HomeMy WebLinkAbout0027 DEBORAH DRIVE - Health 427 DEBORAHFIDCIOVI- MARSTONSWILLS
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No. 2.153LY
11ASTINQ%Ube
SD
r� �s> CERTIFICATE OF ANALYSIS Page: 1 of 1
4; Barnstable County Health Laboratory (M-MA009)
Report Prepared For: Report Dated: 3/20/2015
Craig &Jody Nelson Order No.: G1585824
27 Deborah Drive r a
.m
Marstons Mills, MA 02648
Laboratory ID#: 1585824-01 Description: Water-Drinking Water
,a
Sample#: Sample Location: 27 Deborah Drive, Marstons Mills, MA Collected: 01 6/2015
Collected by: Customer Received: 03/16/2015.
Routine
ITEM RESULT UNITS RL MCL METHOD# TESTED
Nitrate as Nitrogen 0.19 mg/L 0.10 10 EPA 300.0 3/17/2015
Copper 0.82 mg/L 0.10 1:3 SM 3111 B 3/20/2015
Iron ND mg/L 0.10 0.3 SM 31116 3/20/2015
pH 5.8 PH AT 25C NA 6.5-8.5 . SM 4500-H-13 3/17/2015
Sodium 5.8 mg/L 2.5 20 SM 3111B 3/20/2016
Total Coliform Absent P/A 0 0 SM 9223 3/16/2015
Conductance 43 umohs/cm 2.0 EPA 120.1 3/17/2015
Water sample meets the recommended limits for drinking water of all the above tested parameters.
Attached please find the laboratory certified parameter list. Approved By: .
(Lab Director)
/2�
ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
TOWN OF BARNSTABLE ✓
CATION -2 P � ' �SEWAGE # - """/5-0
w
-LAGE ASSESSOR'S MAP & LOT
kO"O
T l
g'4STALLER'S NAME&PHONE N0�9r\c :� A
}
S:3PTIC TANK CAPACITY 1220 <F 1Cf&+X C
LEACHING FACII.TTY: (type)
. (size) 3.5
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: -QL COMPLIANCE DATE: gI l3 v6
Separation Distance Between the: F
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
A 6JA'�
s-u
4 {Y
7E LIS-7 G?b
_ 2
r ® ,ssx
No. Fee
r
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for Mi5po5a[ *pgtem Con5trurtion Permit
Application for a Permit to Construct O Repair(A Upgrade O Abandon O ❑ Complete System Individual Components
Location Address or Lot No. 2,7 Wf re,\A �� V Owner's Name,Address,and Tel.No.
ca-sio-v5 ��\S M(L M(Z $ C rc�.�
Assessor's Map/Parcel G
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
10"5kGc, A liorSle-y W I H-e,j G rov fo
Scams w� c. `3 3 C.
Type of Building: N v
Dwelling No.of Bedrooms 3 Lot Size '3 SS SG G _ sq.ft. Garbage Grin )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.re fired) 3'30 gpd Design flow provided SS7 gpd
Plan Date r'� d Number of sheets Revision Date
Title
i
Size of Septic Tank 00 d CU v,, Type of S.A.S. c1 ", ,.•A r 33.5 XP.2,9 X2
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) l tJS F�.\� iJ�a.� L eG c%%'N o S V 1 r`k-
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 B d of Health.
Signed Date
Application Approved by Date —1/—O 6
—�—
Application Disapproved by: Date
for the following reasons
Permit No. 0 — / Date Issued / G
G �
t No.. 06
Fee. �Qv
THE COMMONWEALTH OF MASSACHUSETTS Entered inlcomputer: e
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZI 'rication for �Biz ozal �& ztemc Cou.5tructiott Permit
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑ Complete System Lp Individual Components
Location Address or Lot No. 2`J ZA)C.>rq 'Q v e Owner's Name,Address,and Tel.No.
MR AA R 5 C ^t SS;IN
Assessor's Map/parcel G
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�c�J�,G� � �rdcrJ� t•IprSt�,l � ,1��•�� �,o,��a '
-300
Type of Building: �
Dwelling No.of Bedrooms 3 Lot Size 3 S 5-6 G _ sq. ft. Garbage Grin ,r )
Other Type of Building 00%e No.of Persons Showers( y ) Cafeteria,( )
OtherPtures
Design Flow(min.fe uired) C7 gpd Design flow provided S 7Y.r'. gpd 9
Plan Date Ald Number of sheets_ Revision Date
Title +
Size of Septicjank X /00 0 ti N 1141,- . � Type of S.A.S. �3 SW Cj Al, (��;.�j�r 33.S .';,!9 X2
Description of Soil
Nature of Repairs or Alterations Answer when applicable) l 0SkG ` p
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.
' Signeda+ Date
� 4p I/
Application Approved by u�.—� Date —D .
Application Disapproved by: Date
for the following reasons
Permit No. a oo G— 5K Date Issued /! d
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( A) Upgraded ( )
Abandoned( )by At 00S C. s to 16
at A 7 "P eboccthv 1,V -�P_ has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 2W 6 r i/SO dated Y /�
fnstailer o o��_ C-s--_k. -- 1J tow Designer i
#bedrooms ~ Approved design flow 3 gpd
The issuance of this permit shall not be construed as a guarantee that the system will]f�tio[Ydesigned Qc
Date `1 13( b Inspector ✓
, y
————————C——————————————————+• ——— --------------
No. .�(�D(J r/ 7 g Fee �QU
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
1=igpo.5al ,p5tem Construction Permit
Permission is hereby granted to Construct ( ). Repair Upgrade ( ) Abandon ( )
System located at 2 7 `fie'po I c.,�K x y �e
and as described in the above Application for Disposal System Construction Permi�.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this pe
Date �/ ' /d Approved by
r
i
Town of Barnstable
ptHE 1p�
o Regulatory Services
Thomas F. Geiler, Director
* BARNSTA13LE
9q, b& �0� Public Health Division
ATF p►��° Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: ' f I D,
Designer: Shay Environmental Services, Inc: Instalter:
yT t
Address:.- P.O. Box 627 Address:' r•.
East Falmouth, MA 02536 caGN1�,
On (:)Ce G�U3 k OC F,)-r ( .was issued a permit to install a
(date) (installer)
septic system at 1 b� G 2 J�J_ t based on a design drawn by
F I
(addle s)
Shay Environmental Services, Inc. dated
(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.
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.
GQN�H OF A4,gS1- i ry
CARMEN
E. \'
SHAY
( staller's ignature)
N
No. 11$1
0
GISTIE
SANITA?0
( esigner's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
I, t?�( � �P�✓l ,hereby certify that the engineered plan signed by me
dated '3 11614,9 , concerning the property located at
VP, meets all of the
following criteria:
• Two soil evaluations excavated for detailed examination(no hand augering) and two
percolation tests shall be conducted.
• This failed system is connected to a residential dwelling only. There are no commercial or
business uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch.
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will be located no less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the
Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation 5-0 + adjustment for high G.W. -3
DIFFERENCE BETWEEN A and B 7
SIGNED : �2� DATE: 3 116A6
NOTICE
Based upon the above information, a repair permit will be issued for bedrooms
maximum. No additional bedrooms are authorized in the future without engineered septic system
plans.
q ASeptic\percexemp.doc
I
Town of Barnstable
.°�T"�'O' ,� Regulatory Services
Thomas F. Geiler,Director
• BARNSfABLE.
