HomeMy WebLinkAbout0027 CHUCKLES WAY - Health 27 Chuckles Way, Marstons Mills
i
�I
101fl
Fac.�l�c� tb
C) 91Zo 1� -
CUVLS a� (9; 'r C�l4r�if L1��
LOT 30
!tit IL,I !fie S�
14,985.8 f S.F.
c"i
S9,
r I
0,110
101�
oE�
e,�NNcrFr�S N�Q4 N
�I N
ROBIN q�yG ROBI
WILLIAM WILLIt,:'1.4
WILCOX
No, 31341 No. 31341 79.00,
p O ��
DF� �C'rSTE� JQJ �Fr �C'/STE.���r' Shy GL
d/OPAL LAN SaAL LAP10
TO THE BEST OF MY INFORMATION, "PROPOSED" PLOT PLAN
KNOWLEDGE, AND BELIEF THE BARNSTABLE, MASS.
STRUCTURES SHOWN ON THIS PLAN LOT 30, PL. BK. 436 PG. 67
HAS BEEN LOCAT D ON THE G UND DATE 916/2016 SCALE 1" 30,
AS INDICATE r JOB 7758-00 CLIENT PARADISE
TSER
9/6/2016 SWE 203 SE CKET ROAD ENGINEERING
DATE AOFESSIONAL LAND SURVEYOR PO BOX 713 SOUTH DENNIS, MA 02660
OFF. 508-385-6900 FAX. 508-385-6991
C: I S8 I PROD 1 7758-00 1 dwg 17758-CPP.DWG 9 2016 SWEETSER ENGINEERING
TOWN OF BAMSTABLE
r L(JCAn0N �7 eG Ur k k S u/i4r.1 SEWAGE # .ADD q— I f Z
VILAGE /h1aHSt0HS ASSESSOR'S MAP & LOT j o i LW-7##S-
INSTALLER'S NAME&PHONE NO.-So?- y20-��38' Js,A WC,5
SEPTIC TANK CAPACITY /000 / /
LEACHING FACILITY: .�-34 S4 h b
(type) ianr �H (size) �f2 AC 1 U
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMIT DATE: �-'2 7-0 9 COMPLIANCE DATE: 3 9
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 leac 'ng facility) Feet
Furnished by
I
CLu��!.�s� �� — �
—�
� 8���
� I �\,�.
[ C[� � Ci ���r�
1. � � �� 3�
t�_ _; •
�I ��,Y
,��e,
' ,
No. (1� '' I ' Fee IP
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISI6N -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
fpplication for disposal bpstem (Construction Permit
Application for a Permit to Construct(Repair( pgrade( .) Abandon( ) ❑Complete System (individual Components
Location Address or Lot No. 4 7 G h ue k -e 5 �/ y Ownej's Name,Address,.and Tel.No.
!�/It�t".�'?'vos 411,(I,s' 4 4411 fTOS
Assessor's Map/Parcel
In taller's Name Add ess,and Tel.No.S OO*_�g®_y�3,F Designer's Name,Address,and Tel.No. S-Og_y2g:4-3�7
j
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
v
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 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 Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by _ Date
Application Disapproved by Date
for the following reasons
Permit No. 6)�� �� Date Issued s a
•No- Vd-/ ' I V)- p- _ a. :..�. Fee do •-
THE COMMONWMEALTH OF MASSACHUSETTS Entered in computer: IJ
s PUBLIC HEALTH DIVISIO TOWN OF BARNSTABLE, MASSACHUSETTS Yes
N
Wication for Bisposal *pstrm Construction 3permit
Application for a Permit to Construct(4YRepair(4y6pgrade( ) Abandon( ) ❑Complete System [I]i Individual Components
Location Address or Lot No. 4 7 G`j ac k z e,5 w,*/ Owner's Name,�orsrlif Address,and and Tel.No.
Assessor's Map/Parcel �6/_ _ a
Installer's Name,Address,and Tel.No.Sag-ago-?7,38 Designer's Name,Address,and Tel.No. S PO-c�2Ca'-(,3/P 7
,los eph 0.0 f ar�'as' .s'rrroy
/a
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) DO gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature oo/ff Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of ih 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 Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date S , � O 1 r
�v -
Application Disapproved by ( Date,,-,
for the following reasons •r
Permit No. 60 y �� Date Issued S G 4)
-------- ------------------------------------------------------------- - - - - - -- - - - -- - --
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(c-.)--- Repaired Upgraded( )
Abandoned( )by 6 nSr�D� 120 S
at �J �/� � �/,rz y has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. D MCI -/(Q-dated �� 7 4 07.
Installer Vpfa,�lj �� ��,���,.� � Designer S'1"'�=7'Sp^� �
#bedrooms 13 Approved design flow 1\2 3() gpd
The issuance of this permit 9hal'1 not be construed as a guarantee that the system will funatio �designed. �
Date k�) (% Inspector ) ) i � �. I�
- i
Ok
No. 06� " /(,/) Fee /(y -
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction permit
Permission is hereby granted to Construct( :.4- Repair( 64�' Upgrade( ) Abandon( )
System located at �j�/r� S ��,,// •�
7
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 mustrbe completed within three years of the date of this permit.
