADJUSTED TO n-,
4* SCH 40 PVC zt z 4m SCH. 40 PVC WITHIN 9* OF F.G. MANHOLE FRAME AND
0 2.OX 20 0 20 40
TYPICAL) r(n*L 9* (min) Cover COVER TO GRADE
0 2.0% FIRST 2' (TO BE LEVEL) 36' (max) Cover (IF UNDER PAVEMENT) 314m IF
�rA 10- Pr,& PROVIDE NEW WLET TEE then 0 2.0% CONNECTION WASHED STONE REMOVEABLE COVER SCALE IN FEET
WITH GAS BAFFLE CONCRETE MWWRMR LEACHING CHWIERS OUTLET PIPES
4* DIP. PVC h 11 REOD.)
PROVIDE INLET ME SCALE:1"=20' DATE: 0 1/16/04
REINFORCED 2*PEASTONL
INV= 24.5 T =3 C=1 ., L, -T V
•
INV=
24' 12a • REV. DATE. REMARKS
T
-2".r INLET PIPE 8/02/04 Add NewTest Pit
DEPTH 12
DIST. BOX
(SEE DETAIL) LEL. 22.0 4' 4' 4# [-8 a t= -2- 3-22-05 Repair C
5o MIN ASHED STONE 12' -3- 5-12-05 Rev. Leaching System
No Groundwater Observed 0 Elev. 11.0 -4- 6-09-05 As-Built Leachin DRAWING NUMBEI?
LEACHING CHAMBERS CONCRETE FLOWDIFTUSOR DETAIL DISTRIBUTION BOX 0:\1999\99083\survey\worksht\99083asbuilt.dwg
EXISTING 1,000 GALLON SEPTIC TANK DISTRIBUTION BOX (H 20 LOADING) NO SCALE JOB # 1999-083
140 SCALE