MASS,, Public Health Division
039. �0
ArED �a Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 1q 13 IC6 Sewage Permit# lAssessor's Map\Parcel
Designer: ntu2( 3, �', &Aq_�A Installer:
Address: C+o-r 4ft vi-tr&A Address: P,0 Zac 1LI S—
v2�63
On —! w..n4as issued a permit to install a
(date) 4 installler)
septic system at DApczGtl based on a design drawn by
(address)
rye dated 114 QG
(designer)
_Z1 certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Locat Wations. Plan revision or
certified as-built by designer to follow.
o SAMIJ J.P. o,
- JENSEN
CAVIL
( taller's Signature) 9No.4605d Q
o90,c�•G'/STEQ`�O�``�,
(15esigner' tgnature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q:Health/Septic/Designer Certification Form 3-26-04.doc
I
o� g CERTIFICATE OF ANALYSIS Page: 1
ysrac�t�s� yF Barnstable County Health Laboratory
Report Dated: 3/23/2006
Report Prepared For: -
Order No.: G0634819
Craig Nelson
27 Deborah Drive O L 5 Q /
Marstons Mills, MA 02648
Laboratory ID#: 0634819-01 Description: Water-Drinking Water
Sample#: Sampling Location ff27 Deb ti Dr.-Mar§tons Mills,M-A Collected: 3/22/2006
Collected by: C.Nelson Received: 3/22/2006
Routine
ITEM RESULT UNITS ��, _ MCL Methcd# Tested
LAB: Inorganics
Nitrate as Nitrogen BRL mg/L 0.10 10 EPA 300.0 3/22/2006
LAB: Metals
Copper BRL mg/L 0.10 1.3 SM 3111B 3/23/2006
Iron BRL mg/L 0.10 0.3 SM 311113 3/23/2006
Sodium 6.8 mg/L 1.0 20 SM 3111B 3/23/2006
LAB: Microbiology .
Total Coliform Absent P/A 0 0 309 3/22/2006
LAB: Physical Chemistry
Conductance 52 umohs/cm 2.0 EPA 120.1 3/22/2006
pH 6,3 pH-units 0 EPA 150.1 3/22/2006
Water—sample—meets the recommended limits-for.drinking water of all the above tested-parameters
Approved By:
(Lab�ie-ct,,)
1-.a
co
RL = Reporting Limit
MCL=Maximum Contaminant Level
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
Massachusetts Department of Environmental Management 119475
r, Office of Water Resources
TYPE OR PRINT ONLY Well Completion Report
1.WELL LOCATION GPS(OPTIONAL) LATITUDE LONGITUDE
Address at Well Location n,E'n1, 60,0(—f Property Owner:
Subdivision Name: Mailing Address:
City/Town: h7.4,P�n.t/S lt.t'iJ_L_5 Citylfown: 4 1'0
Assessors Map n(pS Assessors Lot#: NOTE: Assessors Map and Lot# mandatory if no
4street-address available
? '-1
Board of Health permit obtained: Yes Not Required ❑ Permit Number(�i?m,3-(T3 Date Issued' -
2.WORK PERFORMED 3. PROPOSED USE 4.DRILLING METHOD
�ew Well ❑ Abandon omestic ❑ Irrigation ❑ Cable uger
LJ Deepen [--1Recondition ElMonitoring ElMunicipal ❑ Air Hammer— ❑ Direct Push
❑ Replace ❑ Other ❑ Industrial ❑ Other ❑ Mucl Rota Q ,❑ Other
5.WELL LOG 01 Unconsolidated Consolidated 6. SITE SKETCH (use permanent landmarks with distances)
W Permeability
. . ca > a
From (ft) To (ft) High Low m Other Rock Type I t�
7..WELL CONSTRUCTION 8. CASING
Total Depth Drilled 1 From (ft) To.(ft) Casing Type and Material Size O.D. (in) Well Seal Type
Date Drilling Complete .4-?"
9.SCREEN
From (ft) To (ft) Slot Size a Screen.Type and Material Screen Diameter
10. FILTER PACK/GROUT l ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION
_ _ Developed? Yes ❑ No
a From (ft) To (ft) Material Description Purpose Fracture
Enhancement? ❑ Yes R�,N o
a
Method
�7 Disinfected? ❑ Yes o
12.WELL TEST DATA(PRODUCTION WELLS) 13. STATIC WATER LEVEL(ALL SHELLS)::
Yield .-,,TA 'Pumped Drawdown to Time Recovery to Depth Below
Date Method (GPM),;'(hrs&min) (Ft. BGS) (hrs & min) (R. BGS) Date Measured Ground Surface (FT)
14. PERMANENT PUMP (IF AVAILABLE)' 15.NAMEIADDRESS OF PUMP INSTALLATION'`COMPANY
Pump Description , Horse7:� _(g;prri)
(Pump Intake Depth `rY (ft) rj Nominal Pump Capacity
3
16. COMMENTS
17.WELL DRILLER'S STATEMENT IThis well was drilled and/or abandoned under my supervision, according to applicable rules
and regulations, and this repodds complete and correct to the best of my knowledge.
Driller: ' ` pervising Driller Signature: ( Registration #:
Firm: Date: U Rig Permit#: 1 1
NOTE: Well Completion Reports must be JUM by the registered well driller within 30 days of well completion. #
BOARD OF HbiTH COPY
i
ENVIROTECHLABORATORIES,INC.
r MA CERT.NO.:M-MA 063
449 Rte. 130
Sandwich, MA 02.563
.508(888-6460) 1-800-339-6460
FAX(508)888-6446
CLIENT: Craig Nelson LOCATION: 27 Deborah Way
ADDRESS: 27 Deborah Way Marstons Mills, MA 02648
Marstons Mills, MA 02648
COLLECTED BY. Desmond Wells SAMPLE DATE. 9/23/2002
SAMPLE TIME. 1:30PM
WATER SAMPLE TYPE: New Well DATE RECEIVED: 9/23/2002
LAB I.D. #: 0209509
WELL SPECS.: 4" 607 40'
RESULTS OF ANALYSIS:
Parameters Units Recommended Results Method Date Analyzed
Limits
Coliform bacteria / 100ml 0 0 922213 9/23/2002
pH pH units 6.5-8.5 6.09 4500 H+ 9/23/2002
Conductance umhos/cm 500 61 120.1 9/23/2002
Nitrate-N mg/L 10.0 0.09 300.0 9/23/2002
Nitrite-N mg/L 1.00 < 0.004 300.0 9/23/2002
Sodium mg/L 20.0 9.8 200.7 9/24/2002
Iron mg/L 0.3 < 0.1 200.7 9/24/2002
Manganese mg/L 0.05 < 0.008 200.7 9/24/2002
COMMENTS: pH is below recommended limit and may have corrosive characteristics.
WATER MEETS EPA STANDARDS AND IS SUITABLE FOR DRINKING PURPOSES
FOR PARAMETERS TESTED.