Date S C2 7/,j cf Approved by
r
r
TRANS. NO.:
CITY/TOWN:
APPLICANT: 'i ,_G;'A/n��t— T0.f F S
ADDRESS: �7 G1�yc..«� V„/,4j,
DESIGN FLOW: 13K,30 gpd
REVIEWED BY: DATE:
N/A OK NO
Legal boundaries denoted [310 CMR 15.220(4)(a)]
Street, Lot, tax parcel number and lot number noted on plan [310
CMR 15.220(4)(u)]
Locus Provided [310 CMR 15.2204(t)]
Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for-
components) [310 CMR 15.220(4)] V
Easements shown [310 CMR 15.220(4)(b)]
System located totally on lot served [310 CMR 15.405(1)(a) for
upgrades]- if not, a variance is required [310 CMR 15.412(4)]
Location of impervious surfaces (driveways, parking areas etc.)
[310 CMR 15.220(4)(d)]
Location all buildings existing and proposed 310 CMR
15.220(4)(c)] V
Location and dimensions of system components and reserve areas.
[310 CMR 15.220(4)(e)]
System Calculations [310 CMR 15.220(4)(0]
daily flow
septic tank capacity(required andprovided)
soil absorption system (required andprovided)
whether system designed for garbage grinder ,
North arrow [310 CMR 15.220(4)(g)]
Existing and proposed contours [310 CMR 15.220(4)(g)]
Location and log of deep observation holes (existing grade el. on
each test) [310 CMR 15.220(4)(h)]
Names of soil evaluator and BOH representative [310 CMR
15.220(4)(h) and (i)]
Location and date of percolation tests (performed at proper
elevation?) [310 CMR 15.220(4)(i)]
Percolation test results match loading rate? 310 CMR 15.242]
Certification statement by Soil Evaluator 310 CMR 15.220(4)0)] F S
Observed and Adjusted groundwater(method for adjustment
given or indicated) [310 CMR 15.103(3) and 310 CMR
15.220(4)(n)]
Address Sheet 1 of 7
N/A OK NO
Location of every water supply, public and private, [310 CMR
15.220(4)(k)]
within 400 feet of the proposed system location in the case
of surface water supplies and gravel packed public water supply
within 250 feet of the proposed system location in the case
within 150 feet of the proposed system location in the case
of private water supply wells
Location of all surface waters and wetlands located up to 100 ft.
beyond setbacks listed in 310 CMR 15.211 and any catch basins
located within 50 ft. [310 CMR 15.220(4)(1)]
Water lines and other subsurface utilities located [310 CMR
15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[1])
Profile of system showing invert elevations of all system
components and the'bottom of the SAS [310 CMR15.220(4)(o)]
Stamp of designer [310 CMR 15.220(1) and 310 CMR 15.220(2)]
Stamp of Registered Land Surveyor(required if construction
activities within 5 ft. of lot line) [310 CMR 15.220(3)]
Test Holes adequate (two in each of the primary and reserve
unless trenches as permitted in 310 CMR 15.102(2) or as
approved for an upgrade under LUA at 310 CMR 15.405 1)(k)]
Test hole adequate to demonstrate four feet of suitable material?
[310 CMR 15.103(4
Test Holes adequate to confirm adequate groundwater separation?
[310 CMR 15.103(3)
Benchmark within 50-75' of system [310 CMR 15.220(4)( )]
Materials specifications noted? [various sections of 310 CMR
15.0001
System components not> 36" deep (unless Local Upgrade
Approval or LUA requested) [310 CMR 15.405(1(b)
Address Sheet 2 of 7
N/A OK NO
SEPTIC TANK �� x � ;r � �t ,
Size OK? [310 CMR 15.223(1)]
Inlet tee located ten inches below flow line [310 CMR 15.227(6)]
Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR
15.227(6)
Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)] ✓
Note regarding installation on stable compacted base [310 CMR
15.228(1)] 10606 TN
Separation between inlet and outlet tees (no less than liquid
depth) [310 CMR 15.227(2)]
Inlet/Outlet elevations at least 12" above high groundwater
(except as described 310 CMR 15.227(5)) or permitted for
upgrades under LUA [310 CMR 15.405(1)(k)]
Minimum cover 9" (Tanks buried more than 9" must have risers
on all openings and on the d-box) [310 CMR 15.2228(1) and 310
CMR 15.232(3)(f)]
Three access covers (inlet and outlet must be 20" or greater) -
middle access at least 8" (by 7/07) [310 CMR 15.228(2)]
Access to within 6 " of grade - one port for systems<I 000gpd,
two fors stems >1000 gpd[310 CMR 15.228(2)]
All at-grade covers secured to unauthorized access? [310 CMR
15.228(2)] '
> 10 ft from building foundation [310 CMR 15.211(1)]
Buoyancy calculation Required/Done [310 CMR 15.221(8)]
H-20 Where appropriate? [310 CMR 15.226(3)]
Setbacks from resources [310 CMR 15.211]
Required when other than single-family dwelling or flow>1000
d [310 CMR 15.223(1)(b)]
First compartment 200% daily flow; Second compartment 100%
daily flow [310 CMR 15.224(2) and (3)]
"U" pipe through or over baffle, outlet of each compartment with
gas baffle or approved filter [310 CMR 15.224(4)]
Address Sheet 3 of 7
N/A OK NO
BUILDINGASEWERY ,n�kOTIHERPI?PING2 ?� � $, � x
Located at least ten feet from any water line? [310 CMR
15.222(2)] t
piping Disposal iP in at least 18" below water line (when water and
P
sewer cross, see 310 CMR 15.211(1)[11)
Cleanouts required/provided ? [310 CMR 15.222(8)]
Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)]
Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable
[310 CMR 15.222(6)]
Proper pitch on all runs? (.005 within gravity-distributed trenches /
and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] V
Siphonproblem/ (leachfield below pump chamber)
Endcaps or vent manifoldspecified?
