HomeMy WebLinkAbout0151 CHUCKLES WAY - Health 151 CHUCKLES WAY.
t Marstons;Mills
.A = 101 — 057 00,5 -
t
TOWN OF BARNSTABLE
LOCATION _ t SEWAGE#
V VTLLAGF,� /( '
/SS9ESSOR'S MAP&PARCEL JII—f
INSTALLERS NAME&PHONE NO. �-
SEPTIC TANK CAPACITY
LEACHING FACILITY:( �a &fzsize) o �/
NO.OF BEDROOMS _
OWNER
PERMIT DATE: ls' COMPLIANCE DATE: 0
Separation Distance Betw en 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 wet exisf----.,
within 300 feet of leachi fa ili / Feet
FURNISHED BY i
r"
�
`7
ITOWN OF BARNSTABLE
LOCATION r.��j (® C�� �'�_L SEWAGE #
VILLAGE f Y rAC InS Md� ASSESSOR'S MAP & LOTZOJ,�067-0
INSTALLER'S NAME &'PIIONE NO. \1 _T, h&�SCQ11 !Z7/-/64)6
-SEPTIC TANK CAPACITY / _ 10bb
�.LHACHING FACILITY:(type) AST W;f _ (siZe) /�QQ
rl
,;NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER S((q(A Sictz
'\DATE PERMIT ISSUED:_,- r _
DATE COMPLIANCE ISSUED: l-
VARIANCE GRANTED: Yes No
i
LL
I �
i
L UG K 5 wA
No. a vt 0— � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:_�_Z
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplitation for 3DigpogA1 *paem Construction Permit
Application for a Permit to Construct( ) Repair grade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Loft No�.l t!17/UC� " Owner's Name,Address,and Tel.No. ,2,7 �7 apA&_Z�
Assessor's Map/Parcel
Installer's Name,Addre s,and Tel.No.Wqq tA;L Dir� Designer's Name,Address and Tel.N
5^er25' --�3 02' 3d�- -60�°-
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building _OeNo.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided���j' !GS gpd
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) ,>
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 oQJealth.
� p
Signed Date
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. ab( 0 Date Issued
�-
/ol-OS'7
a QI d w
No. r Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZfppCication for Migogar 6p.5tem Construction 30ermit
Application for a Permit to Construct O Repair(✓)Upgrade O Abandon O ❑Complete System ❑Individual Components
Location Address or Lot No. jl- rllUq,4�,5 WA/ Owner's Name,Address,and Tel.No.,j4tv7 /�- 6LOA
Assessor's Map/Parcel j}��-rp
-
Installer's Name,Address,and Tel.No.� `�t?1(6�t Z�)oDesigner's
4�t/ Name,Address and Tel.No.
�6 /lr ll-74C ! i �y 1k., D
Type of Building:
Dwelling No.of Bedrooms �j�-- Lot Size p /i T sq. ft. Garbage Grinder ( )
Other Type of Building /y_ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) - gpd Design flow provided �'j�j z 9 gpd
Plan Date Number of sheets Revision Date
Title
--"
Size of Septic Tank ;F. ~ Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 4.�1 T -, dy �� S
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 :��°, !J Date
Application Approved by (MjUAQADate
Application Disapproved by: Date
for the following reasons
Permit No. ( � Cj Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( )
Abandoned( )by uwi F/ /Di'loEr
at ., ` t- Z�, ,/' as been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. d 10 - 3 S 5 dated / /d
Installer Designer
#bedrooms 3 Approved design flo j a U gpd
The issuance of this ermit shall not be construed as a guarantee that the system wil� ctton as desi_ned.
Date �u �(� Inspector l ( Kl'•
'.
I '
— No. r� 4Ji /J""—� _�-} - --�— -. --—=—— — ——,--——.— Feet����----—
./
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
Bi!gpo5al *p5tem Construction 30ermit
Permission is hereby granted to Construct ( ) Repair (v) Upgrade ( ) Abandon ( )
System located at
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S a=ust
allowing local provisions or special conditions.