<=less than TuX4 Date--z(�) 144-
>=greater than R nald J. Saari
TNTC=too numerous to count Ldboratory Dirt or
!� Ooa --
--------- -------------
No.-=-------- � Fee- -
BOARD OF HEALTH
TOWN OF BARNSTABLE
Zipp[icat ion-for lVeii Con5tructionPermit
Application is hereby made for a permit to Construct ( , Alter ( ), or Repair ( )an individual Well at:
-7--��_ _ ®21 t F M Sr r1
TONS 6tt_._.S O l / --
Location — Address o'a Assessors Map and Parcel
NELSON
Owner Address
n
Installer — Driller
Type of Building
Dwelling� ��- — -------
Other - Type of Building-=-- -_____ No. of
Type of Well�1P t)c Capacity
--- -- - c
Purpose of Well-R-Ek1--19-LE---a K ELtistT�itiF�- ivtr��.,(_.,
SA-w►? yOG�TiO�(
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until Certificate of Compliance has been issued by the Board of Health.
Signed E
7_ ate
Application Approved By __—___— 2 -0 ?______
date
Application for the following reams: W T" —Yf1�t�_�1_��.rl __ d __----_
- ---------------- date
Permit No. W 2 r1 d,243 ,2-0
— Issued-- --------- _--
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of (Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed Altered ( ), or Repaired ( )
bye ESYyt_ AJO W F-L(- --
Installer —
at- Z 7 'r1-)Va0k-A-" W A-has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. 642 002 3 Dated--9--7 2 q2
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---_ _ Inspector
No.-Wao°a-_� Fee-
3 -��- ----
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applicat ion-for lVell Con5tructionPermit
Application is hereby made fora permit to Construct ( , Alter ( ), or Repair ( )an individual Well at:
Location — Address ;.'c Assessors Map and Parcel ^—
Owner Address
(� Sn't_o lJw c.L_D 2I«�N -R E) 0�2L-rf414S_ o a(-s3
Installer — Driller
Type of Building
Dwelling P LA -
Other - Type of Building--.--- ------- No. of
Type of Well
!/P _ Capacity
Purpose of Well- t-P-ALE—o " EY,,y7j y 4- 4<)FI. _
SAME F.0C,4-r/0Aj
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until ACertificateof Compliance has been issued by the Board of Health.
Signedc c�
- to
Application Approved By
date
Application Di for the following reasons*. - —�-C/I�t �t'J�%
date
Permit No. 2 do?r� -- Issued Q
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed Altered ( ), or Repaired ( )
by -DESIM6AA wtwLf t LL//u�'
Installer
at--a 7 ---
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. 6 3 Dated _12=0.2---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------ —_ Inspector------— - -- —_
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ivell Con5truct ion Permit
No. -,-N 2 u v'?� Fee
Permission is hereby granted 'b GSM O KJ Q W F-L(-- (� L L/,,V& —
to Construct ) Alter ), or Repair ( ) an Individual Well at:
No. d �Ogj414 C.c_) d4�_ m 64 2S—L— --- I L_ L
_S
-----------------------
Street
as shown on the application for a Well Construction Permit
ac��a - '03
No.- �_ Dated 9- l a -U
-DOA;, ./A�\ ----------
--------
DATE ��1 a -GZ Board of Health
ro+ ;�J f t U/'yis A�
f
COMMON'.VEALTH OF 1bW-SACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617)292.5500
TRUDY CORE
all® NQ `��
ARGEO PAUL CE..LUCCI Secretary
Governor DAVID E.STRUHS
'Z s r
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECT(O EEC it t 11F � Commissioner
PART A
CERTIFICATION10,� NST�
Property Address: YVIV���UN w; Name of Owner RVTI-ANMe /. 9f&
Date of Inspection: G/v q J Address off Owner: L 1 1 <j;
Name of Inspector:(Please Print) R� [�- PIIE"cg, f. J,
1 am a DEP approved system prspectar to Section 15.340 of Title 5(310 CMR 15.000)
Company Name:
MoSM Address: (a3
Telephone Number:
CERTIFICATION STATEMNT E
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-she sewage disposal systems. The system:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority'
Fails >/���j�
Inspectors S' - Date. f'/ /V Y 9�
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)w)thin thirty(30) days of
completing this inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
�►�u�4v
►'�PVlN OF k4,9
ti
Eowagn L. r
clv
9 No.32001
Q/S T EP�O
NAL EN
/ AAA?f
revised 9/2/98 Pagel oril
40 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Propertyg�ddress:
Owner
Date at Inspection: •1 q ,
I �
INSPECTION SUMMARY: Check A, B, C, or A
A. SYSTEM PASSES:
: i .
1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
j criteria not evaluated are indicated below.
COMMENTS: 1IN
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.
Indicate yes,no,or not determined(Y,N.or NDI. Describe basis of determination In all instances. If"not determined", explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attachadl.indicating that the tank was installed within twenty 120)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets)
or due to a broken,settled or uneven distribution box. The system will pass inspection if With approval of the Board of
Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pips(s)• The system will pass
Inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
reprised 9/2/98 Page 2of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
• PART A
TIFICATION(Continu
sty , �o�,S-pops
of InspectionL��ly
Date &boVq�
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health. safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING W A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 60 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAR UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY,AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS.is within IGO feet of a surface water supply or .tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less then 100 feet but SO feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
i
I�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(conffirred)
Address: 2� l�U►� 1'r i�� J� '(l'"� u i r ' 1
Property
1 Owner.
Date of 'Ion:ArV''E O �
� 6�av a�
D. SYSTEM FAILS:
You must indicate either"Yes"or 'No" to each of the following: .
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
i Yes No
Backup of sewage into facility,or system component due-to an overloaded or clogged SAS or cesspool.
I
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 1/2 day flow.
Required pumping more than.4 times in the lest year NOT due to clogged or obstructed pipets).
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I 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 wetl with no
acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
conform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAIRS:
You must indicate either"Yes"or"No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional .
office of the Department for further info(rnation.
revised 9/2/98 Page 4orit
I
SUB
SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Data of �ti� p j
CA&gj
Check if the following have been done:You must indicate either "Yes" or"No" as to each of the following:
I
No
_ Pumping information was provided by the owner,occupant,or Board of Health.
_ None of the system components have been pumped for at least two weeks and-the system has been-teceivingmarmal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
Inspection.
l _ 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 system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System,have been located on the site.
_ The septic tank manholes were uncovered,opened,and the interior of the septic tank was'inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
The size and.location of the Soil Absorption System on the site has been determined based on:
Existing information. For example,Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
115.392(3)(b)1
The facility owner (and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
r
I
revised 9/2/98 Page 5ofll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property dress: 2� p � 1 , . �IM4 ,s-wS
Date of
N FLOW CONDI
TIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom.