Size and orientation of discharge holes specified? (not smaller
than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310
CMR 15.252(2)(h)
Materials specified (310 CMR 15.251(5) specifies various pipe
t es allowed)
HINT,)
Stable compacted base [310 CMR 15.221(2) and 310 CMR
15.232(2)(a)]
Splash plate or baffle tee required on inlet/provided? (when
pressure sewer to d-box or steep pitch of gravity sewer) [310 f
CMR 15.323(3).(a)] -
Riser if deeper than.9" [310 CMR 15.232(3)(01
Inside minimum dimension 12" [310 CMR 15.232(2)(b)
Minimum sum 6" [310 CMR15.232(3)(e)
Watertight cover if<2000gpd); waterproof manhole if>2000gpd
[310 CMR 15.232(3)(d)]
PUMP CRa S
Os.G, kn.�.� »�.,,�
Capacity(emergency storage above working--design flow)? [310
CMR 231(2)]
Proper setbacks [310 CMR 15.211 (same as septic tanks)]
Watertight 20-in minium access manhole at least 20" MUST BE ✓
TO GRADE [310 CMR 15.231(5)]
Service components accessible (not too deep with piping,
disconnects accessible
Alarm floats - alarm on circuit separate from pumps specified?
Exceeds two units must have two pumps operating in lead-lag
mode. [310 CMR 15.231(6) and (8)]
Stable Compacted Base 310 CMR 15.221(2
Buoyancy calculations needed ? Provided? [310 CMR 15.221(8)]
Address Sheet 4 of 7
N/A OK NO
SOILABSO:RPTION SYSTElYIS (SASj,GENE' S
Calculations correct?
4 feet of naturally occurring material demonstrated? [310 CMR
15.240(1)]
Required separation to groundwater? [310 CMR 15.212)]
Aggregatespecified as double washed [310 CMR 15.247(2)]
System Venting required/provided? (system under driveway or
>36" deep) [310 CMR 15.241] Cv�6 6 '
Inspection ports specified and within 3"final grade? [310 CMR
15.240(13)]
Breakout requirements met? (No violation of breakout elevation
within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and
Guidance Document]
;,GALLERIES,�ITS CHAIVIBI2S 31i1CIi'I) XS 253Jg,t N
Chambers and Gal. in trench configuration supplied with inlet
every 20 ft. [310 CMR 15.253(6)]
Each structure with one inspection manhole (if>2000 gpd must ✓
be tograde) [310 CMR 15.253(2)]
Aggregate 1'minimum- 4'maximum. [310 CMR 15.253(1)(b)]
2' sidewall credit maximum [310 CMR 15.253(1)(a)]
In bed configuration, inlet every 40 s . ft. [310 CMR 15.253(6)] ✓
TRENiES3, �0Y 81 �3ty . r s
-WON,
Width 2`minimum 3'maximum [310 CMR 15.251(1)(b)] ✓
100 feet - maximum length [310 CMR 15.251(1)(a)]
Minimum separation 2x effective depth or width whichever
greater(3x if reserve between trenches) [310 CMR 251(1)(d)]
Situated along contours [310 CMR 15.251(2)]
Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document]
BED SASS{1VIaximum siz o lied'o e]c� 00�gOEM
minimum 2 distribution lines [310 CMR 15.252(2)(a)] t/
Maximum separation between lines 6' [310 CM R15.252(2)(d)]
Maximum separation between lines and outside of bed 4' [310
CMR 15.252(2)(e)]
Aggregate depth below discharge pipes 6" minimum, 12"
maximum. [310 CMR 15.252(2)O]
Separation between beds 10' minimum. [310 CMR 15.252(2)(f)]
Bottom area used in calculations only [310 CMR 15.252(2)(i)]
Address Sheet 5 of 7
N/A OK NO
,,,x... n..:, d. x�,., ;fir. xw .<o-
Pressure Dosed System ? Provided pump and piping
calculations as required [310 CMR 15.220(4)(r)
Pressure dosing required on all systems >2000gpd or alternative
systems under remedial approval [310 CMR 15.254(2) and I/A
Remedial Use Approvals]
If used in gravelless system -make sure jet is directed as not to
scour soil interface Guidance Document
Inspections once per year(systems<2000 gpd) or quarterly
(>2000 d) good to note on plan [310 CMR 15.254(2)(d)]
Construction in fill Did the plan specify that the fill shall meet
the specification of 310 CMR 15.255(3)?
Impervious barrier and/or retaining wall ? [Guidance Document).
Impervious barrier installation must be supervised by
designer [310 CMR 15.255(2)(b)]
Retaining wall must be designed by Registered Professional
Engineer [310 CMR 15.255(2)(a)]
Side slope not exceed 3:1 ? [310 CMR 15.255(2)] t/
Breakout requirements met? [310 CMR 15.252(2) and v
Guidance Document]
At least 5 ft. from impervious barrier to edge of SAS (10 ft.
recommended) [310 CMR 15.255 (2)(e
Check DEP Approval letters for credits and design conditions
If used with pressure dosing do not allow pressure discharge
to scour soil interface
wrar� '�`,'rn� � �,
Was DEP Approval Letter provided and/or have you
reviewed the letter for conditions?
Is-the-technology-being properly applied and does_it.meet_all_.
DEP Approval Conditions?
Is there a note on the plan regarding the requirement for
e etual maintenance agreement?
