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HomeMy WebLinkAbout0031 EMERALD LANE - Health 31 Emerald Lane Marstons M'ilPs F _v . A = 646 041 f III I Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 31 Emerald Lane UUD D Property Address ' L.Sassone ' �rl Owner Owner's Name information is Marstons Mills MA 02648 06/20/2018 r required for every r.M page. City/Town State Zip Code Date of Inspection " IIQ 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 A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not A.Riker use the return Name of Inspector key. R.L.C. r� Company Name PO Box 726 Company Address few South Yarmouth MA 02664 City/Town State Zip Code 508-776-6460 S 14590 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 06/20/2018 In ctor's Signature . Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M• ,°°V 31 Emerald Lane Property Address L.Sassone Owner Owner's Name information is required for every Marstons Mills MA 02648 06/20/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspection of septic tank, distribution box and SAS was observed to be operating with out failures with less then 6" of standing water in base of 2'depth Drywell and Max observed stain line 12"from bottom of 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 existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6116 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 31 Emerald Lane Property Address L.Sassone Owner Owner's Name information is required for every Marstons Mills MA 02648 06/20/2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Emerald Lane Property Address L.Sassone Owner Owner's Name information is required for every Marstons Mills MA 02648 06/20/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System wil'I 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 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 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 Y2 day flow t5ins.doc-rev.6/16 Title 5 Official Inspecfion Form:Subsurface Sewage Disposal System-Page 4 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Emerald Lane Property Address L.Sassone Owner Owner's Name information is required for every Marstons Mills MA 02648 06/20/2018 page. CityfTown 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Emerald Lane Property Address L.Sassone Owner Owner's Name information is required for every Marstons Mills MA 02648 06/20/2018 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): 330GPD t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 31 Emerald Lane Property Address L.Sassone Owner Owner's Name information is required for every Marstons Mills MA 02648 06/20/2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: ,Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes E. No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2017=77GPD g ( y g (gpd))' 2016=206 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: curent 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Emerald Lane Property Address L.Sassone Owner Owner's Name information is required for every Marstons Mills MA 02648 06/20/2018 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: homeowner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: n/a 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): t5ins.doc-rev.6/16 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 31 Emerald Lane Property Address L.Sassone Owner Owner's Name information is required for every Marstons Mills MA 02648 06/20/2018 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: Tank Orginal apprx.1977 ,distribution box and SAS installed in 04/24/2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): interior plumbing below slab Distance from private water supply well or suction line: Town water service feet Comments (on condition of joints, venting, evidence of leakage, etc.): interior plumbing under basement slab. Septic Tank (locate on site plan): Depth below grade: .5feet 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: 9x5x5 Sludge depth: 6" t5ins.doc-rev.6116 Tide 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 31 Emerald Lane Property Address L.Sassone Owner Owner's Name information is required for every Marstons Mills MA 02648 06/20/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from tcp of sludge to bottom of outlet tee or baffle 28" Scum thickness 3" Distance from to?of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as re.'ated to outlet invert, evidence of leakage, etc.): Tank was observed to be in operating order with no evidence of failure or other adverse conditions. Grease Trap (locale 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 31 Emerald Lane Property Address L.Sassone Owner Owner's Name information is required for every Marstons Mills MA 02648 06/20/2018 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.doc-rev.6/16 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 31 Emerald Lane Property Address L.Sassone Owner Owner's Name information is required for every Marstons Mills MA 02648 06/20/2018 page. CitylTown 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 equal to outlet inverts no high water stains 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.): Distribution box had riser installed and observed to be in working order with no carry-over observed. 