II` Provide : Con ruction completed within three years of the date of this permit.
r-K N ID
at�e� t ��/J ( � Approved by r
f
Town of Barnstable
�yIME a.� Regulatory Services
Thomas F. Geiler,Director
• BAMRABL& +
MAW
Public Health Division
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 503-362-4644 Fax: 503-790-6304
Installer & Designer Certification Form
Date: S116 116 Sewage Permit 3�3Assessor's MaplParcel oar"
Designer: 'V 1
I installer:
Address: _ —0 _90Y Address:
w 1 LH AM 02S37
On Afo f �as issued a permit to install a
(date (installer)
septic system at Ch1z( <JP(- yjk 'l based on a design drawn by
(address)
&/' dated l p
(designer)
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 anchor septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
&(Instal4ler's'ZS:i�gnatZure);�
OFAR" No. 1140
C^_ SANI TAR\P�
V
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BA TABLE 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_10-adoc
APPLICANT: D(A "q- � . M
ADDRESS:
DESIGN FLOW: 330 gPd
REVIEWED BY: DATE:
N/A OK NO
Le al 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)]
Easements shown [310 CMR 15.220(4)(b)]
System located totally on lot served [310 CMR 15.405(1)(a) for
upgrades]- i not, a variance is required 310 CMR 15.412(4)]
Location of impervious surfaces (driveways,parking areas etc.)
LOCMIRZ
15.220(4)(d)]
ll buildings existing and proposed 310 CMR
c)]
nd dimensions of system components and reserve areas
15.220(4)(e)]
lculations [310 CMR 15.220(4)(f)]
flow
c tank capacity (required andprovided)
soil absorption system (required andprovided)
whether system desi ned for garbage grinder
North arrow [310 CMR 15.220(4)( )]
Existing and prqposed contours [310 CMR 15.220(4)( )]
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 b Soil Evaluator [310 CMR 15.220(4) ')]
Observed and Adjusted groundwater(method for adjustment
given or indicated) [310 CMR 15.103(3) and 310 CMR X
15.220(4)(n)]
Location of every water supply,public and private, [310 CMR-
15.220(4)(k)] /
Address L / � �kvcklf-S' W e-t �, M r`I 1S Sheet l of7
within 400 feet of the proposed system location in the case
of surface water supplies and grayel packed public water supply
within 250 feet of the pioposed 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 d'th6f-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
component 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)] X .
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
15.000]
System components not>36" deep(unless Local Upgrade
Approval or LUA_requested)f 310 CMR 15.405(l(b)
Address J ��U ��� �� �S Sheet 2 of 7
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)]
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 x
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" (b 7/07) [310 CMR 15.228(2)]
Access to within 6 "of grade one port for system9<1000gpd,
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)] X
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
as baffle or approved filter[310 CMR 15.224(4)]
Address (/ 1/C lC l e S VVa ' L I I Is . Sheet 3 of 7
Located at least ten feet from any [
water line? 310 CMR
15.222(2)] )(
Disposal piping at least 18"below water line (when water and
sewer cross, see 310 CMR 15.211(1)[1]) �(
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)] x
Proper pitch on all runs?(.005 within gravity-distributed trenches
and beds) 310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] '\
rEndca
oblem/ leachfield below um chamber)
r-vent manifolds ecified?
rientation of discharge holes specified? (not smallernot larger than 5/8") [310 CMR 15.251(8) and 31052(2)(h)]specified (310 CMR 15.251(5) specifies various pipe
ed)
Stable compacted base [310 CMR.15.22](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
CMR 15.323(3)(a)]
Riser if dee er than 9, [310 CMR 15.232(3)(f)]
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)]
1:13 NMI,
Capacity(emergency.storage abovRorking=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
Rode. [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 I� �p /�,,
��'�J� 2 "`�� Y'` oY�'��� Sheet 4 of
e
Calculations correct?