Any alarms involved on separate circuits
Did the applicant-submit an operation and.maintenance
manual?
Has applicant submitted a copy of a maintenance
raz£ �.
C�arlance � - �` �,:�
Are the variances listed on the plan ? [310 CMR 15.220
RLS Stamp necessary on plan if a component is within five
feet of property line [310 CMR 15.412(4)]
""New construction or increased flow proposed - [Refer to 310
CMR 15.414]
Address Sheet 6 of 7
19
N/A OK NO
Is the system in a Designated Nitrogen Sensitive Area(Zone II for
a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and
310 CMR 15.216 - also refer to Policy regarding upgrades of such
existing systems]
Is the system proposed on the same lot as served by private well ?
[310 CMR 15.214(2)]
Are the nitrogen loads proposed in compliance? [310 CMR
15.216(1)]
Mcscellaneoics � n r � �� � ,VR
< � r
Pumping to septic tank ? [ 310 CMM 15.229]
Shared System [310 CMM 15.290]
Address Sheet 7 of 7
f
r`
Town of Barnstable
�. Regulatory Services
Thomas F.Geiler,Director
MASS,SAS public Health Division
%39. Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fait: 508-790-6304
Date: 5 Vn/F / oc f Sewage Permit# oo -/,'/Z- Assessor's Map/Parcel O/ /o o S
Installer& Designer Certification Form
Designer:( T�Tsc7n��. ,�«�s Installer: v0 S
Address: Address:
On J'- 4 ? ^ o ,o s� �� UJ /^�r�S was issued a permit to install a
(date) T (installer)
septic system at W i nit' ./S based on a design drawn by
(add )
dated o po
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State &Local Regulations. Plan revision or
certified as-built by designer to follow. Stripout(if require ected and the soils
were found satisfactory. at-�tN oF44,T0
qc
sTEITON tiN
R.
(Insta ler's Sign e) HALL
� No.sal Q
so��FgFD SA���P�
( EV A I IJP�0
(Designers Signature) (Affix Desire ""V p 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.
gAoffrce formsWesignercer ification form.doc
TOWN OF BARNSTABLE
LbCATION
a�6h�.Ltz-5 (,� � S 4GE
`ILLAGE /�� f�S ASS�ESS�OR'S MAP & LOT/Ll-1b1-v
'S NAME&PHONE NO ��'c(c-�- -�' ,��
SEPTIC TANK CAPACITY 1000
LEACHING FACILITY: (type)"t"� (size)
NO.OF BEDROOMS J
BUILDER O OR\- =i i�n ��e� �' P M0 S
PERMIT DATE: C DATE: I1 I°i /0
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
huck/es Wa y
V
Water
Service
Driveway
i
P
." I :;'?2>??%::ii'tt?�ii'ii'`?:�t�i':'i::::i'iiii'i;'iy;�'';??�c�,:;?%�<';�s;%�i!i��::,•��'-?`,t
31 29
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d
DEPARTMENT OF ENVIRONMENTAL PROTECTION
r
V�v
TITLE 5
OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: :17 Chuckles Way
Marstons Mills MA 02648
Owner's Name: ,ifillian Varetimos = ' �
Owner's Address: Same
Date of Inspection: November 9,2006 Job#06-283 �.
ry
Name of Inspector: PATRICK M. O'CONNELL �
Company Name: SEPTIC INSPECTION SERVICES CO. "'
Mailing Address: 189 CAMMETT ROAD t�
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEr,
Itrr►►►approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evalu on by the Local pproving Authority = M. :—mi
Fai / \
ELL �;
Inspector's Signature: Date: 11/9/06 % o'
;., T�„�t?r!F1�•�o���.
4�•`'�e u 1111111��
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.
Notes and Comments: Tank was pumped as part of inspection,liquid level in pit is currently 12"below inlet.
****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.
Page 2 of 11
OFFICIAL, INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 27 Chuckles Way, Marstons Mills
Owner: Jillian Varetimos
Date of Inspection: November 9,2006
Inspection Summary: Check A,B,C,I)or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ I have not found any infb-mation which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exf Itration 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 ol'sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken„settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAI. INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued).
Property Address: 27 Chuckles Way,Marstons Mills
Owner: Jillian Varetimos
Date of Inspection: November 9,2006
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water:supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".'Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAI.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:27 Chuckles Way,Marstons Mills
Owner: Jillian Varetimos
Date of Inspection: November 9,2006
D. System Failure t['Iriteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
—X—
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_X_ Discharge;or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
—X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
—X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X Any portion of a cesspool or privy is within a Zone 1 of a public well.
—X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
_No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15,303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large 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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone If 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 g y e 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.
r
Page 5 of I 1
OFFICIAI. INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:27 Chuckles Way, Marstons Mills
Owner: Jillian Varetimos
Date of Inspection: November 9,2006
Check if the following have been done. You must indicate" "yes or no as to each of the following: i
Yes No
_X_ _ Pumping information was provided by the owner,occupant,or Board of Health
_ _X_ Were any of the system components pumped out in the previous two weeks?
_X _ Has the system received normal flows in the previous two week period?
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection
_X_ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ — Was the facility or dwelling inspected for signs of sewage back up?
_X_ _ Was the site inspected for signs of break out?
_X_ _ Were all system components,excluding the SAS, located on site?
_X_ _ 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?
_X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
_X_ Existing information. For example,a plan at the Board of Health.