Number of be room Ides1 n):-3 Number of bedrooms(actuall:3
Total DESIGN flow
Number of current residents: �O
Garbage grinder(yes or no):�
Laundry(separate system) (yes or no)/—Va. If yes,separate inspection required
Laundry system inspected s or no)
Seasonal use(yes or nol:
Water meter resdings,igal
le(last two year's usage(gpd):
Sump Pump(yes or Last date of occupa
COMMERCIALMDUSTRIAL•
Type of establishment:
Design flow: ood (Based on 15.203)
Basis of design flow
Grease trap present:(yes or noI_
Industrial Waste Holding Tank present:(yes or no)
Non-sanitary waste discharged to the Title 5 system:(yes or no)
—
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of i f on:
V,
System pumped as part of inspection:(yes or no)
If yes,volume pumped: gallons
..Reason for.pumping:
T1;U�OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) Of yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contact
Tight Tank Copy of DEP Approval
Other / ?APPROXIMATE AGE of all components,date installed Of known)and source of information:
Sewage odors detected when arriving at the site:(yes or no)m
revised 9/2/98 Page 6of11
I
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM BIIFORMATION(cored)
Z� � t2�A N ,�>z�r
P rtt,ropa Address: bp-- ) A�G&S �1 A
Owner: �(•,�L,1A n I,.I,� /�'�t n �y;��
Date of Irspection: IU J iv��
BUILDING SEINER: ' " ��
(locate on site plan) P
Depth below grade:
Material of construction:Xcast iron_40 PVC_other(explain)
Distance fro/m,pr>ivate water supply well or suction line
Diameter
Comments:(condition of joints,venting, evidence of leakage,etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grader
Material of construction:,d�concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance (Yes/No)
Dimension's: ��A `
Sludge depth:
Distance from top of sludge to bottom of outlet toe or baffler
Scum thickness:"
Distance from top of scum to top of outlet tee or baffle:,, f9
Distance from bottom of scum to bovgm of outlet Wo� Me:_a
How dimensions were determined: ezill �
Comments:
(recommendation for pumping,condition of inlet anciputlet tees or baffles,depth of liquid evel in elation to outlets vent,structural integrity,
evidence of leakage,etc.) (�
7E
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions:
Scum thickness-
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping,.condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Page 7ofIt
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
YSTE3A INFORMATION Icontir�red)
Property Address: �/� i-- N . Aowns.: ��1on: 1 tIA
Date of hspe�VY [^ 1 O J16�f_-Z
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
I
Depth below grade:
Material of construction:_concrete_metal_Fiberglass_Polyethylene_otherlexplain)
Dimensions
Capacity gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes_ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX.—
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note-if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 Pages of I]
i
SUBSURFACE SEWAGE� DISPOSAL SYSTEM INSPECTION, FORM
PART C
(� SySTEPA INFOR TIOI�N
Address: (oodttirwed)
Property Addre p 1� p k S U-C
' Owner: ) /►[� � �/{/
l�l A IL
Date of Inspeedon: q�
jSOIL ABSORPTION S�'STEM(SAS):
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
Type;.
leaching pits,number: / AZ
leaching chambers,number: V r`
leaching galleries,number:_
leaching trenches,number,length:
leaching fields,number,1111mensions;
overflow cesspool,number:
Alternative system:
Name of Technology:
Comments:
(note co diti n of soil, ign of by raulic failure,level of ponding, damp so' con on of vegeta'on, a .)
CESSPOOLS:—
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
PRIVY:_
(locate on site plan)
Materials of construction:
Depth of solids: Dimensions:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding, condtion of vegetation,etc.)
revised 9/2/98
Page9ofll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(con )
ProPerty Owner:
Ads: . �
Daft tANNr--
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(locate where public water supply comes into house)
G
jD
/WO&A1
Cy
revised 9/2/98
Page 10 of 11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM
011FORMgnDN(continued)
Daft of hw
/Y V
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow
Moderate Deep
SITE EXAM Slope GJPoM
Surface waerCheck Cellar
Shallow wells �/V® ��U(S Estimated Depth to Groundwater
Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local�excavato►s, installers
Used USGS Data
Describe how You established the High Groundwater Elevation. ( be completed)
►� qel
To T-U
1l0
62 . ✓o
rev_sed 9/2/98 J
Page 11 of 11
-----------------
'I
r
COMMON`.&ALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL
DEPARTMENT OF ENVIRONMENTAL PR�QTECTION
ONE tVUMR STREET,BOSTON MA 02108 (617)29 -5500 WrAVE9
NQ ii 1 1999 �1
uD--COTowOF;pNTR SH�HEP�A&E
ARGEO PAUL CELLUCCI DAVM B 3T8 Governor
SUBSURFACE SEWAGE DWOSAL SYSTEM WSPECTHM FORM. commissin
PART A
N2AA^ CEiiTwCATION _.._
f rVPALMS c,Ls 1 R Arur�►E D �&
�O�y Ate= /�� /) a Nanta d Oamer
Data of impectiert: G NV V I Addrrass d Oayn�r:_$�y►
Name of iupeetar(Please Pdw �� L ���J�) �• IF,
1 sen a approved wrspaetar to Section 15.300 of TM&5(310 CMR 15.000)
m
Compsaw Nae:
Of Addrass: A 1QAG3
Telephone Number:
CERTfACA71ON STATEINEIIIT
1 certify,that I have personally inspected the sewage disposal system at this address and that the kdo►mation
sported below is true. a,
ccurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and'
maintenance of on-site sewage disposal systems. The system:
XParses
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority,
Falls
- : 1IIV
w9
9
The�systenr Inspector shad submit a°copy of this inspection report to the Approving Autho (Board of'He"or DEP)within thirty
completing this (30i do"of
p g 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
shad submit the report to the appropriate regional office of the Department of Envirorwnen>rtN Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
,A&,"AA
1,✓�P�ZH OF M,A4
� tiG
s � EDWARD L
c5 PESCE ^'
c� CIVIL y
No_32001
9 O�
�90 ISTrcQ'�
s/ONALENG\�
revised 9/2/98 Pa`eiorll
0 Printed.Rydd Paper
ISUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART A
CERI. ICATION(condnued)
*Ala
D i , 4ies ,,s pys
Dal~'of Inspection: &/JOV
N�
L
�q
BHSPECTION SUMARY: Chalk A. B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
txiteris not evaluatedare indicated below.
B. SYSTM CONDITIONALLY PASSES:
Ono 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.
Indicate yes,no,or not determined(Y.N.or NO). Describe basis of determination in all instances.-H`not determined'.explain wiry not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance.lattached),Indicating that the tank was installed within twenty 1201 years prior to the date of the
inspection;or
the septic tank,whether or not metal,is cracked.structurally unsound,shows substantial infiltration or extiilvation,or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as,
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken'or obstticted NPels1 `
or due to s broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health). -
broken piWal we replaced
. obstruction Is rem
• Quad
distribution box Is levelled or replaced
.The system reWi►ed pumping more thanard four'dmas a year due to broken or obstructed pipe(:). The system wM Passinspection.if(with approval of the Bo of Health):
broken pipe(:)we replaced
obstruction is removed
revised 9/2/98 Pap 2of11
r
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
AT(ON(eontinu
hopelty . 2 A N plc. r4ASTONS Owner
�qq
Date of kspicOw
&b®vq�
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
Public health,safety and the environment.
11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES B ACCORDANCE WITH 310 CMR 1 S. (1 Nb)THAT THE S
YSTE
IS NOT FUNCTIONING N A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE EI VMoNME NT.
Cesspool or Privy Is within 50 feet of surface water
Cesspool or privy Is within 50 feet of a bordering vegetated wetlend or a salt marsh.