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Emerald Lane Property Address L.Sassone Owner Owner's Name information is required for every Marstons Mills MA 02648 06/20/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2x500 gal.w/stone ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS observed to be in working condition with 1' of seperation from inlet pipe to high stain line and 1.5' to standing water. Cesspools (cesspcol 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 31 Emerald Lane Property Address L.Sassone Owner Owner's Name information is required for every Marstons Mills MA 02648 06/20/2018 page. City/Town 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Emerald Lane Property Address L.Sassone Owner Owner's Name information is required for every Marstons Mills MA 02648 06/20/2018 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 A ®r I 3S, _ 3a t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Emerald Lane Property Address L.Sassone Owner Owner's Name information is required for every Marstons Mills MA 02648 06/20/2018 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: 04/1977 Test hole on file Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Test hole on file 144"with no water observed ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Test Hole on File 04/1977 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Emerald Lane Property Address L.Sassone Owner Owner's Name information is required for every Marstons Mills MA 02648 06/20/2018 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i I YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME imtown (which you must do by M.G.L.-it does not give you permissio o operate. Busi �ess Certificates are available at the Town Clerk's Office, 1'FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) DATE: Fill in please: h" APPLICANT'S YOUR NAME/S: K62 A SA SO fQ t BUSINESS YOUR HOME ADDRESS: CYr�CY� rV e a� r , a i• r ya rn r:2 rrn► t Ls TELEPHONE # Home Telephone Number 5 5- NAME OF CORPORATION: NAME OF NEW BUSINESS --rwT C„t-t-r F Lip KS TYPE OF BUSINESS e ry m r\f rF IS THIS A HOME OCCUPATION? E NO ADDRESS OF BUSINESS i l-,���7� YY1�'1 BLS 1�MAP/PARCEL NUMBER (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main Scorner of Yarmouth Rd. &.Main Street) to make sure you have the appropriate permits and licenses required to legally operate y ruo business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of.business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual ha n info of t e ermit re ements that pertain to this type of business. Vo A orized gnature* COMMENTS: 3. CONSUMER AFFAIRS. (LICENSING AUTHORITY) This indiyi has been informed of the licensing requirements that pertain to this type of business. tF4 I - Authorized Signature** COMMENTS: TOWN OF BARNSTABLE LOCATION 3//c'dil��j /� rA i-� SEWAGE # ?003 VII-LAGEr57`o�r5 ASSESSOR'S MATS & .INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ./000 LEACHING FACILITY: (type) �2 'J?O (size) NO.OF BEDROOMS 3 BUILDER OR OWNER j�,t� PERMTTDATE: COMPLIANCE DATE: Y` 2 9- V5 l 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 leachi g facil' ) Feet Furnished by y ' b� `f TOWN OF BARNSTABLE 7 LOCATION 3/ LWIL'VIV G/9f7iG SEWAGE # 2003 VILLACE /?9W5?Oh5 /5?/// ASSESSOR'S M GAP & LOT 0Y — INSTALLER'S NAME&PHONE NO. Sob— -'12 0 c%11 'r-� Z96 SEPTIC TANK CAPACITY /ODo // LEACHING FACILITY: (type) 'J?O 6 414,�/ 4el E1' (size) NO.OF BEDROOMS - BUILDER OR OWNER OW Z19-wE1 114- PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi g faci )) Feet Furnished by E �/Eft No. ,;k ' Fee � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes ' PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for )Bigozaf *p.5tem Construction Permit Application for a Permit to Construct( )Repair( `' Upgrade( )Abandon( ) ❑Complete System Nklidividual Components Location Address or Lot No. 3 1 E;,i,QY 0.(d L Owner's Name,Address and Tel.No. Assessor's Map/Parcel O �- a Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. t10<,`4 9,,0 -a3 6, HOLVr i"')-to�, S Type of Building: Dwelling No.of Bedrooms Lot Size Z0) 7? sq.ft. Garbage Grinder( ) Other Type of Building t CQ, No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow ?S3 gallons. Plan Date /7—o Number of sheets Revision Date Title _ Size of Septic Tank 9 A Type of S.A.S. Z--Sle-9 G le J - i Description of Soil Q CL, 2_ 0 -d 0 f Z Nature of Repairs or Alterations(Answer when applicable) rej4ke SIV leae-Gs 41•/ we`in Z- 7 /y/Q I c4a4-i4-_J ' sue ct.- C Zs ' x ' x btaci. e4,e,4, ,+v 10to.2 OftcIC,d-iov, r-A a It-lop 0&e do zr-ovi' /0-5 r VS 1SZ) `re!Z9 Qb Ok-SIB&e/lo 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 Certifi- cate of Compliance has been issued by this Board 9f Health. Signed � - Date Application Approved by S Date Application Disapproved for the following reasons Permit No. -a 1)0 3 Date Issued ' U ! I N 5 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: c11001 Yes "} PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE1 MASSACHUSETTS ZIpprication for�Oigozall*p.5tem Construction Permit Application for a Permit to Construct( )Repair( grade( )Abandon( ) ❑Complete System �61dividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 3 J �. R Assessor's Map/Parcel' ®- 16—0 4a/ a�6►�6e.- Installer's Name,Address,and Tel.No. 5 Qg 4i2d_f y y g' Designer's Name,Address and Tel.No. ; S Type of Building: DwellingNo.of Bed 3 Lot SizetiZ0 7 8' Bedrooms �t sq.ft. Garbage Grinder( ) Other Type of Building 7( 1 icY¢.�GP_ No.of Persons Showers:( ) Cafeteria( ) Other Fixtures . Design;ow 3 3 gallons per day. Calculated'daily flow ��3 gallons. Plan Date 4/-/7-07 'Number of sheets Revision Date Title a Size of Septic Tank '5_K a A Type of S.A.S. Sa 9 OA,11�Us 6/- �-�t�7�2 Description of Soil CO C.k-.1.P j o-,,c 0 - ('2 , r. d pp i Nature of Repairs or Alterations(Answer when applicable) A U l �Gr �tQ•tny��.�1 I- r SArvXC Z 7 X ' " 041 f4.,6,y . •1�Qricw/.GP 4,�) to t of /(XX t./fn d 1 Gi.. r'AR L l r 69 04/A,e 'JU /r IYy i 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 Certifi- cate of Compliance has been issued by this Board o Health. Signed 1-f. o n Date Application Approved by �.� K- 5 Date / V Application Disapproved for the following reasons Permit No. ? j 0 Z-/ Date Issued U U l' ---------------------------�1- ---------- THE COMMONWEALTH OF MASSACHUSETTS " BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by at has been construc jed ip`accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 UO3 /l X dated Installer Designer The issuance�bf this p�rmit shall not be construed as a guarantee that the syste wtll n-do a""esig­l d. Date y ?