X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:27 Chuckles Way,Marstons Mills
Owner: Jillian Varetimos
Date of Inspection: November 9,2006
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 4
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):No
Water meter readings, if available(last 2 years usage(gpd)): Two years total:310,000 gal.=424 gpd.
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIALAN]DUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records: tank pumped every 18-24 months.
Source of information: Owner
Was system pumped a,part of the inspection(yes or no): Yes
If yes,volume pumped:_1000_gallons--How was quantity pumped determined?
Reason for pumping: Scheduled Maintenance
TYPE OF SYSTEM
_X_Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool'
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_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:
1991
Were sewage odors detected when arriving at the site(yes or no): No
Page 7 of 11
OFFICIAI. INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 27 Chuckles Way,Marstons Mills
Owner: Jillian Varetimos
Date of Inspection: November 9,2006
BUILDING SEWER: XX (locate on site plan)
Depth below grade: P
Materials of construction:_cast iron X40 PVC_other(explain):
Distance from private water supply well—or—suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 18"
Material of construction:_X_concrete_metal fiberglass_polyethylene
_other(explain)_
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: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 slum 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: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees are intact and clear,tank shows no evidence of leaks
GREASE TRAP: No (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(on pumping;recommendations, inlet and outlet tee or'baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
r
Page 8 of 11
OFFICIAL, INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:27 Chuckles Way,Marstons Mills
Owner: Jillian Varetimos
Date of Inspection: November 9,2006
TIGHT or HOLDING TANK: No (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and'float switches,etc.):
DISTRIBUTION BOX:XX (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: 0"
Comments(note if boa:is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
No solids or hieh stains.
PUMP CHAMBER: No (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.):
I�
Page 9 of l l
OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:27 Chuckles Way,Marstons Mills
Owner: Jillian Varetimos
Date of Inspection: November 9,2006
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X leaching pits,member: One 6x6 pit.
_leaching chambers,number:
_leaching galleries, number:
_leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.): Liguid level in pit is 12"below inlet pipe,high stain lines indicate pit'has 1"of effective leaching
Leaching pit was chemically treated following inspection to reduce standing water in pit
CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: No (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.):
t
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:27 Chuckles Way,Marstons Mills
Owner: Jillian Varetimos
Date of Inspection: November 9,2006
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.
Chuckles Wa
Water
Service
Driveway
............................... ......... . ....
..... ..... ......
31 29
7
5
Page 11 of 11
OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:27 Chuckles Way,Marstons Mills
Owner: Jillian Varetimos
Date of Inspection: November 9,2006
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 20 feet
Please indicate(check:)all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
_X_Accessed USG""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.40 and topo map shows property above el.60.
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 7 CAue
Owner's name 9 h h Morris
Date of Inspection _ ,: -
1�1.7rr - l,,r� C url> �. PART A
CHECKLIST
Check if the following have been done:
✓ Pumping information was requested of the owner, occupant, and Board of
Health.
L/ -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 built plans have been obtained and .examined. Note if they are not
available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
All system components, excluding the SAS, have been located on the
C_ site.
tL The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
11 l2
�O
4 1
AUG 3 1 1995
=0FWM= w
�r
n ,
i
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
number of bedrooms
number of current residents
garbage grinder, yes or no'
laundry connected to system, yes or no
seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
' Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information: `
J ' System pumped as part of inspection, yes or no
if yes, volume pumped
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)
Other (explain)
Approximate age of all components Date installed, if known. Source of
information: ��v t. a-.°' fe�J�
wt-
Sewage odors detected, when arriving at- the site, yes or no
i
i,7 R
` I
f
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: P .
(locate on site plan)
depth below grade: � �
material of construction: uHconcrete metal FRP other(explain)
dimensions: Tk"&
3 sludge depth
distance from top of sludge to bottom of outlet tee or baffle
scum thickness
- 477 distance from top of scum to top of outlet tee or baffle
distance from bottom of scum to bottom of outlet tee- or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
DISTRIBUTION BOX: ✓
(1-ocate on site plan)
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc.)
PUMP BER:
(locate site plan)
pumps in king order, yes or no
Comments:
(note condition of pump chambe ond' 'on of pumps and appurtenances,
recommendations for maintenance 'rs,etc. )
f
• 1�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) : t/
(locate on site plan, if possible; excavation
approximated oximated not required, but may be
pp by non-intrusive methods)
If not determined to be present, explain:
Type
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool , number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
. condition of vegetation, recommendations for maintenance or repairs,etc. )
7
CESSPOOLS (locate on site plan) :
number and c iguration
depth-top of li 'd to inlet invert
depth of solids lay
depth of scum layer
dimensions of cesspool
materials of construction
indication of groundwater
inflow (cesspool must umped as
part of inspectio
Comments
(no condition of soil, signs of hydraulic failure, leve f ponding,
co dition of vegetation, recommendations for maintenance or re irs,etc. )
PRIVY:
(locate on si plan)
materials of construc n
dimensions
depth of solids
Comments:
(note condition of soi igns of hydraulic ure, - level of ponding, '
condition of ve ion, recommendations for main nc --i e or repairs etc. )
f
. 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
L)
C
DEPTH TO GROUNDWATER
depth to* groundwater
method of determination or approximation:
/Qll�"'� r�' 4�=� [r y: F�ry.: {�'D'1 O� ��7 /{e:5^:: ✓1�u 7':%s� 'g,?:z.a:
}r!
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOM FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, H, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not).
Alt' Backup of sewage into facility?