4 feet of naturally occurring material demonstrated?[310 CMR
15.240(1)] �(
Required separation togroundwater? 310 CMR 15.212A X
Aggregate specified as double washed [310 CMR 15.247(2)] X
System Venting required/provided? (system under driveway or
>36" deep) [310 CMR 15.241]
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]
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)] k
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)]
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
eater(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]
ffi
minimum 2 distribution lines[310 CMR 15.252(2)(a)]
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)(g)]
Separation betweerLbeds 10' minimum. [310 CMR 15.252(2)(f)]
Bottom area used in calculations only 310 CMR 15.252(2)(i)]
I
Address Sheet 5 of 7
Pressure Dosed System ? Provided pump and piping
calculations as re uired,(310 CMR 15:220(4)(r)] X
Pressure dosing required on all systems>2000gpd or alternative
systems und�-mmedial approval [310 CMR 15.254(2) and UA
Remedial Use Approvals] X
If used in gravelless system -make sure jet is directed as not to
scour soil interface [Guidance Document] x
Inspections once per year(systems<2000 gpd)or quarterly
(>2000 dgood to note on plan [310 CMR 15.254(2)(d)] ?t
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)] X
Retaining wall must be designed by Registered Professional
En ineer[310 CMR 15.25'5(2)(a)]
Side s10 e not exceed 3:1 ? 310 CMR 15.255(2)]
Breakout requirements met? [310 CMR 15.252(2)and
Guidance Document 1�
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 cr!!!e!7discharge
If used with pressure dosing do not allow pressur
to scour soil interface X
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
perpetual 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
Are the variances listed on the plan ? [310 CMR 15.220
(`l)( )]
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 3 10
CMR 15.414]
Address . C6(-1 tC,5 IS Sheet 6 of 7
Is the system in a Designated Nitrogen Sensitive Area(Zone I1 for'
a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and
310 CMR-i5.216 - also refer to Policy regarding upgrades of such 1,
existing systems] 'C
Is the system proposed on the same lot as served by private well ?
[310 CMR 15.214(2)] >C
Are the nitrogen loads proposed in compliance? [310 CMR
15.216(1)] _
Pumping to septic tank? [ 310 CMR 15.229
Shared System [310 CMR 15.290
Address ( �/ �S �V tY(r lCS Sheet 7 of 7
Town of BArnstable P#
of�
Department of Regulatory Services
�sece
]Public Health Division Bate_ � `'
ptngsre
ibJp• �e 200 Main Street,Hyannis MA 02601
�rFD µ/2I Q
Date Scheduled (,�Iz/l Time L ____ Fee Pd.
S U
i
i -
- I
$oil Suitability Assessm"ent for Sewage Disposal
Performed By: Witnessed By:
i
LOCATION & GENERAL INFORMATION _
Location Address Owner's Name FF-D r�r11 �. AS$�.�
44 L Z, jl� Address
O P L��t'3 T-X 75 aT
Assessor's Map/P4rcel: (/ �� 71vo I Engineer's Name �� � 1
NEW CON5IRU�'i'ION REPAIR j Telephone# .�v� �' 2 "�'
Land Use )kylh�y/ Slopes(%) �� Surface Stones
Distances from: Open Water Body ?Zoo ft Possible Wet Area >?J Oft Drinking Water Well >/J A ft
3 )n() ft. Property Line ?I� ft Other ft
Drainage Way •
SKETCH:(Street name,dimcnsiods'of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
32.00'fl 1
T 000G \
a�Hs �TH-2 mA`" 15� 11
PNK
d / &TH-1 5�1�II/
IPP..
Leoch pit
(Not{e90) I /
• P
P
+ 1 �
rO � OWE N ,•. � � / �/\ �
J w of a9 /
o"- \c, ,
. II I l�
Parent material(geologic) 7 GI L(" Depth to Bedrock
Depth to Groundwatdr. Standing Water in Hole: i Weeping from Plt Face
Estimated Seasonaliigh Groundwater h�I
DtTERM N TION FOR SEASONAL HIGH WATER TAME
Method Used: In.
