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HomeMy WebLinkAbout0011 FAIRHAVEN LANE - Health 11 Fairhaven Lane Marstuns Mills A= 149- 150 1 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v r_ 11 Fairhaven Lane 1 Property Address Aida Bielkus Strydom == Owner Owners Name / information is Marstons Mills 1' Ma 02648 6/23/2017 required for every page. Cityrrown State Zip Code Date of Inspection Chi 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 Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection reb Company Name 74 Beldan Ln. Centerville Ma 02632 Cltyfrown State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/23/2017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 L O �� f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Fairhaven Lane Property Address Aida Bielkus Strydom Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/23/2017 page. Cityrrown 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: The dwelling located at 11 Fairhaven Ln is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and Infiltrators. The system was found to be in proper working condition at the time of inspection. 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 lIndicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): !Sins-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Fairhaven Lane Property Address Aida Bielkus Strydom Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/23/2017 page. CityrTown 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•3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Fairhaven Lane Property Address Aida Bielkus Strydom Owner Owner's Name information is Marstons Mills Ma 02648 6/23/2017 required for every page. Cityrrown 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 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 %day flow t5ins•3/13 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 11 Fairhaven Lane Property Address Aida Bielkus Strydom Owner Owners Name information is required for every Marstons Mills Ma 02648 6/23/2017 page. Cityrrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Fairhaven Lane Property Address Aida Bielkus Strydom Owner Owner's Name information is required for every Marstons Mills _ Ma 02648 6/23/2017 page. Cityrrown 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 gpd t5ins-3/13 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 11 Fairhaven Lane Property Address Aida Bielkus Strydom Owner Owner's Name information is Marstons Mills Ma 02648 6/23/2017 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump ?P ❑ 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 i Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M °p 11 Fairhaven Lane Property Address Aida Bielkus Strydom Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/23/2017 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: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? size of tank Reason for pumping: routine maintenance 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts N . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Fairhaven Lane Property Address Aida Bielkus Strydom Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/23/2017 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 original, s.a.s. unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Fairhaven Lane Property Address Aida Bielkus Strydom Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/23/2017 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 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was pumped for inspection and should be done again every 2 years for proper maintenance. Outlet tee intact, water level even with outlet invert, tank was structurally sound and not leaking. 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•3/13 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 ,e 11 Fairhaven Lane Property Address Aida Bielkus Strydom Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/23/2017 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.): I 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 11 Fairhaven Lane Property Address Aida Bielkus Strydom Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/23/2017 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.): Distribution box was video inspected and found in good condition, no rot, water level was even with outlet invert. 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•3/13 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 11 Fairhaven Lane Property Address Aida Bielkus Strydom Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/23/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: i ❑ 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.): no signs of past hydraulic overloading, vegetation was normal, soil was dry with no signs of past saturation. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Fairhaven Lane Property Address Aida Bielkus Strydom Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/23/2017 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 j Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Fairhaven Lane Property Address Aida Bielkus Strydcm Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/23/2017 page. Cityrrown 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 att-ached separately Pc � 0 A QZ 32 A3 32 133 O9 I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Fairhaven Lane Property Address Aida Bielkus Strydom Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/23/2017 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: 12'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) i ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Sv.,y 11 Fairhaven Lane Property Address Aida Bielkus Strydom Owner Owner's Name information is Marstons Mills Ma 02648 6/23/2017 required for every 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION L SEWAGE#1 5 VILLAGE _ ASSESSOR'S MAP&PARCEL Ir RS NAME&PHONE NO��'% lm- SEPTIC TANK CAPACITY 1600 LEACHING FACILITY:(type)----- (size) NO.OF BEDROOMS OWNER //-eax PERMIT DATE: CA E DATE` ;F SP. Les 1!y I a') 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 f - Fairhaven Lane ater Service l i i I f f - 43 48 5 32 32 89 f a COMMONWEALTH OF MASSACHUSETTS W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION h� SVO V� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 11 Fairhaven Lane Marstons Mills MA 02648 Owner's Name: Colleen Gray Owner's Address: Same x� Date of Inspection: June 14,2007 Job#07-128 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. w =` Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address;and that the informa ion 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: _X_ Passes Conditionally Passes Needs Further Evaluatio y the Local Appr ving Authority Fails Inspector's Signature: �';S Date:' 6/14/07 The system inspector shall submit a copy of this inspection report to the Approving;Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Tank is not in need of pumping at this time,leaching field shows no evidence of backup or saturation.Recommend discontinuing use of garbage grinder. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 11 Fairhaven Lane,Marstons Mills Owner: Colleen Gray Date of Inspection: June 14,2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated:below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by,the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: i Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 Fairhaven Lane, Marstons Mills Owner: Colleen Gray Date of Inspection: June 14,2007 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 orla salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,iif any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 Fairhaven Lane,Marstons Mills Owner: Colleen Gray Date of Inspection: June 14,2007 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_day flow —X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X Any portion of the SAS,cesspool or privy is below high ground water elevation. —X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X Any portion of a cesspool or privy is within 50 feet of a private water supply well. —X— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,001)gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone 11 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. � 1 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 11 Fairhaven Lane, Marstons Mills Owner: Colleen Gray Date of Inspection: June 14,2007 Check if the following 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)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 11 Fairhaven Lane, Marstons Mills Owner: Colleen Gray Date of Inspection: June 14,2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Two years total: 102,000 gal.=139 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tan.{present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: None Source of information: Owner Was system pumped as part-of the inspection(yes or no): No If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X Septic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: New leaching system installed: 2001 +/- Were sewage odors detected when arriving at the site(yes or no): No Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Fairhaven Lane, Marstons Mills Owner: Colleen Gray Date of Inspection: June 14,2007 BUILDING SEWER: XX (locate on site plan) Depth below grade: 2' Materials of construction:_cast iron X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) ) Depth below grade: I' Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8.5'long x 5.2' wide—1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:28" Scum thickness: 1" 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: 13" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees are intact and clear,liquid level at bottom of outlet invert. Tank is not in need of aumaine at this time. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Fairhaven Lane, Marstons Mills Owner: Colleen Gray Date of Inspection: June 14,2007 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): No solids or hieh stains present. No evidence of surcharee from SAS. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Fairhaven Lane,Marstons Mills Owner: Colleen Gray Date of Inspection: June 14,2007 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _X_leaching chambers,number: Four Infiltrators. _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.): Probed stone and soils around SAS and found no evidence of saturation. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM —NOT FO R VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Fairhaven Lane,Marstons Mills Owner: Colleen Gray Date of Inspection: June 1.4,2007 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. Fairhaven Lane Water ervice . .:: 43 48 5 32 89 32 i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Fairhaven Lane,Marstons Mills Owner: Colleen Gray Date of Inspection: June 14,2007 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 20 feet Please indicate(check)all methods used to determine the t; high round water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) _Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.40 and topo map shows property at or above el.60. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION b II MAP t yQ lal PARCEL TITLE 5 LOT OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A _ CERTIFICATION - •_�_ � Property Address: / G !r'/�Gv�Cvi �- NOV 19 2003 Owner's Name: 1e S TOWN OF BARNSTABLE Owner's Address: (—q i av�e H /f/ HEALTH DEPT. Date of Inspection: !O o Name of Inspector: (please print) Company Name• C/f/ Mailing Address: Telephone Number: O 17 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: V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: /0 /9 The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****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. I I I I I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Gt I, G v) L Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A.z1have asses: not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: ,�/-"a or more system components as described in the"Conditional Pass" section need to be replaced or repaired The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltaation or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: �I Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION(continued) Property Address: Gt I/, Aci✓'e" L� Owner: Ae �55L;7 Date of Inspection: O / Q C. Further Evaluation is Required by the Board of Health: Z,' Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: G(/`Aa ve,,v, /- .%s�/jI� Owner: Date of Inspection: /0 / D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes Ncy _ (/__/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 quid depth in cesspool is less than 6"below invert or available volume is less than%2 day flow _ quired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number f times pumped /Y y portion of the SAS,cesspool or privy is below high ground water elevation. Qc►y.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface ater supply. ny .