Discharge or ponding of effluent to the surface of the ground or
surface waters?
Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
°! Required pumping 4 times or more in the last year?
number of times pumped
4 ' Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent? ,
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water.
i ! within . 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
within 50 feet of a private water supply well?
less than 100 feet bu
t t greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analysis
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector
Company Name
Company Address
Certification Statement
I certify that I have personally inspected the sewage disposal system at
. this .address and that the information reported is true, accurate and
complete as of the tine of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Check one:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector' s Signature
Date Y
Original to system owner
Copies to:
Buyer (if applicable)
Approving authority
KEY NUMBER <10354 >
- -
NAME MORRIS, NELSON W > B C 1 B C 2
B-C 3 B-C 4 ZOC
STREET 27 CHUCKLES WAY
CITY MARSTONS MILLS ST MA ZIP 02648-1504 REF 1 REF 2
PHONE ( ) - REF 3 REF 4
METER NO. < 10015> DATE READING CONS
STREET <CHUCKLES WY NO. 27> 06/30/95 342 15
CITY MM I ST LOC 12/31/94 327 42
PHONE ( 508) 420-3221 06/30/94 285 24
12/31/93 261 61 -
ROUTE NUMBER 03 06/30/93 200 29
SERVICE DATE 10/13/90 12/31/92 171 53
METER DATE 11/02/90 06/30/92 118 31
CAPACITY 7 12/31/91 87 60
STYLE T10
SIZE 1 RATE SCHEDULE
KEY PIT PLASTIC X
NOTE RR LEFT SIDE LEAKS 1/18/94 ADDITIONAL CONS 0
ALTERNATE MIN 0
TOWN OF BARNSTABLE 4
LOCATION CO 114 ) <<"`jc�'�5 �` SEWAGE #
1
VILLAGE �AcS �c+h5 w,1S ASSESSOR'S MAP & LOT
p INSTAL&.ER'S NAME & PHONE NO. 7-T ��'ScO� � '5o6 -771-10
.b .
A SEPTIC TANK CAPACITY (� � A((0►`S
' LEACHING FACILITY:(type) L2 c_t cl l •1 (size) ( d
- IC WATER
NO. OF BEDROOMS __PRIVATE WELL O PUBL
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COZIPLIANCE ISSUED: /V ��
VARIANCE GRANTED: Yes No
N
�W
N S
as ti
ti-50
i
fwpiI
I
06°ro OF BARNSTABLE
L'&ATION #3() yc�tc5 6y SEWAGE #
L
VILLAGE WIC"5 4o,f Wt.,,5 ASSESSOR'S MAP & LOT
p INSTALLER'S NAME & PHONE NO.
b /
SEPTIC TANK CAPACITY
c LEACHING FACILATY:(type) o►c V `t (size) t Odd (t_d
NO. OF BEDROOMS _PRIVATE WELL O PUBLIC �iVATER
BUILDER OR OWNER F;7, S'� Co.
Ca
DATE PERMIT ISSUED:_9-/�7/7C)
DATE COZIPLIANCEtiISSUED:
L0410
VARIANCE GRANTED: Yes No
—i- AA
�3�r /2 ✓/ c� 14
EVE�a
'~ THE COMMONWEALTH orMAssAo*ussTrs
BOARD OF HEALTH
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
JAqm�»y ��(��
............. - -' ----�-------' ----- ' ------ ''' ' ------------' .
'22
'� --'�'����''�---'�'~�-'--�����.����' _-- -'
---------------'-----------------'--'-'--- ----....-..........----'--'-..........................................................
�^^ Installer Address A
Ivne of BuildingS�oc Lot v feet
Dwelling--No. of Bedrooms --' . �� -----_--IIxpmuaioo Attic ( ) Garbage' Grinder (Z'L))
CIL4O8z�r--.�y�� �� 8uJJio� �&��t�� No. o6 persons-.-------.-_.- Showers ( ) Cafeteria ( )
1:14 Other 6xtoncu -------------_----------- . --------' |
Design Flow.......................... ....gallons per person per day. Total daily flow.-'---__--.-����c�--.gallons. �
04 Septic Tank—Liquid -galoou Length................ Width................ Diameter---------------- Depth................ �
Disposal Trench N Width.................... Total .................... Total area.-- __ag ft.
�� l�u . ��.-. D�oz�tcc �i Depth b6m� ��cL-' ��__ Total leaching area f�
- _--,_"_ -_- -�' -._.. -. ^ _ -_ __ ---___-,
Z Other Distributi Dosing tank
~~ Percolation Test Ileoolto Performed 6r--. 4C ............... Date........0��K!'Ao........
Test Pit No. ]--_Z"_'minutes per inch Depth of Test Pit.........1.7..... Depth to ground wotec--����-',-
Tea Pb No. 3................minutes per inch Depth of Test Pit.................... Depth toground water........................
0
'- Nutons of Repairs or Alterations--Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned uAneeo to ivatu8 the ufore6esoibed Individual Sewage Disposal System in accordance with
the provisions o{ TITLE 5 of the State Environmental Code--The undersigned 6uct6cru0cccy not to place the
system i . until a Certifi te of[o pliuu b h o6ofhealth.
Signed ------'-------------T-------------. ---�-���`-----
Application Approved By ------ ���~� ---------------------' -.��'=������^-
Application Disapproved for the following reasons: '_'_----__------_-_-----------_------.
---- -- ----------------------------------------
D�'
Permit No. Esued
No.... .:. �� FE$......
