HomeMy WebLinkAbout0085 DEVON LANE - Health 85 DEVON LANE, MARSTONS MILLS
A=057.002.007
r
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
P
85 Devon Lane ^ -00 7067
7M SBy`' 1
Property Address
Owner S�1 �Il
Owner's Name
information is Bate M 'tl1y� Ma 12/8/11
required for every �'
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. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector: It
key to move your
cursor-do not Chad Hathaway
use the return Name of Inspector
key.
H.P.S
VQ Company Name
1 Wawick Way
Company Address
Mashpee Ma 02649
City/Town State Zip Code
774 274 2581 12866
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 pn site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.3a40 of-,'i
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
12/8/11
Inspec is Signature Date
The system inspector shall s 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.
4 1
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 85 Devon Lane
Property Address
Owner Owner's Name
information is required for every Barnstable Ma 12/8/11
page. Cityfrown 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:
1500 gal tank in working condition with pvc tees in place Dbox is level with no signs of leaks or
cracks no sign that dbox has ever been over full do to over loaded SAS
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existingtank is replaced with a complyingse tic tank as approved b the Board of
p P pp Y
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 85 Devon Lane
M
Property Address
Owner Owner's Name
information is required for every Barnstable Ma 12/8/11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
85 Devon Lane
M
Property Address
Owner Owner's Name
information is required for every Barnstable Ma 12/8/11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
85 Devon Lane
Property Address
Owner Owner's Name
information is required for every Barnstable Ma 12/8/11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 85 Devon Lane
Property Address
Owner Owner's Name
information is Barnstable Ma 12/8/11
required for every
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 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 85 Devon Lane
Property Address
Owner Owner's Name
information is required for every Barnstable Ma 12/8/11
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
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:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 85 Devon Lane
Property Address
Owner Owner's Name
information is required for every Barnstable Ma 12/8/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Owner
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):
l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 85 Devon Lane
Property Address
Owner Owner's Name
information is required for every Barnstable Ma 12/8/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1997
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade: 1.75'
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 20
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1.25'
p
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:
1500 gall
Sludge depth:
3"
t5ins•09/OE Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 85 Devon Lane
Property Address
Owner Owner's Name
information is required for every Barnstable Ma 12/8/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
35"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
7"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? sludge judge and tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/0E Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 85 Devon Lane
Property Address
Owner Owner's Name
information is required for every Barnstable Ma 12/8/11
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.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 85 Devon Lane
Property Address
Owner Owner's Name
information is required for every Barnstable Ma 12/8/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan).-
Depth of liquid level above outlet invert 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.):
dbox level at working level no signs of ever being over full do to sas failure
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
trench with no inspection port
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 85 Devon Lane
Property Address
Owner Owner's Name
information is required for every Barnstable Ma 12/8/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 1) 56'
❑ 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.):
Cesspools.(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
85 Devon Lane
4'M
Property Address
Owner Owner's Name
information is required far every Barnstable Ma 12/8/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
85 Devon Lane
Property Address
Owner Owner's Name
information is required for every Barnstable Ma 12/8/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
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t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 85 Devon Lane
Property Address
Owner Owner's Name
information is required for every Barnstable Ma 12/8/11
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: N/A
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: 1997
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:
no gw at 144" per perc test on file bottom of leaching is 60" in ground
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 85 Devon Lane
Property Address
Owner Owner's Name
information is required for every Barnstable Ma 12/8/11
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
508 238-9797 (Home)
Lot 11(85)Devon Lane Cheryl Smith ( ) 540-4176 (Cheryl's Work)
31 Daniel Drive
Builder: "The Norman Trust" North Easton,MA.02356
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Lot 11(85)Devon Lane �' - 540-4176 Che 1's Work
Cotuit 31 Daniel Drive ( ry )
IBuilder: "The Norman Trust' North Easton, MA 02356
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LOCATION lot }.D SEWAGr# 5?
VILLAGE M N�PLS'-OA Ar le11t ASSESSOR'S MAP & LOT S-Z oe l-- ba7
INSTALLER'S NAME&PHONE NO. Read S
SEPTIC TANK CAPACITY / its
LEACHING FACILITY: (type) �'?��u �f'f' (size) ,
NO.OF BEDROOMS
BUILDER OR OWNER lN U►rLitmcs, t,�
PERMTTDATE: B® -�13— � COMPLIANCE DATE:_3_T
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist,
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by - -
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No.6o r FEE cc
f' 7 7 COMMONWEALTH OF MASSAC14USETIS
Board of Health, Barnstable ' AM.
APPLICATION FOP, DISPOSAL SYSUM CONSTRUCTION PERMIT
Application for a Permit to Construct(X) Repair( ) Upgrade( Abandon( - ❑Complete System ❑Individual Components
Location 85 Devon Lane Owner's Name The Norman Trust
Map/Parcel# 57-2-7- Address P.O. Box 599 , Mash pee, MA
Lot# 11 Telephone# 477-0023
Installer's Name Designer's Name Ferreira Associates
Address Address 131 Spring Bars Rd . Falmouth
Telephone# Telephone# 5 4 0-3 6 9 9
Type of Building S i n ci 1 e Family lbw e l l i n g Lot Size 48 ,720 sq.ft.