?J SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETF�(ES F THAT THE SYSTEM IS
UINCTIOII1Nti IN YAIIBNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY,AND THE 6NVRRONS191IT;
_ The system has a septic taf*and sal absorption system(SAS)and the SAS.is within 100 feet at
.a surface water supp(y or
tributary to a surface water supply.
The system has a septic tank and sod absorption system and the SAS is within a Zone 1 of a pubic water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet.of a private water lea supply well.The system has aseptic tank and soil absorption system.and the SAS is Iess.then 100 private wets►supply won,unless a wed water analysis for
bacteria evolnd sole oryerrc cfen,but�ornpohhrhds indicates
eaatorrn fifes
wed is free from pollution f►olri that fa presence of amnions mb that the
ciliity and the` open and nitrate nitrogen is'
than 5 ppm. Method used to determine defence (appro)imation;rot��, equal to or less
3) OTHER
revised 9/2/98 Par 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM
PART A
CERTWCATHM(cor tiraiaQ
Property Address: � l�/t�y+
Data ofC&--14A1VN)e—
kov qD_ SYSTEM FALLS:
You must indicate either"Yes"or"No" to each of the following: .
I have determined that one or more of the following failure conditions exist as described in 310 CMR 16.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what wig be necessary to correct the fa%".
Yes No
{ Backup of sewage into facility or system componant due-to an overloaded or dogged SAS or cesspool.
Discharge or pondmg of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or
cesspool.
Static liquid level In the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than.4 times in the lest year NOT due to dogged or obstructed pipets).
Number of times pumped
_ Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool OF privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a coup"_a privy is within a Zane 1 of a public wdl. .
Any portion at a cesspool or privy is within,50 feet of a private water supply well. '
_ Any portion of a cesspool or privy is'less4han 100 feet but greatat-f so few from a pmrate water supply well with no
acceptable.water quality analysis. If the well has been analysed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nhratrnitrogen._ "
E. LARGE SYSTEM FALLS:
You must Indicate either"Yes"or"No" to each of the following:
The following criteria apply to large systems In addition to the criteria above:
The system serves a facility with a design flow of 10.000 gpd or greater(Large System(and the system is a significant threw to public
health and safety and the environment because one or more of the following conditions exist:
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 was(Interim Wellhead Protection Area:IWPA)or a mapped Zone 11 of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consolt the local regional
office of the Department for further kdopnation.
revised 9/2/98 Page 4or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
f�/�►p CHECKLIST
Property Address:
Owner: 12 . .Wnn
Data�
CoA&gq
Check if the following have been done:You must indicate either'Yes'or'No'as to each of the following.-
No
Pumping infomretion was provided by the owner,occupant,or Board of Health.
i k
(V - None of the system components have been pumped for at least two weeks and-the system has been-we
that eriod. l "^g flow
rates dur
ing p ergs volumes of water have not been introduced into tNrs system raeemly or as part of this
Inspection.
_ As buAt plans have been obtained and examined. Note if they are not evadable with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
• The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
All system components, excluding the Sod Absorption System,have been located on the sits.
_ The septic tank manholes were uncovered,opsrrod,.end the interior of the septic tank wae'inapeeted for dition of baffles
or tees,material of construction.dimensions,depth of liquid.`depth of sludge.depth'of scum.
The sat and,location of the Soil Absorption System on the site has been determined bard on:
Existing information. For example.Plan at B.O.H.
_ Determined in the field ref any of the failure criteria related to Part C is at issue,aPproxdniation'of dmatancais unacceptable)
)
_ The.facilky owner land occupants.H different from owner)were provided with information-on the prop arniaintananceof
SubSurface Disposal Systems:
revised 9/2/98 Pages orlt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
nopmty dd►ess: 2� p� � l . , f 4 ,s� s 1 �s
Owner.�� plrVL
NUJ a�
ROW CONDITIONS
RESIDENTULL:
Design flow. p.d. m.
Number of r 1 esi Number of bedrooms(actuall:�
Total DESIGN 100�
Numbs of current residents: 2D
Garbage grinder(yes or no):
Laundry Iseparau system) (yes or n0)N H yes,separateinspection required
Laundry system Inspectoi s or no).
Seasonal.use(yes or no)
Water meter remaw.N a (last two yew's usage(gpd)•
Sump Pump lyess or
Last date of occupancy _ Z,
COMMERCMUNDUSTRUU--
Type of establishment:
Design flow: and (Based on 15.2031
Basis of design flow
Grease trap present:(yes or no)_
Industrial Waste Holding To presort:(yes or nol_
Non-sanitary waste discharged nk ed to the Title 5 system:(yes or nol_
Water meter readings.if available:
Last date of oc=gM ey:
OTHER:(Desaibel
Last date of occupancy:
GENERAL NFORMATWN
PUMPN6 RECORDS and source of /►V1�-N / ��, : 01N/��iV ,.
System pumped as part of inspection:lyes ornoAIV
H yes,volume pumped: gMDns
.Reason for.pumping:
OF SYSTEM
Septic tank/disWbutlon box/soll absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes.attech previous Inspection records,U any)
1/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXMATE AGE of all components.date katelledOf known)and source of information: 1e AS
Sewage odors detected when arriving at the site:(yes or nolw
revised 9/2/98 Page 6of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM B1ISPECTH M FORM
PART C
SYSTEM NFORMATtO11(corrdmred)
Owner
A 1
BUILDING SEWER: co ' o q_I
(locate on site plan)
Depth below grade:
Material of construction:Xcest iron_40 PVC_other(explain)
Distance from pnvete water supply well or suction fine
Diameter _
Comments:(condition of joints.venting.evidence of leakage,etc.)
SEPTIC TANK:_
(locate on site plan) A
Depth below grade-
Material of construction:�concrsta metal_Fibergless _Polyethylene_othedexpldn)
If tank is metal.Bat age Is age confirmed by Certificate of Compliance IYes/Noi
- D Zak 'Dimensio
Sludge depth-
Distance from �— g
top of sludge to bottom of outlet too or bailie
Scum thickness:
Distance from top of scum to top of outlet tee or baffle. 9
Distance from bottom of scum to.boVWn of outlet or battle.
How dimensions were determined: ZQ 4� O -
Comments:
(recommendation for pumping,condition of Met and et tees of tieffles,depth`of bquid-oval in' a to outlet invert,structural.
evidence of Icakape,Oft.)
itbgriq,_
CA b
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_Fiberglass _Polyethylene_othw(explain)
Dinrenafons:
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:
Ireeommmdation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level In relation to outlet invert alto evidence of leakage,etc.) curd Integrity,
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DEPOSAL SYSTEM INSPECTION FORM
PART C
VSTEM NFORMATMU(continued)
Property Address: �/? p � �S-��/��s VA
Ownce er:. ti '" V►" /
Da of Inspection q q
�N
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of,inspection)
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_Fiberglass_Polyethylene_otherlexplain)
• Dimensions:
Capacity:_gallons
Design flow: gallons/day
Alarm presern .
Alarm level: Alarm In working order:Yes_ No_
Date of previous,pumping:
Comments:
(condition of inlet tee.condition of alarm and float switches,aft.)