THE COMMONWEALTH OF MASSACHUSETTS
y BOARD OF HEALTH
..............-i�t'C.................OF.. .n t 1.:�'::6. -t .....................................
Appliration for Disposal Works Toustrnr#ilan amit
Application is hereby made for' a Permit to Construct ( or Repair. ( ) an Individual Sewage Disposal
System at: C . r
... __............................... .....•.......... .............. -•---...--•-----••--•-•-••-------••--.............._..... ..........._...............---•--
... . !yoCy...i.o. ddre, o
. .................._._......_. tN o
�_� .. ......•............. .........
O ner .....Address
Installer Address
Type of Building Size Lot.......__._.z..............Sq. feet
V Dwelling—No. of Bedrooms............................................_" Expansion Attic ( ) Garbage Grinder (Ajj)
LVV___1d` 1W__?-No. of persons............................ Showers — Cafeteria
per,, Other—Type of Building .___ p � ( ) ( )
a' Other fixtures oa
W Design Flow...........................��.. _........_gallons per person per day. Total daily flow.............................;�9.....gallons.
WSeptic Tank—Liquid capacityJ gallons Length................ Width........,....... Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.........._.. Total leaching area....................sq. ft.
Seepage Pit No__________________y Diameter------------a---- Depth below inlet.................... Total leaching area...... `_-4«�._sq. ft.
Z Other Distribution box Dosing tank ( )
`° � ���
a Percolation Test Result Performed by.......�....� >•r...�. ` �._...._�:.............. Date........................................
Test Pit No. 1-__------.-_-_minutes per inch Depth of Test Pit---------A-_... Depth to ground water.._...'"`.`""".........
(sir/• Test Pit No. 2................minutes per inch Depth of Test yPiit.................... Depth to ground water........................
O Description of Soil..-------••------....�....�°'.. ----•------- ) .M '1 '��d 3
. •....--•-.•... .------•---------------------------------•--....-----------------------•--•-------_-----
.
UNature 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in op n until a Certifi to of Complian has been issu d by the board of health.
�7�rs !
—�
'Kw Signed /..... _...
------- ---------- - --- -- ---- -- --
Dace
Application Approved B 1�---� ---------------------- -------- -----------
Pp PP Y ....-- ' 17 -pG
Application Disapproved for the following reasons: .......................... ........................ ..........................................................................
------------------------------------------.----------------------------------------------------------------------------------- .............................. ........................................
Dace
PermitNo- -------------------------------------------------------------------- Issued -------....---------------------------------------------------------
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
------------------ ---...... OF ----, - ---------------- -------- ----------- ............ ....
Cfez#tftrate of C�umplianre
T IS T CCE T FY, That the Individual Sewage Disposal System constructed (�( ) or Repaired ( )
by .f _)_
------------------------------------------.......................---------------............................-------
...---Installer �.
at ------.30------------------ - ----.. . ------ -�'f'/.---:C-.-------------------------------------------------------------------
has been installed in accordance with the provisio s of TITLE �ThQSt�Environmental Code as described in
the application for Disposal Works Construction Permit No. ................................................ dated ...............---.....-------..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---' . .......................................................... ---------..... Inspector ................... ----------------------------------------------------.........-- --
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
��- 37 ...........:. ..................................OF....... ...__........................ /DC�
No.....................��.. FEE........................
i �a1rk #rndilan rrmit
Permission is hereby granted..
---- -- ----
.....................................................
to Constr�ctQ(�C ) or R 'r ( ) an In,'vi ual Sewage osal yst
at No... �7. � --•---------* -------------------------------------------
- ------. - - -- ---------
- --- -------
Street �—
as shown on the application for Disposal Works Construction Permit No .....�..... Dated..........................................
C� S Board of Health
DATE-------------------/ = ..............................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ��
-ldciy
. anrn�t•,5 ;s-��s.��o =ar+i �'- ,�•_tn:•:n�. 1rt_�v�rr��:
'Ssv>N .VIO n��,`o�c� 1.or9 it I�+v't ct 511-11
I> 2i�.�xv'g
aW
st a
t 7-)V V-Il�I ZIVE ---,o rim c
Q 1Q �H� �v N51ry vY� tr•bia QN
r�1-VaaiS =�r-t1t N..IM
c�sa�dz,
n
ro
t�t011Y70� ,
121
'73 OAS `Rv!
MLI-A
a NZ. . S
• *Tv-D
-Ivv -nil 151Q �a•��t7 ���
wil
� 1.:. d�i 4v •�C
aw
NVAnins
-0 . Ii rr..�/rN���� ♦r��N�•IiI��NI/1 idn,�Iii //• _
8311d
�. �4� -•--x�F `� : ��'� �;4y � .�a •Ss�.�o•n�nr� nt„1 : ��qz� hoi�'v�Q���
Cud 9
OSS M
co -MSl O js <
N �'� ci'd•;� 4�� ;.L. x Oil = rnC'l.-d !.'1I
'mar-+tZ
xya
..�...._...�.�.........:..._.:.....w....^--.•:.^r=xs+�n:;w+a-rssrvurcawr a-.. -+y.wav ..r..v.-r.-c.--n-...+r-_ -•.....•....,... .....:.�.._««..�..._. ..w.._.._ .r.....« �..-_ «....._ 1 �
T
�l Ay '
r .�iIJ✓T�F� 'nlcsE ilJ6 //oi,/i✓�s�vT 3A /�/���J✓ •��/3L 7
"1 i�FG or r r;
zC1/ r✓��
�..- , +� ! , � �E�a ; .�x,�sr�!✓G Cvl,JT�v�s `, r- -..,` �,c�r Q'
C)
4�
y�' D�/-+ /`� 'I ; /AlraTv'�! J' /s,;!a% (rl�'C5 ) is �oc�F!� �.,1 1��<<H�.�� v/ c�Gv✓ s�`�E.��GY✓ �
,r I ,
1
t -7
ram,'' h� G/ i> t� /✓G>�E U S !T •.�G��l� TnJ�`-/� i9'%O',` l�i3f%�S W� ve
• ,. �"/����`�" r�T' ��� utr ✓� na more l �v2 G�Q�' 'J0 4,ucv�
1
{
!