�I l3 3 Inspector 777, No. Fee Q T— THE COMMONWEALTH OF MASSACHUSETTS �G y� Y/ PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpogal bp5tem Construction Permit Permission is hereby granted to Construct( )Repair(( grade( )Abandon( ) System located.at 31 P t-A/ 0' Z H and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided Construction must be completed within three years of the date of this p� Date: L4 �l f Approved by Gn ` f � 5/25/01 Aw Notice: This Form-Is To Be Used For the Repair T Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM h�f , l�,.hereby-certify that the engineered plan.signed by me dated rif 1174 ZovT,concerning the property located at C Z'"R Id L h, /14^nJ fr+f A,,'O meets all of-the following criteria: `4/This failed system is connected to a residential dwelling only: There are no commercial or business uses associated with the.dwelling._ ` t ve The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this p app y . fact or may conduct preliminary tests at the site without a health agent present. There is no increase in flow and/or change in use proposed LA/11lere 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 4,Pr_+adjustment for high G.W. _ 4-- DfFFERENCE BETWEEN A and B C �� r SIGNED DATE: NOTICE 3 Based'upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized m the future without engineered septic system per• q:health folder pero map CERTIFICATE OF ANALYSISp��o ■�q �e L nfi �'@ECE Y E® Barnstable County Health Laboratory .-�s3,icrtti 5t� Report Prepared For: Report Dated: 3/10/2003 APR 16 2003 Order Number: Toriv7MBARNSTABLE Diane P.Jensen HEALTH DEPT. 1330 Phinney's Lane Hyannis, MA 02601 Laboratory ID#: '0318945-01 Description: Water-Drinking Water Sample#: 18945 Sampling Location: 31 Emerald Lane,Marstons Mills Collected 2/21/2003 "ollected by: Diane P Jense 046-041 Received 2/21/2003 Routine ITEM RESULT UNITS MCL Method# Tested LAB: IC Lab Nitrates 3.1 mg/L 10 EPA 300.0 2/21/2003 LAB: Metals Copper <0.1 mg/L 1.3 SM 3111B 3/10/2003 Iron <0.1 mg/L 0.3 SM 311113 3/10/2003 Sodium 11 mg/L 20 SM 3111B 3/10/2003 LAB: Microbiology Total Coliform Absent P/A Absent 309 2/21/2003 LAB: Physical Chemistry Conductance 141 umohs/cm EPA 120.1 2/21/2003 pH 5.9 pH-units EPA 150.1 2/21/2003 Note: Water sample meets the recommended limits for drinking water of all above tested parameters. Approved By: o.....-_. (Lab Director) 3�/0�Zooj • F Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph:508-375-6605 I RECEIVED APR 0 9 2003 COMMONWEALTH OF MASSACHUSETTS WN OF BARNSTABLE •\ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI S H LTH DEPT. DEPARTMENT OF ENVIRONMENTAL PROTECT ^� F z m �+ C FAILED INSPECTION i� yJev TITLE 5 OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 31 EMERALD LANE MARSTON MILLS 02648 M046 P041 Owner's Name: MARIA P. LOMBA Owner's Address: 31 EMERALD LANE MARSTON MILLS 02648 Date of Inspection: 3/12/03 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA. 02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes _ Conditionally P es _ Needs Further aluation by the Local Approving Authority X Fails Inspector's Signature: t, Date: 3/12/03 The system inspector shall submit a py of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspectio . If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments THE SYSTEM FAILS TITLE V INSPECTION.THE LEACH PIT WAS FULL UP TO COVER WITH NO VISABLE LEACHING LEFT. THE PIT IS IN HYDRAULIC FAILURE. ****This report only describes conditions at the time of inspection and under Me 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. i Title S tncnPrtinn Fnrm A/1 V?000 1 f Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 31 EMERALD LANE MARSTON MILLS 02648 M046 P041 Owner: MARIA P.LOMBA Date of Inspection: 3/12/03 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: THE SYSTEM FAILS TITLE V INSPECTION.THE LEACH PIT WAS FULL UP TO COVER WITH NO VISABLE LEACHING LEFT.THE PIT IS IN HYDRAULIC FAILURE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 31 EMERALD LANE MARSTON MILLS 02648 M046 P041 Owner: MARIA P. LOMBA Date of Inspection: 3/12/03 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 31 EMERALD LANE MARSTON MILLS 02648 M046 P041 Owner: MARIA P.LOMBA Date of Inspection: 3/12/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped NOT IN LAST YEAR. X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] X _ (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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. A Page 5.of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 31 EMERALD LANE MARSTON MILLS 02648 M046 P041 Owner: MARIA P.LOMBA Date of Inspection: 3/12/03 Check if the followinb have been done. You must indicate"yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner, occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site'? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ X Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 �� f Page 6,of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 31 EMERALD LANE MARSTON MILLS 02648 M046 P041 Owner: MARIA P. LOMBA Date of Inspection: 3/12/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents:2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings., if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings,if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: NOT IN LAST YEAR Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1977 Were sewage odors detected when arriving at the site(yes or no): NO A Page 7.of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 31 EMERALD LANE MARSTON MILLS 02648 M046 P041 Owner: MARIA P. LOMBA Date of Inspection: 3/12/03 BUILDING SEWER(locate on site plan) Depth below grade: 9" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: 100Fe0' Comments(on condition of joints,venting,evidence of leakage,etc.): WELL WATER OUT FRONT SEPTIC TANK: X(locate on site plan) Depth below grade: 3" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6"H 5' 7" W 4' 10"" Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle:30" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: MEASURED Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL SEPTIC TANK COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.RECOMMEND PUMPING ENOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8.of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 31 EMERALD LANE MARSTON MILLS 02648 M046 P041 Owner: MARIA P.LOMBA Date of Inspection: 3/12/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): THE DISTRIBUTION BOX IS BEGINNING TO ROT PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 31 EMERALD LANE MARSTON MILLS 02648 M046 P041 Owner: MARIA P. LOMBA Date of Inspection: 3/12/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): THE LEACH PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING,THE LIQUID LEVEL IN THE PIT WAS UP TO INVERT PIPE WITH NO VISABLE LEACHING LEFT.THE PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING AND NEEDS TO BE UPGRADED.BOTTOM AT 8' CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs-of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 4 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 31 EMERALD LANE MARSTON MILLS 02648 M046 P041 Owner: MARIA P. LOMBA Date of Inspection: 3/12/03 SKETCH OF SEWAGE DISPOSAL'SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. s'tiel� �poI &'CIS A c A4 I� AC a6 9W 33 (�c 3� I in Page,11,of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 31 EMERALD LANE MARSTON MILLS 02648 M046 P041 Owner: MARIA P. LOMBA Date of Inspection: 3/12/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from systenl.design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER WAS DETERMINED BY HAND AUGER AND USGS DATA- 12+FT it wit Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection ' ` ; William F.Weld Governor Trudy Coxe t3sereta y EOEA ` David B.Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION „ Property Addres ;,7 Address of Owner: !'n tee Date of Inspection: .—� �j— different) Name of lnspectc . a c c, e��.��e Company Name, Address and Telephone Number: CERTIFICATION STATEMENT r . centF)'that I have personally inspected the sewage,disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site see ge disposal systems. The system: passes ' _ Conditionally Passes _ Needs Further Evaluation By the Local Ap ving Authority P' r'' _ Fails Inspector's Signat Date: .�, w' The System Inspector shall submit a cop (40 y of thi inspection report to the Approving Authority within thirty (30) days of completing this. .� 3x 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 _ , the repon to the appropriate, regional office of the Department of Environmental Protection. . The,original should be sent tv the system owner and copies sent to the buyer, if applicable and the appro�ing authorl,y. # S, RY INSPECTION SUMMARY: Nr004 }'. r p ' Check A B C, or D: r N x�� xF AJ v SYSTEMPASSES r ' XW,,�-t�& r ?R.!$,d +`l.9i9 , r, ` •;`; :;` ,f i �1�..[iJ'i' rr f� + l,'} ,: fi? .-`^`'4'« kV�,3,, I have,not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303 r Any failure criteria not evaluated are indicated below. BJ SYSTEM CONDITIONALLY PASSES: n _ t :i Fll�i 3 .✓r•.P ii , ,:,o,.� t"l ;:k. ....'I:r ' ., i'S tt - �+, y. , n{: '.(,� I- i"pi Stlx ' � N1x One or more system components need to be replaced or repaired.' The system, upon completion of the replacement or,.repair, , . passes inspection. Indicate' es, or not determined (Y,'N;'or ND).�.Describe basis of determination in all instances If"not determine ,,explain 2 Y , ,......_ a 4 k The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or ezfiltrat ion, or tank failurekls � x imminent.,'iThe system will pass inspection if the existing septic tank is.replaced With a conforming septic tank fit, e Y approved by the Board of Health. �1wY•,�l #t revised $/15/95) j< � One Winter Street • Boston,Massachusetts 02108 • FAX(617)656-1049 • Telephone(617)292 SS00 Printed on Recycled Paper ;Ykaa r , 2 x SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM p = ` PART A CERTIFICATION (continued) =' n VIA \ Property A dress: � Ir �Y'��� �..r(.. Vv` a Owner: c arV ey , Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) Lf Sewage backup or breakout or high static water level observed in the distribution box is due to broken`or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the y. Board of Health): broken pipes) are replaced obstruction is removed _ distribution box is levelled or replaced ;` < t?W .9rs , = _ The system required pumping more than four times a year due to broken or obstructed pipe(s),, The system;will pass, { ' inspection if(with approval of the Board of Health): broken pipes) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: : ;, t &n.{,n ;Aft, Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. t e 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER ;WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: , Cesspool or privy is within 50 feet of a surface water _ • within 0 feet of a bordering vegetated wetland or a salt marsh. a I r m iswt i 5 . Cesspool o g g P P 1 'I ' H ND PUBLIC WATER SUPPLIER IF APPROPRIATE) DETERMINES THAT f'- BOARD OF HEALTH , 1), SYSTEM WILL FAIL UNLESS THE,B. (A , ,�,.I sit, THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE,`;, �,„$ ENVIRONMENT: Ihp wstem has a septic tank anu.soii ausorption System anu is within 100 fee',to a surface 'vioi Suajri') or tributari surface water supply. The system hay a septic tank,and soil absorption system and,is within a Zone I of a public water supply well The system has a septic tank and soil absorption system and is within 50 feet of a private water supply Yvell m " �' tit The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more fro a priiv�ate'wate- � k , supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that,, T 4V 7l,i A . free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less`tl�an 5 � fVi m• `3at,.:i n vl",. :J'1.>`3il+f 'f` r< t, h,i r }t,?•,f` P,l { rr 'pp d '3 ,,,. "SS! rfr �1 F1e l�tftsd`�i v f^; " D) SYSTEM FAILS: � � 3 I have:determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303 sJhe basis _ "for this determination is identified below' The Board of Health should be contacted to determine,what will,be necessary �o the failure. iBackup'of sewage into facility or system component due to an overloaded or clogged SAS or,cesspool 1(r�� C �,k ' 4 r. i� ..