DISTRMUflON BOX:
(locate on site plan)
Depth of liquid legal above outlet invert:
Comments:
(note-if level and distribution is equal.evidence of solids carryover..evidence of leakage into or out of box,atc.1
PUMP CHAMBBt:
(locate on aite plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 Pages of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
A : EM MON
z� p �� N Spy.
owns.: �A ► ►
Date of In� "'" 1e7 D N��
SOY ABSO�nw S�Nov aq
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
Type:. ,
leaching pits,r*rmber:1
leaching chambers,number;
leeching galleries,number:_
leaching benches.number,length:
leaching fields,number,dimensions:
overflow cesspool.number:
Alternative system:
Comments: Nan*of Technology:
(note c of soil, 'gn of by a bilure,level of pan g,damp s
conon of veg on, )
IOLS
� :
(locate on site plant
Number and eonfipuration
Depthtop of Squid to inlet imnrt:
Depth of solids layer:
Depth of scum layer
Dimensions of cesspool:
Materials of construction: .
Indication_ of groundwater:
inflow(cesspool must be Pumped as part of inspection)
Comments:
(note condition of son,signs of hydraulic failure.level of ponding,condition of vegetation. etc.)
PRIVY:_
(locate on site plan)
Materials of construction:
Depth of sands: Dimenslons•
Comments:
(note condition of son. signs of hydraulic failure,level of Pending, condition o1 vegetation, etc.)
revised 9/2/98
i Page 9 of I1 '
SUBSURFACE SEWAGE DISPOSAL SYSTEPA MISPECTION FORM
PART C
SYSTEM DIFORMATN M�corr trued)
i addrosa: a 80RA II
Dade of � /VN
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(locate where public water supply/ pply comes into house)
6-A
G DD
Ali - qD, s '
revised 9/2/98
Page 10 of 11
y
i
SUBSURFACE SEWAGE DISPOSAL SY
PART C STD FORM
�„ � ,
°emofk
DaBe of
NRCS Report name
Son Type_
TYpical depth to groundwater
USGS Date websits visited
Observation Wells checked
Groundwater depth: Shallow
Moderate D
SITE EXAM eve G �B
Barbee w�` V�W
Check CeAar
Shallow was A)O �J�,[}
Estlmated Depth to Groundwater Feet
Please indicate all the methods used to
determine Nigh Groundwater Elevation:
T_Obtained front Design pesos on record
Observed Site(Abutting property,observation hole,be sump etc.l
OetenNned from local condign
Checked with local Board of,health
Checked FEMA Maps
Checked Pumping records
Checked localexeavniors,installers
Used USGS Data
Describe how you eateblishad the Nigh Groundwater Elevation. (M_nst be completed)
G®)!�Lam' S
(Appp-oy, Lo. ' Mav
62 "SO "7
revised 9/2/98
PW it of ll /L
��pp�
r TOWN OF BARNSTA UE
c .00ATION ,DC3094tI 49eNE SEWAGE # 4mP7
VILLAGE AW51-0!?/S /,k&LS ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY /DOD y,4L ZZ
LEACHING FACILITY:(type) 14se J�ws (size) AIM
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER OyE/LL
DATE p4��
DATE COMPLIANCE ISSUED: 7.7?
VARIANCE GRANTED: Yes No
O
1
ti°�V CJ
13ox_ r
c
Zg 7� ��
No. 7....... Fnx. :-'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
„ S V4� Q. .. .. .....---- -.OF............A���.*3... ��� � _ ------..._--............
Appliration for Did nuttf VarksZontitrurtion VivrMit
Application is hereby made for a Permit to Construct Repair ( ) an Individual Sewage Disposal
J� System at: in
��............................P• .� Ption:�-4Zress �. .�1 --------�/GCS---------------------------------•-----
L or Lots L. P
/7 C.—
.....................I.,.---.fit....-- it-##.....-•--•-------------..... .�,fr"td . .........................................
Owner Address
W
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms..... ................................Expansion Attic ( ) Garbage Grinder ( )
a Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other
�tt�res -------------------------------- -
W Design Flow............................................gallons per person per day. Total daily flow-------..... Q_. ____--------------gallons.
WSeptic Tank—Liquid capacity/64W.gallons Length-------------_ Width----------- .... Diameter---------------- Depth-..-_--_--------
x Disposal Trench—No..................... Width.................... Total Length------ Total leaching area --------sq. ft.
Seepage Pit No .... Diameter.................... Depth below inlet....... Total leaching ar _t&rft.
Z Other Distribution box ( ) Dosing tank (
'-' Percolation Test Results Performed by...._____ �� LOB
a �--- --------� ----•-... ••• Date----------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit----- ..............Depth to ground water.-_._____---_____-_--_--
fLq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---___-__-______--_-_---
9 ---•------- -------
O Description of Soil----- ------J.,Aj --- •-- -.........-U � -----'-..................................... -- - - -
x
U
W
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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in-
operation until a Certificate of Compliance has been issued by the board of health.
Signed--- ......
' D e
Application Approved B ...... --------------
Date
------------
Application Disapproved for the following reasons---------------------•-------------------------------------------------------------------------------------_.....
•..••-••-••---•••••••••--••-•-----•-•----•-••-----•-•••...-----•••---••-••----------------•-•••--•--------------------------------------•---------------------------------------------------------•-•-•-
Date
PermitNo......................................................... Issued........................................................
Date
:ems
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
A-
DATA
No...=L..-=....---- Fxu 1004,..:...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... .. .._.....OF................... ....`. .......
Application for Disposal Works
Tonstrttrtioat rrutit
Application is hereby made for a Permit to Construct (-`'',) or Repair ( ) an Individual Sewage Disposal
System at:
.rf :
...............----_._ .. ¢ -- ------- i -------- -- --------••-_---------------'
Location Address or Lot o., --
t, a. . .
Owner Address
W
Installer Address
UType of Building Size Lot____________________________Sq. feet
Dwelling—No. of Bedrooms------- ---------______________________ _Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons----------------------------- Showers ( ) — Cafeteria ( )
d Other f"ires --••---------------'--'•-'-'••-'---•---------•------.------------.....--------------------------------------------------------------•---'•-•-'--•---
...
W Design Flow..........__-:.._fl `........................gallons per person per day. Total daily flow....:d,.__.___' '._�_'___:.______.___._..gallons.
W Septic Tank—Liquid capacity=%".!' _gallons Length................ IvVidth---------....... Diameter---------------- Depth.-.-------------
x Disposal Trench—No..................... Width-------------------- Total Length----------/....... Total leaching area-------------------sq. ft.
Seepage Pit No... ...... Diameter____________________ Depth below inlet...... Total leaching area_ -._- '____ aq. ft.
Z Other Distribution box ( ) Dosing tank
Percolation Test Results Performed b -__--._ -- f ,#
a x Y ---.._ -- -�-;- -E-:------------------ Date--------------------------------------
Test Pit No. 1.......:........minutes per inch Depth of Test Pit.___f"___ Depth to ground water-------------------
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----------------._.-__-
ap ' ;1-------------------------------------------------•--•--•--••----.-------••----------•---•----•-----
OAw Description of Soil______________ .......................
w ff
U ...........................................................................:.............................................................................................................................
W
........................................................................................................................................................................................................
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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed, �a� �.�w. � ..
.. .___ .....................a __..___ ____ ................................