Dwelling-No.of Bedrooms 3 Garbage grinder ( )
Other-Type of Building No.of persons Showers ( ),Cafeteria ( )
Other Fixtures
Design Flow(min.required) 330 gpd Calculated design flow Design flow provided 344 gpd
Plan: Date 10-15-9 7 Number of sheets i Revision Date
Title Sewage Disposal System prepared for The Norman. Trust
Description ofSoil(s) see plan
Soil Evaluator Form Nc9 2 4()h R Name of Soil Evaluator R F e r r e i r a Date of Evaluation c og r,�+ �2 4 --19 9 7
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
9-,qA
Inspections
6C
TOWN OF BARNSTABLE
LOCATION • C) Uhl SEWAGE # 6
VILLAGE_-__M A P-S 1* I f f ASSESSOR'S MAP & LOT V-6&1- C�p7
INSTALLER'S NAME&PHONE NO. All. Y-71•-0/))
i SEPTIC,TANK CAPACITY / �W
LEACHING FACIL=: (type) -T ]-Y% C-(f (size)
SAS /
NO.PF BEDROOMS_3_
BUI bER`;OROWNER IV
PERWMATE: 1 m - 5 "Y COMPLIANCE DATE: fie
i Separition Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Pnvate:V1!ater Supply Well and Leaching Facility (If any wells exist
o ...ai(e'or within 200 feet of leaching facility) Feet
Edge:of:Wedand and Leaching Facility(If any wetlands exist
wttiiit,300 feet of leaching facility) Feet
Furnished`by
4
Q'Y"
1 7�V
j
_ r t
No. / _ / o FEE CEO
Board of Health, Barnstable MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
� q
Application for a Permit to Construct(()- Repair( Upg`r`adeO Abandon( - ❑Complete System'. ❑Individual Components
Location 85 Devon. Lane _ Owner's Name The Norman Trust
Map/Parcel# 57-2-7- Address P.O. BOX 599, Mash pee, MA
Lot# 11 Telephone# 477-0023
Installer's Name Designer's Name Ferreira Associates
Address Address 131 Spring Bars Rd. '.Falmbuth
Telephone# Telephone# 540-3699
�{Type ofBuilding �Sinale Family Dwelling _ Lot Size 48,720 sq.ft.
Dwelling-No.of Bedrooms 3 Garbage grinder ( )
Other-Type of Building No.of persons Showers ( ),Cafeteria( )
Other Fixtures
Design Flow (min.required) 330 gpd Calculated design flow Design flow provided 344 gpd
Plan: Date 10-15-97 Number of sheets 1 Revision Date
Title ! Sewage Disposal System prepared for The Norman Trust
Description of Soil(s) see plan
Soil Evaluator Form Nc9249613 Name of Soil Evaluator R. Ferreira Date of Evaluation Sept . 2.4 1 997
DESCRIPTION OF REPAIRS OR ALTERATIONS
}
The undersigned agrees to install the above described Individual'Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed; Date
t 9 f r!
Inspections
No. t'(mod FEE GO
C®MMONWEALT14 ®f MASSACHUSETTS
Board of Health, {.)oti✓1 to S {e MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑Individual Component(s) l!116omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ,Repaired ( ),Upgraded ( ),Abandoned ( )
at � !�(�)ni✓` (a, WI G i2C.4r,.^ iM 1 U 3 r
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
Installer- -
✓r c
Designer: Inspector: _ �e i Date: J
The issuance of this permit shall not be construed as a guarantee t the system will function as designed.
No. - O 7 FEE /Q 0
COMMONWEALTH Of MASSAC14USETTS
Board of Health, �e,►Q a S�,t?�-� MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby f
granted to; Construct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at �' fkoo A Le, cm ccctA Lwi ('1�� as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of .' permit. All local conditions must be met.