• `''i.. 't. t ' e , jp,) al ,! ainro 'h 1Ptg0a kfef e.,.3 5ti �4"' Discharge or'ponding'of effluent to the surface of the ground or surface,waters due to an,overloadedt ofrdogged SAS or, ` cesspool. u,: t:. z'ii ° SV t.k 1,iryta ! 4.. (revised ,8/15/95) 2 ;�` x�� i fS i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:3 LK„ � 1 Owner: VAAir v e Date of Inspection: -7- D) SYSTEM FAILS (continued): l' 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. L Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped b. 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 well with no }, acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for �. coliform.bacteria, volatile organic.compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: 7 The following criteria apply to large systems in addition to the criteria above: ` The design flog," of system is 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: _ the system is within 400 feet of a surface drinking water supply 10 the system is within 200 feet of a tributary to a surface drinking water supply �x 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! .5 The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program,," rMA requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. m � , F fir' 3! + ti -�2 (revised 8/15/95) 3 � . n � f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property =dress: 31 vw�r�1 N. .yl�t°VM'\s Owner: v°V- 1 Date of Inspection: Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. ,_tCone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates ,j during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. �s built plans have been obtained and examined. Note if they are not available with N/A. �e facility or dwelling was'inspected for signs of sewage back-up. e system does not receive non-sanitary or industrial waste flow ` a _L.-The site was inspected for signs of breakout. t v t a1�dI system components, excluding the Soil Absorption System, have been located on the site. .� CJ(he 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. r✓ he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods, 111e facilii) occupants, if differ , from owner) were provided with information on the proper maintenance of Sub.. Surface Disposal System. ' add kV S4 ,• 1 y mt�id� 17 (revised 8115195) 4 f } v,. it SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION '.Property A ress: Owner: Date of Inspection` { a.^ FLOW CONDITIONS . ft RESIDENTIAL: Design flow: gallons Number of bedrooms:'_:::,_; Number of current residents: 01-- Garbage grinder(yes or no): /` Laundry connected to system dyes or no): 'T�`' '"'s Seasonal use (yes or no):_ 'rar Water meter readings, if available: .Last date of occupancy: LiZ`SC�� COMMERCIALIINDUSTRIAL: Type of establishment: ` Design flow: gallons/day t. t fir: b•;�:.r �`�irns )._ Grease trap present: (yes'or no)_ t � 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: t , OTHER: (Describe) r o Y, .;, Last date of occupanq,: ' e r M GENERAL INFORMATION .- PUMPING RECORDS and source of information: ,.,Zi.,V)ec,T mt.VWN System pumped as part of inspection: (yes or no)\L If yes, volume p,imped: gallons t Reason jor pumping: s+`S s aYo . b i •, bCttt i€r1 f,1"F}7�isist"t#�:Ty� ' rsR t TYPE Of SYSTEM b n eptic ank/disfribution box/soil absorption system - , "`: ° ingle`_t cesspool ' Overflow cesspool.. • , . . . �. w,�s 1,M++gr V+r4k•ae'J+w«rF+rfii ,z Privy r Shared system (yes or no) (if yes, attach previous inspection records, if any) fT l Other (explain) oll APPROXIMATE AGE of all components, date installed (if known) and source of information: I7 x�4 Sewage odors detected when arriving at the site: (yes.or no)_ r ,Xr(sevised 8/25/95) T A � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Ad ress: ` VA V�-• . `Ula. l�l� Z��' t , .:, � ; Owner: V V`e Date of Inspection: T �-7-a qR SEPTIC TANK:/✓ �` ° (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP —other(explain) Dimensions: Nc Sludge depth: &f jay, Distance from top of sludge to bottom of outlet tee or baffle: V Scum thickness: el /y/ Distance from top of scum to top of outlet tee or baffle: y„ Distance from bottom of scum to bottom of outlet tee or baffler Comments: (recommendation for pumping, condition of inlet and outlet tees o baffles, dept of liquid level in rel�tio to outlet env rt, structural =#ti" integrity, evidence of leakage, etc.) �/O/� L_ P'c ce/ C� `'P 4 c •ita' F'''a f''fr'' °=S iS' M w ' l GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP —other(explain) y* ' Dimensions: x ,? Scum thickness: ,M Distance from top of scum to top of outlet tee or baffle: "` :) tlt`�•t�E f Distance from bottom ni earn in hottnm oa owlet tee or bailie Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural t *tom gh integrity, evidence of leakage, etc.) " 4 >Y s f� `a 9•. •emu iv-dif k d k F F 1't �f 4 MY<"'rw w.trc�.w+rpm,ro a•N .?, .. y .. .. .. a%FIY. } .:+e 7 6`J iYtA 1�.!'�+r :1I '1,10}WS.V rr+t93k3 ` (revised 6/:5/95) 6 r �.rn f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued) Property Ad ess: 3 �iM'e V'"��� �-►� 1/I�` o Z Owner: ✓U-� t »r; a� �SC33a. 2 y Date of Inspection / " TIGHT OR HOLDING TANK:A/ (locate on site plan) Depth below grade: `')"r' ijj f.h ron)) Material 'f construction: concrete—metal —FRP—other(explain) Dimensions:. ' Capacity, gallons Design flow: gallons/day '3 Alarm level: Comments:' (condition of inlet tee, condition of alarm and float switches, etc.) T DISTRIBUTION BOX:?/ �42 (locate on site plan) ' Depth of liquid level above outlet invert:/�' L `$°'' ' " (fit-, ` } kif A Comments: rs�s.� s� li cta ttui;r*lc� r{.,r1 aiTp�R'` is :'mote it ievei anddrstributl(,i, t'4u8i, e��uencE of surd: cair)o�er, evi&nce of leakage into or out of box, etc.) �,;� .r.0 Y W a..WfT,�1F a $f ,-.PUMP CHAMBER:•+�" cf, �1, (locate on site'plan). ._ w. r y.Pumps in working order.(yes or no) s' , l `:Comments • ', f.