Depth Obperved standing;in obs.hole: in. Depth to Sall Mottles,
i in. Groundwater Adjustment
Depth toiweeping from side of obs.hole: A ,faetor,.....�_..- Adj.flroundwatee level
Index Well# Reading Date Index Well level
i
PERCOLATION TEST . Date
Observation 7 Time at 9"
Hole# y
-1 1 Time at 6" .-.-.
Depth of Perc
0 Time(9"-6") -- —
Stan Pre-soak Time.CID
End Pre-soak
Z-
Rate MinJInch
Additional Testing Needed(YIN)
Site Suitability Assessment: Site Passed
Site Failed:
Original:.Public k 41th Division
Observation Hole Data To Be Completed on Back—
of wetland,,you must first notify the
***If percolaibn testis to be conducted within 100'
Barnstable Cdnservatiou Division at least one(1)week grioi to beginning.
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil they
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.g'a Gravel
it
DEEP OBSERVATION HOLE LOG Hole#_Z
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistenc %Gravel)
- F—i
.� "1 fit,
-9Y 6,
DEEP OBSERVATION HOLE LOG Hole# ..
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.90 Gravel
DEEP OBIF1111VATION HOLE LOG Hole#
Depth from Soil Horizon oil Texture Soil Color Soil Other
Surface(in.) ( A) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency, Gravel)
Flood Insurance Rate Map:
Above 500 year flood boundary No— Yes
Within 500 year boundary No Yes
Within 100 year flood boundary No Yes -
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the
area proposed for the soil absorption system?
If not, what is the depth of naturally occurring per ious material?
Certification c
I certify that on 1,L-� (date)I have passed the soil evaluator examination approved by the
Department of Enviroi imental Protection and that the above analysis was performed by me consistent with
the require training,expertise and experience described in 3,10 CMR 15.017.
Signature (AA,44Date l IL L)
Q:�SEPTIC\PERCFORM.DOC
TOWN OF BARNSTABLE
Lor�ATION /�/ d
nc Lkle, sEwACE ---
WLAGE CV 7n,5 S ASSESSOR'S &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACIiING FACII.I'I'Y: (type)^jel l-+— (size). /000,���a 1
NO.OFBEDROOMS 3
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE.
Separation Distance Between the:
Maximum Adjuster}Groundwater Table to the Bottom of Leaching Facility Feet
Private water Supply Well and Leaching Facility (If any wells exist
on site or witWa 200 feet of leaching facility) Feet
Edge of Wetland and I.eaclung Facility(If an etlands exist
within 300 feet !u'n,�Ca jy) / jZ Feet
Furnished by �(�f k2 C-C
i
1! � �_
.� .. r. L., _,
��`
„ ,
o ..
i+,
� -�-as� �� a c- 3�'
.� -D- a a'y�- d-0- 4a'
..
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. . ,�,
• H
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 151 Chuckles Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-14-10
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
A. General Information •� ���
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
6-15-10
Inspector'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. f `
I�6
t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal stem•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
151 Chuckles Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-14-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B S Passes:
� ) System Conditionally
❑ 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
i
❑ obstruction is removed
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
151 Chuckles Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-14-10
page. City/Town 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.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Fora'
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 151 Chuckles Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-14-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cost.)
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 'h day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ z 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.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
151 Chuckles Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 6-14-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont):
Yes 'No p. 10 ,. ,
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either`yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply.