_X Fli —_r,r47;a;:: /Z-1; 1
_ v_
!.. O%?o/G.aaG ENO%=--.• sr c v� J!
TOP OF FOUND4-10II
�;� CONCR�"Tc COVERS
M 1 d'S Rom"J-�`�. --{ — f��!•���-l-1 c L �X IS y�N •Y: .:.«.�-1( .-�:. ...•.... •• X , I �A .5 •---
.� -sir .✓.EC./ G' !
' /S�1n� 4 CAST i1RON t 9 . .. . ..,. �, a
,'`; OR SCHEDULE YO - 4"SCHEDULE 4O P.V.C. (ONLY) 9,`'MIN. LEACHING TRENCH (�)REQ.� '
P.V.C.PIPE mIN. r P -M rr n
PITCH I/4"P .F'L PIPE
IN. �, 1/e - 1/2 WASHED STONc' +
J PITCH 1/4 PS_R.F is
77-c r GAS BAFFLE-y. L- IN_
�J/'�_rQ�` /'I / 'l� � �... •.« LL �., ,�0 E�'i. ' ��./ r
! Q �`aY T�D%.7 �L �8/ ;.. INVERT SEPTi��Tp►CAt 1NVr' T EL��.3
x.sa T /FFWij7�/ x�9' i� �' , fir, Ye• El. � ' ../.A. DIST, INv�R►--� ,, , _ , r. Y.� . ;"
W .3lS>f•.Sj , .\ , ,`uti —,•� :b' + - M `u5:-`/.Q7 BOX E' ,'��` 'r .54 .Lc$?,9EF=�Fi.., ,�� /n/,-rG
��S'i!> Cr�USHED STONE ZQ �':l f`=- / / b.'�SHED SMNE1 �;.¢
'/ 'r'�?O�=�1! : Or" � �saT-ram o-- rc— _
-•/. 147 /ZSS GROUND WXt'ERR 1ABLE _05I✓C
SEWAGE DI�aF't}5��L 5YS'rENI
_`�-- SOIL Iron '
1 1 -•=-r'"•..-- DATr44. K ;Z ..Q,,1` TIME NO SCALD
> ! ! -
_ GAO 7"�Si HOL= I i4Si HOL= 2 ~fir-'----�--,- -;; ;
_LEV r_:_V. DESIGN DATA : �• i�j`,
A -
0= SE:rR0 his
J'z �py�''�y.�l-�,✓c� /-3 Lro.rli►'Ij/cSA�?OTAL ESTtt►SA��D FLOW ....-a:SQ... GALLONS/DAY ��r' ,• '•,-' '/ = a,
` !! BOr OM L£ACHIN AREA 9.2Z,%' SOJ-s./—MENC'ri F`s 'I
`G�' /�'1/-7 �� �aQ sR/�/6 �o ass/�3 Q f s S V
I r11 J [ . .30 �'L �.G R + 41,-<&>e,A0r/r 42,?-: _ � t � �7
�� » G,TGl1'nl►h`// SIDES L ACHING AREA . . . _,�Qla..`�GaO.: ./TRENCH �`��` r —' �•—� n•
IU R �/!'�3= C/ -aCaa .q�/, 3��/.fir/o,,//G�`/orll6 x2 10(�.�6 j,�,� 1 .,x�, •�
C G+ARBAGc D15?OSAL R R h1.2....(50% ARaA INCEASF-) 1~ wry -4 S/.5
r ,ay,�6/y .r �r= � �/6.
�vls loses TOTAL LEACHING AREA
SITE PLAN 27 C- HUCKL ES WA Y MA P S TONS MILLS R �� ��-Esc :� 2.9�z,,,� PERCOLATIONAT�•... . ....
- 9 AJ yZ' 7 iiV ? _. lON PATE V/,�ZS</E13�rTais
/17 rF<:-?nl1 �Q�!?7/3 CO��i 9/x i7� �CO•��G Gl�.� �OT f-r^
FOR ._�/.... r ._ _ VE . . . . . .. . ..... aFGROUND '�1."iEn t"..�L= �'
E4'�G•/-3 AP?ROV s7 . . $OArh.D OF HEAL%1
..JY:;.Y1:.iER ENCOU'VirAIEs7 DATE....... ..... . .... . ..... . . . \&CFh9 S
JILLIAN Ck CHP/S T OS VA PE T I MOS WITNESSED BY AGENT OR INSP—TOR
.&,4e)3O ARD Or I:--' LT H
ENGINEER . . . . . . . . . . . . . . . . . . . . . �` 2f
v
r r
. . . R;? //M . . . .. . . .
w.....rs-snrsC�T•,r..•....ram.. ..w...v...+..+'.. ...w-r,.✓+.�.�.«.-«...-.r.-.«,.a.+r+�R
li