£`t {d)e 91fT � a..k (note condition of pump chamber, condition of pumps and appurtenances, etc.) d y yhx$ 5. X�q�, R S83'1`}kjt' t'}Ytl'Y• e t4l ava a V ws ndSY�+q R"p.��y'+�.f s (revised 6/15/95) 7All ' � `fit - •f.: ' P�E • SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I aN1 r',,^c�:�, � 1.;4� `..' ✓�,S��ha F°t.( Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not.determined to be present, explain: Type: leaching pits, number: leaching chambers, number. leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments:,(note condition of.soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) 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 ground„atc inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic.failure, level of ponding, condition of vegetation, etc.) (revised 8./15/95) 8 f - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: `"S V\4 r'w c�� � �:,.,��;, �AA Owner: ��c:\\r\1 c,•.'' Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: - include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' L . DEPTH TO GROUNDWATER t v'V tJ t Depth togroundwater:_ feet method of determination or approximation:Al (f C'. tRC'_._ (jVt:'.4'' ��� a'«►'(? (revised 8/15/95)`, 9 L i TOWN OF BAARNSTABLE "(qe- LOCATION SEWAGE # C? VILLAGE Nw �'`��4 � ASSESSOR'S MAP & LO INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY \.CJM �-/b4C\ems LEACHING FACILITY:(type) P�,Lo-��C�r— P1—(size ) ZC� NO. OF BEDROOMS _PRIVATE WELL O UBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: A 01 VARIANCE GRANTED: Yes No 1� I o - No.- ............................ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiuu for Bi-q1taiial Works To u urtiu �t Application is hereby made for a Permit to Construct ( ) or Repair (�n In ividual Sewage System-at: ............ .I----._1;1�_:,MnCV.� ......lr. sc�- ------------- ------------- ....................................................... � Location-Address or Lot No. ............ .Y..1` ...........Y..v ....................................... .................� . .......... Owner Addre s- - - - Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms....._?.................................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building .............. No. of ersons._...................__._... Showers —Type g -------------- p ( ) — Cafeteria ( ) 04 Other fixtures ---------------------------------•-•------------•------•----••••-•--•------•------•-•-•----•---•--••- W Design Flow.......... .....................gallons per person per day. Total daily flow.....DQ�62....................gallons. 04 W Septic Tank—Liquid capacity............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 area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (-1, Test Pit No. 2................minutes per inch Depth of.Test Pit...:................ Depth to ground water........................ 19 .•-•--•••-•-------------------•••----•......._...•--•-•----••••••--•--•-....•-•-•••-----------•........._....•---•--------•-•-•----••......------•-----...... ODescription of Soil........................................................................................................................................................................ c.� --------------- ••--------------- -•---------------------------------- ---------------------- -•--------------------------------------------------- •----------- ------------- --•--------------- W U Nature of Repairs or Alterations—Answer when applicable....- ESTA .. ........ ......................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigngo further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boa ealth. Signed . /e�C;;0 .. 1�----------- ...... .. ---- --- ------ --- - .............. A�plication Approved BY - ���%�---- --" _. ........ . tee......... Dare Application Disapproved for the following reasons: ....... .......... ---..........-----------------.-- .... -------------- ---------------------------- ------ ----------- .................................................-.........---------........----------- ce Permit No. .r Issued ------------- - Dace NoQ I/--` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �Y Appliration for Dispuuttl Works Tnnsfrudionlividu!IMS�ewage � Application is hereby made for a Permit to Construct ( ) or Repair (�an In Dispos�a­`)/ System at: \i~?..-----� {�............... .............l.' L�?.�1�S -`-- ------- ------ Lot No. �..._........�ry Location-Address S'} r _ ............ :.+_. .._.---........_:::V..::j..................................»--- -----------------C-�-------- .... ._._..w_..._..__...-• _---- --. ae W Owner ` / �� . ` r (Q - eS Installer Address Type of Building Size Lot---------------------------Sq. feet V Dwelling—No. of Bedrooms•_-_-_3.................................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ---------------------------- No. of persons---------------------------- - Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------------------------ - w Design Flow........... ��-.....................gallons per person per day. Total daily flow_.._..7�_C?•_-_------___-•--_-•gallons. WSeptic,Tank—Liquid capacity............gallons Length---------------- Width................ Diameter................ Depth-_-_••_---_-•-__ x Disposal Trench—No_____________________ Width.................... Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet-------------------- Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date---------------------------------------- �_j Test Pit No. 1.................minutes per inch Depth of Test Pit•-_-__•-•---__--_•- Depth to ground water.................... .__. rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ a •--•-------•---••----•--•-•-••-•-••-•-•--•-•-•-•------....