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to.any question in Section E the system is considered a significant threat,
or answered "yes"in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CM 15.304. The system owner should contact the appropriate
regional office of the Department.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
151 Chuckles Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-14-10
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate yes or no as to each of the following:
Yes - No
❑ ® 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 CM 15.302(5)]
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
151 Chuckles Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-14-10
page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy:_ 4-2010
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary.waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
t5insp official document•03/08 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
a 9 P Y rY
,M 151 Chuckles Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-14-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1990
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
II
-7
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 151 Chuckles Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-14-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 24"
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.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 18
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 1000 gal
Sludge depth:
16"
Distance from top of sludge.to bottom of outlet tee or baffle
t 6"
Scum thickness 3
Distance from top of scum to top.of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Tape
t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
l
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 151 Chuckles Way
Property Address
P Y
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-14-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage. '
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass 0-polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form..=Not for Voluntary Assessments
�M 151 Chuckles Way
Property Address
Bank Owned (Contact David.Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-14-10 .
page. City/Town 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.):
D-box had clear signs of back-up from leach pit.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary"Assessments
151 Chuckles Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-14-10
page. City/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: 1000 gal
❑ 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.):
Leach pit had clear signs of failure with stain line above inlet invert and into riser.
i
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 151 Chuckles Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-14-10
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.):
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
r -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
151 Chuckles Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-14-10
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
9 p Y 9 P Y 9
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building. "
fl �
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M 151 Chuckles Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-14-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 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:
You must describe how you established the high ground water elevation:
Usgs and town maps show groundwater at 20'.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
t3
t y
.A
Fi$......lf-19..........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
J.0W_`J............OF.......i_ ..AAA J_ ......................................
I
ApplirFation for Dhipmai Vorkg Tonstrnr#iun ramit
Application is hereby made for a Permit to Construct ( L.,Kor Repair ( ) an Individual Sewage Disposal
System at:
ati ddtes X- • - or I:ot
.... = _..- .....s. --- ------------------------------ s_ .......... .... ........----
wn r ,,'�' /f Address
Installer Address 2.1
UType of Building Size Lot..............54a..Sq. feet
a Dwelling YP o. of Bedrooms��..........3..........................Expansion Attic ( ) (Garbage Grinder 40j
Other—T e of Building F _L No. of persons........................... Showers — Cafeteria
Q' Other fixtures -----------------------------------------•--••----
W Design Flow........................S._._.:...._.gallons per person per day. Total daily flow_--_--_---------.�-j2(2.........._gallons.
WSeptic Tank—Liquid capacity!..gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-----------i......... Diameter-__----_-- %.._. Depth below inlet.........!....... Total leaching area.... ..sq. ft.
Z Other Distribution box (411 Dosing tank ( )
'~ Percolation Test Results Performed by BA .........9.1f15..._.. f�........ Date___......�."......��.........
as Test Pit No. 1......Z`..minutes per inch Depth of Test Pit....... Depth to ground water........
f� Test Pit No. 2................minutes per inch Depth of Test Pit__._-___---_____--_ Depth to ground water........................
a --- -- ---------------------------------------------------------------
p cj
Descriptionof Soil...................------�-=-�9�-........- .11�9�..�..�1�2f�.......--------------------------------------------------------•---------............----
U ....-----•-••-•--•-------•-•--------•-•-••-•-•-••--•-• � -------:..S"py------(- -o------------------------------------------------------------------------------------
W ---- ---------------- -----------------------------------�=----` 5 �
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
syste i oper do until a Certificate of Complianc has been issued by the board of health.
.�`'ri1 411 Signed ....�E ...--/...¢G ` C�®
�Da e
Application Approved By -------------- .. ..� c' ,'''...�.......-.......... - . ------te
Application Disapproved for the following reasons: ...................... ............... ...... ... ....................... ...... .........------...........-----------
........................................................................................ .......-------------------------------------.-..-...
Permit No. ----------- — . .
-_------- ..............._ Issued -..............---------------------------------------------------
Date
No.....X, Fim 14i90..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............. ------......OF.....-1 .ao.'7 !--�. ......................................
Appliration for Disposal Works Tonstrurtion Prrmit
Application is hereby made for a Permit to Construct ( k.Kor Repair an Individual Sewage Disposal
System at: 60
..... ........ ......
0 Hatddr.es or t
• ... ............................... ...... .. . ......7.r .................... .......................................
wn r Address
......... .... ......
....... ... .........