Form 1255 Rev,5/96 A.M.Sulkin Co.Boston,MA Date ` �47 Board of Health ,= /�R�'!�""�,r✓
v
lAREA PLAN 40 SCA L E. _s YS TEM PROFILE FINISH ORADE NOT TO SCALE SOXL EVA L UA rrOM A8%Lrcd77aV A00__L1V777 Ir FINSH SAWE FINISH "R SEPMAW9 24. ism 0 VER 7AA1K, 0 VEIQ rRE ws a EDWARD Ir. BARRY TOWN OF BARNS7ABLE Apc TOP FtVD fA MST MXE I TEST hmE 2 0. 01 40 P.0. .0. OR CAST IRON TEFS 2* I C)C) 911 Q 0 CA 00 Q0 a a 0 9 0 0 0'A 4c. CA E'A 40 0 asm r PL R 7_ L6 SAAVY LOAK JOYR 312 ,I E_SAAVY LOAM I 0 YR 31P 0 log 1500 SAL. EOUALZERS 941 0" s 9'A 4- 0 040 0 0 0 4 0 clot 0 a ..0 D 64 REINFoRCE 6AS DIST.BOX ,CONCRETE 0 0 00 SAAVY LOAN JOYR 518 BAPFLE QQ 6 5 6, �SAAVY LOAN fOYR 516 00 71, TO BE NS7ALLED ON A 0 0 I'd I 24' 24- LEVEL STABLE BASE SAAV 2.5 Y 516 SAAV 2.5Y 516 SEPTIC TAW COARSE SAAV WrTH TREIVCH L ENS rH COARSE SAAC W17N COMLES S rOWS 40S em VEL COBOL Es s S 7**-S 4OX au VEL TO BE XAIS 7A L L ED ON A C2. 40'. LEVEL STABLE BASE PERC'D A r 6o SAAV 2.SY 514 SAAV 2.5Y 614 <2 AflAfIrAf A*DUrN - FINE SAAV WTH AEDrUV - FrNE SAAC WrM 4'MIN.HEISHT OBSE RV"
COWLES 2aw em VEL .120, D.144, mars m N%vn NOTE' DO NOT RUIV HEA V Y EQUIPMEN T 0 VER S YS TEM ABOVE AV 990(#WWA 707 &#q0UjVD WA rEjq ..........L EA CHING TRENCH SEC TION _DA NO T TO SCA L E SOIL A ND PERCOL A TION': :r-A FOR rINISH GRA DE SEE 5 8"7 AfIA,YS TEM PROFIL E APPUCA rraV AV.
PERC. TE,. _rV<5 12"MIA1, TAKENr By Mr TAIESSE0 B Y EDM4W DA TE .8.4 AfIN.2" .118"-112" M2 LOT 12
4"DIA.PIPE TES T T ELEV.TONE A SHED S DOSE DR44 EASE74ENT 2 641--IVATUPAL s6lL-- 2 M4X EFFEC TI VE DEP TH S 25 1 8 53 NE ——--------------- . ELEWMW BASW.W S.'L 314--1 .112" O TES:167. 79 A SHED S TONE Itfj/v. 3x_EC T.1 V EFF WID TH 2. TOW NA TER ON SITE,EXCA VA TED SIDEWALL 4. V. F vC'LOW Z&W OP DEPTH EV 4. AROWA6mo TER EL" A TX&4'26 7,BASIN m4)w EFFEC TI VE WID TH kBEp 0#- FROM HaUTOR hELLS�VU TRENCHES LOT 1 48, 720 SF :�DA TA 'DESIGN S. F SIDEPVALL ARE 24o A u GAL SISF GALS.U) NO Of' BEDROOMS DISPOSA L AV-'K 224 S. F. BOTTOM AREA . 74 GALSISF 166 GALS. ES T. TO TA L DA IL Y EFFL UENT S rC TANK U) 464 S. F. TOTAL AREA SEPTA GA L S.tu GENEA L NO TES NAM NO TE.' BE IN log INS TA LL E A CCORDA NCE WI TH TI TL E 5 OF THE STA TE SANITARY EXCAVATE TO ELEV.!53-0 OR L OWER AS EGUITRED CA TO REMO VE ALL LOAM AND CLA Y CONTAINMG DA TED 9 M4 _95 AND ANY LOCAL RULES APPLI BL E,::AfA rERIA L BENEA TH THE L EA CHrNG A REA REPLACE 2. ANY CHANGE�-IN THIS PLAN MUS T BE A PPRO VED 7 TH zt EXCA VA TED MA 7691A L k1r TH CL EA Al. CL A Y FREE GRA VEL BY THE ,,00AR0,VF HEAL�"WVCH MECHANICALLY COMPACTED IN PLACE 'ING(1) L EA 0AW. 4'MME 3. HEIV CONS TRUC TION IS COMPL E TED PRIOR TO A CKFIL L NOTIFY BOARD OF HEALTH FOR INSPECTION 4. FND. ELEV. MUST BE ,CHECKED IHEN COMPLETED 'r 'BE�CH ' WtT ANGEDr HOL&.1 r
5. THESE EL E V.MUS T NO T LEGEND THE BOA RD OF HEA L TH A PPRO VA L TED D 70' 6. BOARD r OF,HEAL,TH INSPEC TION i'REG WHEN�'EXCA VA r
__ (*4-- EXrS r.SROUND ELEV.1K aqAI�A FrAIrSH SROUND ELEV.UAIDERLIAIED EASi*W S M_T e SEWA GE DSPOSA L P 4,4 PIPE rAIVERT ELEV. E PREPAED FER.TEST PX T L OCA TION ISEPTIC 7AA1K LOT 10 7HE !NORMA TRUSI 0 DTSTRIBUTrON BOX ._DErV LO T� JJ Off� I4 OC.1.OR SCH 40 PVC A9L AfA 55 BA RNS rS MACE LAC W D. "BIT. -.rBER p.rp.& T.r6H7*I N 64'41 '07E 36.00 4 cirs GEORGE:r PROPE9 T Y r L Xt4ES SCR 0 N OCr-srovev 'DA TE No 7' SoCrA,A w :AS SHOW t 85 E* DrS 7A NCE REZAA,MIN.CODL ts I-S 57 2 ORA MI M�HECKED HSE, C mAp SEC L 6S PCL OT 4