•----------•--•-------------------------------- -------------------------------------- 0 Description of Soil--------------------------------------------------------------------------------------------------------------------- x w . ----------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Rep ITS or Alterations—Answer when applicable____�'�-5-T. __--•_•_1�.4 s _____ 1 ________________________ + ��` ------------------- Agreement: The undersigned agrees to instalF the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersign further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the boar of-health. Signed r �t r c Dare Application Approved B PP PP Y t -- '`------ ` � 1e - T , _: s reaons.Application DisapprQvedforthefollowins - -------------------------------------------------------------------- --P erm-it- - -------- ----------------- Issued -------- _ f ----- _ --------- . 4P -- -------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cger#ticttte of 01outpliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by--------------------------_----' L— V `-S�.k— .L.V .C.0... (' taller at -------------------------------------3 ------ tM_� --------L-•c�----e--------------- ,Y--- i� ----------------- has been installed in accordance with the provisions of TITLE 5 e ironmental Code as described in the application for Disposal Works Construction Permit No ---�- �. ._..-- dated ------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE ONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISVACT V. j Inspector r 1/�: d 1 DATE .. _ . /.. p �'' ---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �� `� No._._ ICI _.... FRE------------------------ i 1iupfasa1 Workii Tono#rudiun f rrutu Permission is hereby granted......... --S?r_ra_�----------------------- to Construct ( ) or Repair (4)_an-Individual Sewage Disposal Syst at No....................... 4 -Wta'�_. L L `' M- 4 C��iC_(t ------------------- -... street as shown on the plication fo Disposal Works Construction PermitateA&___l ----------------------y ��F A ;, - - 1 ---- --�-1 ---_-----_------------------ Board of�FI DATE_... t/•i" r ////�11�111--111 ���/// FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS L:O,CATION SEWAGE PERMIT NO. 17 VILLAGE i INSTA LLER'$t NAME & ADDRESS d B U IL D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �'~ �sus �� .� �- 1 r ���, �� �7 �,� �, No.----.� ....�.. Fwic.............................. AI THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... ... . ................OF......................................................................................... Appliratiun -for M-4pooat Worko Towstrnrtinn Vamit Application is hereby"made for a Permit to Construct ( ✓S or Repair ( ) an Individual Sewage Disposal ystem at -----..... -�"�nl►"A--.----- �! j� Location-Address or Lot No. ---------4-AR48------------------------- _ B3® s 7. =-- ......................................... Owner Address W0 ----------------------------------------------------- ........................5 A.m.F......................................................... Installer Address UType of Building C.p p a Size Lot---P.dr,).$. "........Sq. feet �-, Dwelling—No. of Bedrooms-------3..................................Expansion Attic ( ) Garbage Grinder ( �►p 114 Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) C4 Other fixtures -------------------------------- . W Design Flow...............T.a......................gallons per person per day. Total daily flow.........lo..Q...........................gallons. WSeptic Tank L Liquid capacity/00-0---gallons Length---._I........ Width------r.....--.. Diameter-------!r----- Depth....r--_------ x Disposal Trench—No-------------------- Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------I----------- Diameter........j--------- Depth below inlet-.....6............ Total leaching area.-- ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by----------- -------------------------------------------------------------- Date---------------------------------------- Test Pit No. 1----------------minutes per inch Depth of Test Pit..................-- Depth to ground water...._--._-_---.----..._. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1:4 ------------------------------------------------------------------------------------------------------------------------------------------------------------ 0 Description of Soil----------------------- ------------ ---------- - - - 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 NI 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------ , �t' ��.. 7 y Date ApplicationApproved By----- A----------------------------------------------------------------------------- --------------- Date Application Disapproved for t to following reasons--------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ........................ Date PermitNo.....&.3.......................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BPAIRD OF HEALTH Ap'pliMipp 4s_h�reby'made for a.Permit to Construct VI or Repair an Individual Sewage Disposal System at: 0 Address or Lot No. Owner: Address Installer Address < Type of Building p F_- Size Lot.... -------Sq. feet Other Distribution box ( ) Dosing tank ( ) -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 Conipliance.has beeil'isisued.by-the board of health. Date Date -'--.._-_--_-_—._---.__'--_'---'----------------.---_—'--__—_-----------._''- »"te Permit Issued...................... —._-_-` ____ o^� � ^ ' / . ` � BOARD OF HEALTH THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired Installer lias been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the THE ISSUANCE OF THIS CERTIRCATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE .................... . ......0 4�A.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF 'HEA,'LTH to Construct or Repair an Individual Sewage Disposal System as shown 9tithe application for bfs`�1 0.s 11 Works Constru`qt tp -ht ------- Dated-------- r -'~�~~°-= .--'--Board I - - FORM 1255 H0138S WARREN. INC.. 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AN' ACTUAL; FIELD'.SURVEY. ©N 0'N / , �, f sJw r .. I " Y�� ►,P+e.�c,�t�;19T7x AND '.CONFORMS TQl .THE_ �-'' p?' ,f �4 `� ` r �Fx; ,ZONIPIt� � ,tAW OF THE TOWN 0 ;". 1. ! '� xt� s f. t , ��:ry* . ��'���y{`,�'�}�a�e�y, � MASSACHUSETT z r F.a .... .3'?b� �1F+,yY6�.5,4">• .+ . 1 ,1 si•I N i ;,a s s 4 't, h 'rr jirti'S`'{ -.h .1, 2. rr-off t.q,d 1. 