Installer Address
Size Lot..______7-1 149 Type of Building 9 .-..Sq. feet
Dwelling—No. of Bedrooms.............. ..........................Expansion Attic Garbage Grinder (4V)
Other—Type of Building No. of persons............................ Showers Cafeteria
Otherfixtures ......................................................................................................................................................
Design Flow________________________` 5 1Z
.:A............_gallons per person per day. Total daily flow..........................O.SP...........gallons.
Septic Tank—Liquid capacityA9PP..gallons Length................ Width................ Diameter-_._____-______- Depth_...._......._..
Disposal Trench—No Width.................... Total Length......I.............. Total leaching area....................sq. f t.
Seepage Pit No-----------
......... Diameter............ .... Depth below inlet.._...._....... Total leaching area..... ...sq. ft.
vo�
Z Other Distribution box Dosing tank
t 4 - 7#10 Percolation Test Results Per-formed by....... .........4.qg......11.4........ Date..................
Test Pit No. I................minutesperinch Depth of Test Pit.._....Aln�... Depth to ground water-------------*-------_-.
.'*"*-----------------
Test Pit No. 2................minutes per inch Depth of Test Pit.._......._......... Depth to ground water..__....._..........__..
.........................i
0 D 'J'." ----------- ------------------------ ............ .................Description of Soil................... J-�_oll........................................................................................
41 . �1. &AAU
...................SA�A ....................................................................................................
17-— --------tAA -...t;D..
..........................................................------------------ . ___5AA0....................................................................................
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
............................. ..........................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
syste I oper tiog until a Certificate of Complianc has been issued by the board of health.
............ .......I.......... ............................................. .........x. .......
Da e
Application Approved By -------------- ....... -------pta:
------------------------------------------------------------------------------------
Application Disapproved for the following reasons: .........................................................................................................................................
-------------------------------------------------------------------I--------------------..........................................-------------- ........................................................ ...........................--------
Date
PermitNo. ----------- ---------1_7�_--------------- Issued ....................................................................
Due
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................1.0 0--- OF --------�_e\.40.ezT��z................
... .. .......... -------------------------------
(9-crtifirate of Qlantplianre
)YIS '��LTO aCEjY, That the Individual Sewage Disposal System constructed ( X or Repaired
-----------------------------------------------------------------------------------------
by -------------- ------ ------------- ............................................................................
nstaller
at .......... ........&
X�� ...................--------_................................../--------------I--------------------------------- ------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5, f The State Environmental Code as described in
0. .......!�7'. '5'7 --- -------- dated ................................................
the application for Disposal Works Construction Permit N - -------_ --/----3
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
owki ��11 1�41rA 5 id
No..A�373 ..........................................OF.........P....................................................................... FEE./e(S)
.................
Disposal Works Tonstrurtion Firrutit
Permissionis hereby granted..............................................................................................................................................
to ConstrUct or Individual Sem ag�e isP al
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atNo...0•..W.....6..... r., ................r............................St.r-eet................................................................................
as shown on the application for Disposal Works Construction Permit 7 .
37- - Dated.......................................... 1
----------------------------------**---------------c Board of Health
DATE------------------------/.........T._ A.............................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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MARSTONS MILLS
BENCH MARK 'Z,NT
PAINT SPOT / `'• v
ON STEP CORNER
ELEVATION = 65.O8
BARNSTABLE GIS DATUM / �� ��
1. SITE
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/ 32.00'
I.0 / OLD FALMOUTH RDA
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/ 9OOOG LOCUS MAP
ti / a�Hs S �15�•G
TH-1 cJ���1 ; LOCUS INFORMATION
h pit I PLAN REF: 436/067
Xist
~ oc .� I / TITLE REF: 15132/083
e10)Le / PARCEL ID: MAP 101 PAR. 057 005
/
/ Existing
Note o �"' IN ZONE II /
I P
/ SEPTIC SYSTEM
m G 1 REPAIR PLAN
LOCATED AT:
151 CHUCKLES WAY
�X� MARSTONS MILLS, MA.