- Date
Application Approved BY---- --..d i�...let ...... '".."°...--•-•-.
Date
Application Disapproved for the following reasons------------------------------------------------------------------------------------...... ---------•----
t Date
PermitNo.......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
i'
(Irrtifiratr of Toutphattrr
11:H,& IS TO tC�FRTIF,T That the Individual Sewage Disposal System constructed -.-) or Repaired ( )
Installer
at -22.. i. F • .h.,5........... w,'_-_4a,_. 5--1 3 +Y +�-------------- ---•--••--------•----------•--._-----.--------------------•-•-- -----•---
has been installed in accordance with the provisions of Article XI of The State Sanitary Cocte as .escri) 6d it the
application for Disposal Works Construction Permit No............... ,4 .. dated___..... ... .._, _,
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD-'OF HEALTH
No..n •' ---• FEE - ..............
Disposal marks Tonstru " 'ai Pamir,
Permission is,hefeby, granted---- � � ` . �: r /
to Construct A-, or Repair'( ,,) an Individual Sewage Did, osal System
at No.... .. ........ '---------- �e% t .�f„ i�'{,d./•_ -------------------••---
Street
as shown on the application for Disposal Works Construction Permit Ng................... Dated__af_..f_�.___
.............fyaC� ..__4______:ir::at'..fy,.: ._.ay.''-ems✓ I,/�
j� Board of'fIealth
DATE.................................................................................
_
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
FINISH GRADE OVER CHAMBERS = 98.7' - 97.9' 3/4" TO 1-1/2" DOUBLE WASHED) STONE TO CROWN OF PIPE GENERAL NOTES
4" SCHEDULE 40 PVC SLOPE 02% MIN. OVER SYSTEM TOP OF U TION 99.71 MIN SLOPE 1%
2" OF 1/8" TO 1/2" DOUBLE WASHED STONE 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION
FONDA = t
f METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE
PROVIDE HIGH DENSITY POLYELYLENE PLACE RISERS ON ALL CHAMBERS WITH PIPED INLETS ENVIRONMENTAL CODE AND THE RULES AND REGULATIONS OF THE BARNSTABLE
RISER WITH CONCRETE COVER TO WITHIN TO WITHIN 6" OF FINISHED GRADE BOARD OF HEALTH.
6" OF FINISH GRADE WHEN NECESSARY. _ - - - - - - - - -
y FINISH GRADE OVER TANK TOP OF SAS = 95.83' 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BARNSTABLE BOARD
EL.= 98.5t FINAL GRADE OVER D-BOX=98.2t 9" MIN. 6" LOAM OF HEALTH AND THE DESIGN ENGINEER.
: .1. 95.00' 36" MAX. BREAKOUT EL = 95.50'
PROVIDE RISER TO WITHIN 3. USE 4 IN. SCH. 40 PVC PIPING WITH WATERTIGHT JOINTS UNLESS OTHERWISE
6" OF FINAL GRADE
g s' CLEAN BACKFILL NOTE. CONTRACTOR NOTED ON PLAN.
TO CONFIRM TANK
SIZE AT TIME OF O O 4. THIS ON-SITE WASTEWATER TREATMENT SYSTEM IS NOT DESIGNED FOR USE WITH
INSTALLATION. 6" LOAM A GARBAGE DISPOSAL.
s" 3" 3" 6" Fly" Q mow 0 0 0 0 5. ELEVATIONS BASED ON FIELD SURVEY BY THE HORSLEY WITTEN GROUP, SANDWICH,
1=95.50 ►=95.33 2' 0 0 0 0 0CX`C)I_U
MA. AND AN ASSUMED DATUM.
1=96.42t i-• REMOVE CONCRETE 6. IT IS THE INSTALLING CONTRACTORS RESPONSIBILITY TO CALL "DIGSAFE" AT
ft
(CONTRACTOR
TO VERIFY 6".1` ; MIN 48" BAFFLE AND INSTALL 1=96.17 CRUSHED STONE OVER LEAST 72 HOURS PRIOR TO COMMENCING CONSTRUCTION AT 1-888-DIG-SAFE
2"- ' ,
PVC TEE W/ GAS (CONTRACTOR UNDISTURBED EARTH OR AND ANY OTHER APPLICABLE AGENCIES NECESSARY TO FIELD VERIFY LOCATION
INVERT AND -'�- 3" MAX. BAFFLE TO VERIFY) COMPACTED BACKFILL 4.0' 8.5' (typ) 4.0'
BAFFLE 4.0' 4.0' OF EXISTING UTILITIES.
DIMENSIONS) PROVIDE 3 OUTLET DISTRIBUTION BOX INSTALLED 33.5' 4.9'
f (TMP)
ON LEVEL STABLE BASE. INSTALL FIRST TWO FEET ' 7. PROVIDE WATERTIGHT SEALS BY USE OF NON-SHRINK GROUT AT ALL POINTS
• - r• ~' ' ~'' OF OUTLET PIPES LEVEL. GROUND WATER = ELE1< <88' 12.9' WHERE PIPES ENTER OR LEAVE ANY CONCRETE STRUCTURES.
6" CRUSHED STONE 93.00'
3 - 500 GAL. CHAMBERS
UNDISTURBED EARTH OR COMPACTED BACKFILL PROFILE VI EW 5' MIN. CHAMBER END VIEW 8. REFER TO SITE PLAN KEY NOTES FOR LOADING CAPACITIES OF INDIVIDUAL SEPTIC
PROPOSED SYSTEM COMPONENTS.
EXISTING 1000 GALLON SEPTIC TANK PROFILE (TO REMAIN) DISTRIBUTION BOX DETAIL PROPOSED CHAMBER SYSTEM 9. ALL STONE TO BE DOUBLE WASHED AND FREE OF DIRT, DUST AND FINES.
NOT-TO-SCALE NOT-TO-SCALE
Nor-To-SCALE 10. THE CONTRACTOR IS RESPONSIBLE TO REPORT ANY DISCREPANCIES FOUND IN
SITE CONDITIONS FROM THOSE SHOWN ON THE PLAN TO THE DESIGN ENGINEER.
TEST PIT DATA
�-'-^ 11. CHANGES TO EFFLUENT FLOW, GRADING OR LANDSCAPING EITHER ON-SITE OR
SOIL EVALUATOR: Samuel J.P. Jensen ADJACENT TO THE SITE OR FAILING TO PROPERLY INSPECT OR PUMP THE SEPTIC
TANK MAY EFFECT THE PROPER FUNCTIONING OF THE LEACHING SYSTEM.
EXISTING WELL MAP 65 :!� _f ►I � � _FND. 114 r� 4's 1. DATE: MARCH 5, 2006
!' I 12. THE OWNER SHALL INSPECT AND PUMP THE SEPTIC TANK EVERY 2 YEARS.
PARCEL 9 ' AP 65 I c �, ='� f(�4� _.._ TEST PIT#: 1
I PARCEL 10 LO S E1 - - � ELEV WATER- <88.0' 13. THIS PLAN IS INTENDED TO ADEQUATELY PROVIDE THE INFORMATION NECESSARY TO
- CONSTRUCT THE PROPOSED SEWAGE DISPOSAL SYSTEM REPRESENTED ON IT AND
® • PERC RATE <2 MiN/IN
SHOULD NOT BE USED FOR ANY OTHER PURPOSES.