3 § >s. a f r ei r.. A _/ may.Syr. //f ��te.i,;: 3,�1 �r fb. •I da .. - Ii - �'w kT A54 Y 'K` ';"<{nx` "' }2F�OISTERED LAND, ! t t a is y !'t F t .r ' �� ."Aas 11 r z . sa 5�>Tr/ ' 1,` ' " y, � yY-Kl w : �, \ Sic.., SCALE I - 4to st /fir c197�, x q t �..w 1 ., .� ,.r .. .<.j t.,1 J. a..,�., Pt u `� '!��*by � ;' Wr rt :� � I, I Z� IiLAN yr' i—I w r,,v� x &�p "'z �dFj T SJrF � sv A !a �� I k ' V .Y'. ,,►y) F e Nt t9 > �u" ` q `r4 S �.'t d-+!' 't.+,t�9 a r O uA11TRINOT JR .' - ,I ' y. ���;` v�,-N`?�P i ' r j a .a No 24351 n �u °- - '/ �q ;q :� ,o CAPE � COD SURVEY CONSULTAIyTS ` �§, '3�'t`'r4��da �r �J. p���!�rrti' 4 it nt - It b. � ., a� i s t, isTE �yo % A DIVISION OF BOSTON SURVEY CO_SUL,,TANT$,INC 1i ;u�a r t§y h s y 6 T t*n N V : ` tr r�``ice 4 ` " S 7N S 4t1 'Ir.�'i".Fdf -1 � ., : 1 9 C { .�Y h` 3•t J' �, qpl,• , w+`' , t , 0 $UR ROUTE 13 2: u„ `s't Nib ? ., r +� - a t ih +��.^t z 4 1.. itd•7 - �/ n . FF " rrt i.:.ro v-p F d, + �1-,1Y HYANNIS,MASS ; f fi �� 5+ " '4 � + �' I !S °", Yn9 n t,,. ..( oi,4 aza ` I ,k...' t ' t> 3 :J 1 a ur t �t p�, r r. , r x�J R'3.s1 4xa�pdi d Y Y j r{R�r J''t`{x 51�'.�1. #•�1p- dr yt� :, ,?! ,•+ xY s A �t Itt;�ur i h,y- xpr r a h {e-c r 1 �, , T •n tF' 11 'I -: J t 5' t j J�'ts[,t�,r r• _ }� u Ate I n Y �{, :.q� � x M 1,.�,�,,il + I rt,. rRl Y.x s ' L� J'V 1 f r11 r t T Fy' 4 i� ha fa ti•Le'�j ,fit 'fir �,}} t1.ka . a`•k�i r.,:.,Y:A„�,°' .y�''w 7 1J..,. •'r.., { . ...» .:si „,,., a r ... ., _ Y.: . ,:, :FX,T ;�'�.,. -...,Y .,.. n {: , x.l..: a .d •t `{t ''A +"ma's'r. i RACE LANE INSITE PLAN 11213' Design Calculations �. I SCAI._E: , ,,:::::20' Number of Bedrooms: 3 Gorbage Grinder: NO . 1 A ro f7 Q i EiENp....'-i FY, I�K on€ TOP CORNER OF o CONC. WING-WALL ELEV.=IOO,OO` ( su sEO) �` Leaching Copacity Required: 330 Gal./Day .32, Le':achlnq Area Reau:re : 330 Gfalj 0.74 Gal.J Sq,Ft.j:::::446 Sq1 Ft, //Z OO 112.36' 110.33' Proposed Leaching Structure: 1-251 X 13V X 2'D Leacching l rencrl Blackthorn Ln Leaching Area Provided: 477 Sq.Ft, Rio Proposed Leaching Capacity, 353 gpd > 330 apd. req'd. y 1 30' \dud, 60 00. %� SchoolX 10 . �' LOCUS �J 7�O rs X 1 2' 0$ NO Sr,AI..E /06 5 C.& fnd. n GENERAL NOTES paved driveway l LOT 4 ` 1. ADDRESS: 31 EMERALD LANE ` AREA 20,785t SO.FT. 2. ASSESSORS NUMBER. 046041 X 105.23' 3. DE'VELCPER`S LOT: LOT 485 4. TOPOGRA:-'I'IIC INFORMATION WAS COMPL.:E1.0 FORM AN ON TH- GROUND INSTRUMENT SURVEY, 3. WELL WATER IS PROVIDED `0 Sl''€'E. TOWN WATER IS PRO iDED to3z o TO SURROUNDING PROPERT€ES. �� A 6. REFEREN^ti PLAN: L.C.C. NO. 307 t 1 l 7. NO WETLANDS ARE LOCATED WI T I.-IIN 100 FEET OF SAS, 8. NO POTAB:: WELL ARE LOCATED WITHIN 150 FEET OF SAS;. �o+102.79' QQ °lA t'_ Xc e C W✓l � 03.49' /�� O J� f- CONSTRUCTION NOTES 41 1. Contractor is responsible for Digsafe notification d and protection of all underground utilities and pipes. 2. T^e septic,tank and distribution box sho l be set 6 r levee€ oh 6" of 3%4"-11 j2'" stone, SSW X 0�, �,� Ili 3. Bockfill should be clean sar:d or gravel wiTh no stones over 3" in size, 9 99.30' f��� rot u 4. This systern is subject to ins.pection during installation ",e'1?�` by Glen: E. €..arrington, R.S. O °f'fJ 5. Tke contractor shall install this system in accordance �, 0• FCjrq CO/� o, o wit^ 'rifleLf of thetasssachfisetts Environmental Code and the Regulations of tiae Town of Barnstable. 5. €:'rovide a Acme Precast H-•10, 5-hole D-Box and 9? O 2 H 10 500 dal, chambers or equal. 93.7 ' X O 7. No vehicle or heavy machinery shall drive ever Lune rho B.M. 999L "septic :iyl,Stern :.,ties nf.%`ke d az: .'•l-20 SC pi'iC CfirTtp:<iE�tl{,7. ® 0, :install oas baffle or equal or. septic tank outlet tee end. 9. All exist inc. inverts rrd site conditinr=s sho€ be verified by contractor, :-2W ViRk A=33 f3MW,% 10, Exisi:na leach pit to be pumped. and backfMed. X 9726' . 1s• •. 1-2 'L X 1 'W X 2.0 leach tren using chambe 2 H ' o- . 4 ne on ides & ends. `a`S' X 18 } i •5 �v �r :_p�r �.i� STD REINFORCED PMCAST CONCRETE P� PERK TEST & SOIL EVALUATION PLAN VIEW 91,00' X + Date of Perc. Test & Soil Eval.: April, 1977 IrJ O �fk- X 97.06' X 9s. Test Performed By. R. John 9 444, Witnessed by. John Kelly 5' c4 Perk Rate: <2 mpi #'9�SCy00 l�s¢0' Test Hole 1,c%W, 4 No. 1 'T STRFFj DEPTH SOILS ELEV. Q o24" 34" X 89.54' 96 0 . LOCAL VARIANCE REQUEST Part XII, Section 2.00 — A variance is requested to install the proposed SAS 2 H-10 500 C:!gal. chambers less than 150 feet from the potable on—site well. Approx. 105 feet 9 is proposed. END—SECTION cow" H-10 500 GALLON CHAMBER NOT TO SCALE 9k USE ACME PRECAST OR EQUAL ................. ►ne. . .......... .................................................................................................._............................................................................. OF PROPOSED SEPTIC SYSTEM UPGRADE 144" t� L PREPARED FOR Q e;. LEGEND o y RR 4N --I MARIA P. DALOMBA 0. :X:SIIP 3 BE ATP 0 PaP`D cfF:LLEc 9 �a 31 EMERALD LANE EXIST.-MG ,coo GAL gN/TA�0P BARNSTABLE (MARSTONS MILLS), MA --,0' rrlr:. frorn-- *NOTE: ALL PIPES ARE TO BE 4" DIA. SCHEDULE 40 P.V.C. a a --I €€a s�Zt?11w '€'ANK ."Use to septic tank *NOTE: INSTALL GAS BAFFLE OR EQUAL ON SEPTIC TANK OUTLET TEE. Srgkc acnk ooaera must ias r'inie„ed ode over slam i,G sf c rma ME_S EXl$l€NG ExistingHouse »it#,ir. 8"o€finis�,ad Orada '� �' X 104.46 PREPARED BY: 5 HOLE SPOT GRADE a 'i GLEN E. HARRINGTON R.S. Y.7R'75?T, i .13X" :v'.l PDX Existing Grade Qw.=9o't L 2�MY,. 95 £Xl3'l'€NG ;I -L :z 9 LEDA ROSE LANE fUII 4" S42' , c., levcE rcw 2` Min 2'-,/8'-1/2" ' cellar `g' 1oo0GAL 7' S=.o, f'..eti.dsta,. =93.50' > _ Apprcx. IUCGtiUr1 MARSTONS MILLS, MA 02648 SEPTIC TANK c ex,nt.E;9. firv.m35.3x' +ri H-10 � „� 1£s` .00 ex:5t:riC t�iGter Itr1t, $ S %- 0 - o 000 0 :�• TEL: 508-428-3862 'd j. 2S' Trenchev.= .00' Approx. Iocaat:on a LEACH TRENCH ,atexisting gas service FAX: 508-428-3862 � '6' OF sja'-iifz' STONE` r� W VAoorox. GW per USGS SCALE: 1 "=20' DRAWN BY: GEH APRIL 17, 2003 DATU.M.......ASSUMED................FILE........DALOMBAMM............................SHEET.....�.......OF.....1.... SYSTEM PROFILE 'dot to .Sacrie 1