% --� Q / G ON �. \ V PREPARED FOR
w F .FN " '� O
Qg MIKE DEDECKO
AUGUST 18, 2010
SCALE: 1 20 ft.=
i
10 OF Mqs
DAR Mw M
LD
No. 1140
MNITA?0
1�
\ \ \ i905
DARREN M. MEYER R.S.
P.O. BOX 981
�-- EAST SANDWICH MA. 02537
- (508)362- 2922
SHEET 1 OF 2
I
NOTE: TO PREVENT BREAKOUT, THE PROPOSED DESIGN CRITERIA
NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:61.39
FOR A DISTANCE OF 15' AROUND THE
PERIMETER OF THE S.A.S. NUMBER OF BEDROOMS: 3 BR DESIGN (PROP IS IN ZONE II)
SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. SOIL TEXTURAL CLASS: CLASS I DESIGN PERCOLATION RATE: <2 MIN/IN
T.O.F. EL.=65.49 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER DAILY FLOW: 110 G.P.D/BR. DESIGN FLOW: 330 G.P.D.
OUTLET AND SET TO 6" OF FINISH GRADE SET TO 6" OF GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G. GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER)
' F.G. EL.=64.50f F.G. EL.=64.50t F.G. EL: 65.1 t F.G. EL: 65.5-64.5(MAX.)
1„ VENT PROPOSED SEPTIC TANK:
200% X 330gpd = 660GPD (USE EXISTING 1,000 GAL CAPACITY)
L = 10't s" MIN COVER/ L = 30' L = 10' MAX LEACHING AREA REQUIRED: 330 0:74 = 445.94 S.F.
® S-1X (MIN.) 36" MAX COVER 0 S=1% (MIN.) 0 S=1X((MIN) INSTALL TWO INSPECTION PORTS (MIN.) ( )/
4"SCH40 17 PVC 4"SCH40 PVC 4"SCH40 PVC7 ( )
DISTRIBUTION BOX: 3 OUTLETS MINIMUM
10• PRIMARY S.A.S.
14" e' 11.3" TO USE 3 ROWS OF 5 - 16" ADS 160OBD BIODIFFUSER H-20 UNITS
INV.= 61.82 48"LIQUID INVERT
�EVFt INV.=61.5YIDB-3(H-20)
NO STONE AND EXTENDED 0.75 W/ CONTOURED WEDGES
PROPOSED
GAS BAFFLE D BOX INV.=61.10 BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.70 SF/LF OF BIODUFUSER)
3 ROWS OF 5 UNITS AT 6.25'/UNIT + 0.75' WEDGE = 32.0/ROW
INV.=61.00J (BIODIFFUSERS) 15 UNITS x 6.25 LF x 4.70 SF/LF = 440.63 SF
INV.=61.27SOIL ABSORPTION SYSTEM (PROFILE) (CONTOURED WEDGE) 3 ROWS x 0.75' x 4.70 SF/LF = 10.58 SF
EXISTING 1,000 GALLON SEPTIC TANK TOTAL AREA = 451.21 SF
EXISTING SEWE RESTORE VEGETATIVE COVER DESIGN FLOW PROVIDED: 0.74GPD/SF(451.21 SF) = 333.89 GPD>330 GPD req'd
R OUTLET
BACKFILL WITH CLEAN PERC SAND
TO TOP OF CHAMBERS 75"
NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING
PIPE INVERTS PRIOR TO CONSTRUCTION ;'
BREAKOUT=TOP ELEV.=61.39
2) D-BOX SHALL BE SET LEVEL AND TRUE TO INV. ELEV.= 61.00
GRADE ON A MECHANICALL COMPACTED SIX BOTTOM ELEV.= 60.06
INCH CRUSHED STONE BASE, AS SPECIFIED IN EXISTING SUITABLE
310 CMR 15.221(2) 2.83' MATERIAL
3) REPLACE EXISTING 1,000 GALLON SEPTIC 5' MIN. ABOVE BOTTOM OF
TANK WITH 1500 GALLON SEPTIC TANK
T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 3 x 2.83 = 8.49' r� „
(6.06 PROVIDED) USE 3 ROWS OF 5-HIGH CAPACITY
76
IF FAILED, DAMAGED, OR UNDERSIZED. BOTTOM OF TESTHOLE EL.=54.00-=- ADS 16008D BIODIFFUSER UNITS-NO STONE
4) INSTALL INLET & OUTLET TEES AS REQUIRED PROFILE
(1120) W/ CONTOURED WEDGE
SEPTIC SYSTEM PROFILE TYPICAL SECTION _
N.T.S. N.T.S.