_ _
O TEXTURAL CLASS: 1
/ - fr 1 ' ��r o. 14. ASSESSORS MAP#: 065 PARCEL: 11
D ` 5 �f'°` ~M` ' ' '' `i - OWNER OF RECORD: NELSON, CRAIG T. & JODY S.
ti ADDRESS: 27 DEBORAH DRIVE, MARSTONS MILLS, MA. 02648
�3, - - ORS
MAP 65 0 - � i - Q ,r :.�u - t
PARCEL 7 R�8•a3 _ / D i j' 1 r;r s " i�. f ,
�50_ i� r`' � I s r 15. PLANS OF REFERENCE: LAND COURT PLAN 9484.
/ � Y R �r � 0 98.00
C � t i
o�T) o # �, `` rr` ''' / .a� l = _ A Sandy Loam 10YR 4/2 16. ZONE. RESIDENTIAL - RF, WELLHEAD PROTECTION OVERLAY DISTRICT
Massive;Very Friable
97.50 17. THE LOCUS IS LOCATED IN FLOOD ZONE C AS SHOWN ON F.L R.M. PANEL
6"CE �- 250001 0015 C REVISED 19 AUGUST 1985.
/ Al R 2 7S O �53 ✓`�o B Loamy Sand 7.5YR 5/8
Very Massive,Ve Friable,
18. NO SURFACE WATER SUPPLY OR GRAVEL PACKED WELLS WERE FOUND WITHIN 400
�� °•� r`��b• a +.�� OF THE PROPOSED SEWAGE DISPOSAL SYSTEM. NO TUBULAR PUBLIC WELLS WERE
36" 95.00 FOUND WITHIN 250' OF THE PROPOSED SANITARY SEWAGE DISPOSAL SYSTEM.
C1 Med. Sand 10YR6/6 ,
/ �, / �<v� i `..�:6. v ✓�;` Loose; Single Grain; G- 19. NO PRIVATE POTABLE WELLS WERE FOUND WITHIN 100 OF THE PROPOSED
CB/DH d �A; 1 ° SEWAGE DISPOSAL SYSTEM.
,�� r' � �a �r` 15/° Gray., Cobbles
FND _- � 4-
,> 20. NO PRIVATE POTABLE WELLS SERVING ADJACENT LOTS WERE FOUND WITHIN 150'
c" �" Y a 'X."� 61" 92.92 OF THE PROPOSED SEWAGE DISPOSAL SYSTEM.
IV C2
MAP 6 2 O ' ', _ /f` Med. Sand 2.5Y 7/4 21. THE PROPOSED DISPOSAL SYSTEM IS LOCATED 1 12. 1 FROM THE PRIVATE POTABLE
� o
YA�'4 Loose; Single Grain; 5- WELL SERVING THE SUBJECT PROPERTY.
PARCEL 11 �,`�/ 35,566 S.F.f Q C`v` LOCUS PLAN15% Gray., CobblesJ���' /N SCALE: 1" - 1000' �0. �./S ✓A �� � &I iy nrc� f Js
DECK 27 Co/, J lI c U
DEBORAH DR.
EXISTING 3-BDRM v 120" 88.00 p� c: /� S••
DWELLING � DESIGN DATA
/ M
TOP OF �
SHED DECK FOUND. EL. / ��`' ? DESIGN FLOW INSPECTION NOTE
/ 99.71 / p NUMBER OF BEDROOMS: 3
/ 150' SETBACK '�� k} DESIGN FLOW: 110 GPD/BEDROOM TOTAL FINAL CONTRUCTION INSPECTION OF ALL SYSTEM COMPONENTS INCLUDING
/ (3 DESIGN FLOW: 330 GPD INVERT ELEVATIONS ARE TO BE CONDUCTED BY THE DESIGN ENGINEER AND THE
TO EXI STI NG PLC \� BOARD OF HEALTH OR THEIR REPRESENTATIVE PRIOR TO BACKFILLING SYSTEM.
I �\
SEPTIC TANK
/ REQUIRED CAPACITY: 660 GAL (200% OF DESIGN FLOW))
3 / / EXISTING 1000-GAL. SEPTIC USE EXISTING 1000 GALLON SEPTIC TANK VARIANCES
TANK TO REMAIN
500-GAL. CHAMBER SYSTEM TOWN OF BARNSTABLE CODE
/ SST REMOVE EXISTING D-BOX SYSTEM LENGTH: 33.5 FT
N ` ` REGULATION REQUIRED PROVIDED
CD
/ EXISTING LEACH PIT TO BE SYSTEM WIDTH: 12.9 FT Q
3 PUMPED AND FILLED WITH SYSTEM HEIGHT: 2.0 FT SETBACK FROM WELL 150' 1 12. 1'
\ CLEAN SAND BENCHMARK SIDEWALL AREA: 186 SF SERVING PROPERTY
�._.., NAIL IN TREE SET BOTTOM AREA: 432 SF
I? / \ / ELEVATION 100.00 ( )
N ♦ LTAR: 0.74 GPD/SF CLASS 1
/ AREA REQUIRED: 446 SF
/ (ASSUMED DATUM) AREA PROVIDED: 618 SF
•S c
\ 3g 3 CAPACITY PROVIDED: 457 GPD
p t,cu
PROPOSED D-BOX
CL
/ ys�0,\ /
c�
Z
�\ � ° REV. DATE BY APP'D. DESCRIPTION
M :� MAP 65
c i / X 9�7 / Legend
PARCEL 12 PROPOSED SEWAGE DISPOSAL
MAP 64
/ T / 50 EXISTING CONTOUR TEST PIT LOCATION
INSTALL THREE 500-GAL. CHAMBERS SYTEM UPGRADE
1 \ (CONNECTED TO 50 PROPOSED CONTOUR O O EXISTING SEPTIC TANK
PARCEL 26 PUBLIC WATER SUPPLY) LOCATED AT:
Q ` EXISTING ELEC. UTILITIES 4"SOLIDI SCHED. 40 PVC PIPE 27 DEBORAH DRIVE
Cn / MARSTONS MILLS, MA
EXISTING WATERLINE ❑ DISTRIBUTION BOX PREPARED FOR:
MR. & MRS. CRAIG NELSON
co !CB/DH EXISTING GASLINE - 4" PERFORATED SCHED. 40 PVC
Cl) \ FND - �-
d - - SCALE. 1" = 20' DATE. 16 MARCH 2O06
0 10 20 40 80 FEET
-6 EXISTING WELL o
a) ^� h' BOARD OF HEALTH APPROVAL:
c FND.
a PREPARED BY:
>200' TO MAP 64 0��``�`�r y M�s�'�y Horsley Witten Group
C) / EXISTING WELL PARCEL 25 +UELJ.P.
JENSE� Environmental Services
QVIL
o / ►`�.arose Sextant Hill Office Park
9 9F Q/ST 90 Route 6A
or �' EP`�``'
Sandwich, MA 02563
Fs
phone: 508.833.6600
f fax: 508.833.3150
0
SITE PLAN ,- �,�- _:.:.n�
! 3
N De Drawn By: SJ signed By: SJ Checked By: . JOB No. 6021
Cc SCALE: 1" =20