GENERAL NOTES: �� OF MA 11.2" 16"
1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL f 3. s SOIL LOG P#: 13020 rN
BOARD OF HEALTH AND THE DESIGN ENGINEER. ` D R M. -i () A
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS o .MEYER DATE: AUGUST 18, 2010 �- 34" �
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE No. 1140 SOIL EVALUATOR: DARKEN M. MEYER, R.S., CSE. #1614
LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW:- 310 CMR 15.405 (1) (B): WITNESS: DAVE STANTON, BARNS. BOH SECTION END CAP
_
1) A 1.11 FT. VARIANCE FROM 310CMR15.221(7) TO ALLOW LEACHING TO BE C/$TE��a Elegy. TP- 1 Depth Elev. TP-2 Depth 16"" HIGH CAPACITY 16008D (H-20) BIODIFFUSER UNIT
4.11 FT BELOW GRADE VS REO'D 3 FT. (H20/VENT PROVIDED) MNITAR�a 65.0 0" 65.10 0"
3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. FILL FILL MODEL 16" HICAP
4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOS SHOWN HEREON 64.0 A 12" 64.10 A 12" LENGTH 76" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT
SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. LOAMY SAND LOAMY SAND EFFECTIVE LENGTH 75" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY
5. ALL ELEVATIONS BASED ON,ASSUMED DATUM. 10YR 4/1 10YR 4/1 DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE.
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF THE CONTRACTOR OR OWNER TO 63.67 B 16" 63.77 B 16" SIDE WALL HEIGHT 11.2"
NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. LOAMY SAND LOAMY SAND OVERALL HEIGHT 16"
10YR 6/6 OVERALL WIDTH 34" 4640 TRUEMAN BLVD
10YR 6/6 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. �8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED 61.58 C1 41" 61.68 41" 13.6 CF HILLIARD, OHIO 43026
TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. C1 CAPACITY (101.7 GAL) ADVANCED DRAINAGE SYSTEMS. INC.
9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY 177
MED. SANG MED. SAND
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. 2.5YED. SAN 2.5YD. 6/4 PROPOSED SEPTIC SYSTEM SITE P LA N
10. EXISTING LEACH PIT TO BE PUMPED, CRUSHED AND FILLED PER TITLE V. PERC 060.25
11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 54.0 132" 54.10 132" 151 . CHUCKLES WAY MAR STO N S MILLS MA
12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY PERC RATE <2 MIN/IN. ("C" HORIZON) Prepared for: Mike Dedecko
AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY
13. NO PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING NO GROUNDWATER OBSERVED Engineering by: Surveying by: SCALE DRAWN
14. ALL PIPING TO BE 4" SCH 40 0. 1/8-/FT (UNLESS SPEC. OTHERWISE) DARRENM.MEYER,R.S. Boo-Tech MmiroamemW NTS D.M.M.
• 1, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW to conduct soil evaluations and that the above analysis has been PO BOX (508) 364-0894 DATE:
Y performed by Ev consistent ct the EAST SANDWICH,MA02537 CHECKED SHEET NO.
FOR THE USE OF A GARBAGE GRINDER requirements of 310 CMR 15.017. I further certify that I have passed the Soil Eval. Exam to October, 1999. 508�62-2922 DS 18 10 16. NO WETLANDS W HI 00 FT. PROP S CHIN / / D.M.M. 2 Of 2