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 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 /j� are triggered.A copy of the analysis must be attached to this form.] / �)O(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CUR 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 ust indicate either`yes"or"no"to each of the following: (Th following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface;ddnldng water supply _ the system is within 200 feet of a tributary to a surface drinldng 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. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / T CHECKLIST Property Address: ` r lr I/'AC4 v,P+, L- Owner•��O Date of Inspection: p 9 Check if the following have been done.You must indicate"yes'or"no"as to each of the following: Pqmpmg information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks v — Has the system received normal flows in the previous two week period 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 lz_ Was the site inspected for signs of break out. ZWere all system components,excluding the SAS,located on site Z— 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 tenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes ► ESnsting 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 CNM 15.302(3)(b)j Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Add s- t Q N Owner: s Date of Inspection: p 01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(ye or no): [i_ f yes separate inspection required] Laundry system inspected(yes or no): V Seasonal use: (yes or no): ;,b4 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no}:Last date of occupancy: _ u✓�e.—� COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: AO ro W►�t�✓' Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:---gallons—How was quantity pumped determined? Reason for pumping: 4c=TS bution box,soil absorption system _Single cesspool _Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ^Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date inll (if %V and sourceofri haon: Xze / "Y- JS 0 f f- I Were sewage odors detected when arriving at the site(yes or no): i Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: l :g 146;", /— Owner: Date of Inspection: /O 9 03 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction ��tastron _ 0� PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate 9 site plan) Depth below grade: �/ ncre/� Material of construction:= te— _ metal fiberglass polyethylene __other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: Sludge depth: _ �f Distance from top of sludge to bottom of outlet tee or baffle: 3� Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee r baffle: How were dimensions determined e le Comments(on pumping recommendations,inlet and ou et tee or baffle condition,structural integrity,liquid levels as to outlet invert, dance of leakage, ): 1 U ✓'7 n el I'm es ar h � G r•d `1�CC'f ✓1 oCJo v c 0 GREASE TRAP:4(locate on site plan) Depth below grade:_ Material of construction:_concrete—metal—fiberglass_polyethylene—other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): r Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �GII a e..�; Owner. Date of Inspection: 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: C�(ffesent must be opened)(locate on site plan) Depth of liquid level above outlet invert: r�B�✓'?0� Comments(note if box is level and distnbution to outlets equal,any evidence of solids carryover,any evidence of leakage' o or out of box,etc.): lee A/10 So/er. /r"o L e�!✓� PUMP CHAMBER:Adz4te on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): � I 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: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type Ieacg�/ pits,number:L �� S leaching chambers,number: leaching galleries,number nu /��G leaching trenches,number,length: 9 y I leaching fields,number,dimensions. / ✓ P overflow cesspool,number: C 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:&/O�cate 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.): I I Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Q Date of Inspection: O J 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. 1 i°° Page 11 of 11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C }SYSTEM INFORMATION(continued) Property Address: / /—G •- Dt„e,,� L. /(/ Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water -3O"'�eet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: erved site(abutting property/observation hole within 150 feet of SAS) C hecked with local Board of Health-explain: ✓`�t �T p Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must deri ow you established the high ground w ter elevatio o OV-, o - S• S •oZ l w de i s © 0�0. ( , O 0,0 - S n TOWN OF BARNSTABLE 0!. G -L&CATIQN ,LZ— E/,Qr vaa ! / SEWAGE # VILLAGE 1'%L( 5Z ASSESSOR'S MAP & LOT4L �. r INSTALLER'S NAME&PHONE NO. /11h L id 3'�'n"3�i e_ ola SEPTIC TANK CAPACITY �o G LEACHING FACILITY: (type) T �'�tOal��T�l� � 5 (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: -),a0gL- COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and.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 /I 3 =-9? t No. �Uy _'s�`� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Zigogar *pgtem Cottgtruction Permit Application for a Permit to Construct( )Repair( )Upgrade(V)Abandon( ) ❑Complete System t .Jndividual Components Location Address or Lot No. f/5;Li r per( Owner's Name,Address and Tel.No. Assessor's Ma /Parcel o% ov�`S �5 p »�,� t5o Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. AA-t o.'-1 iA'�22S� G I'S 10 J i S ST, Ali C Type of Building: Dwelling No.of Bedrooms_ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) • Other Fixtures Design Flow O gallons per day. Calculated daily flow —3 LV�-j gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank !Ezet STi+v l ci°i0 Type of S.A.S. ��Nn�P-Le-1 - Description of Soil iV af,6ZCOP,Q.S,' 514A-A5 Nature of Repairs or Alterations(Answer when applicable) (V sTl�l �C•-�Ul� - �P`�`�' CC, or- N 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 bee a t Signed Date Application Approved by Date Application Disapproved for the following reasons— Permit N . 7i6 UU 'J_ /_2 • )ate Issue — TOWN OF BARNSTABLE S EWAGE # LOCATION ���/= _ASSESSOR'S MAP &LOT VILLAGE— . Y i e-v!= INSTALLER'S NAME&PHONE N • SEPTIC TANK CAPACITY (size) LEACHING FACILITY: (type) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Feet and Bottom of Leaching Facility Maximum Adjusted Groundwater Table aching Facility (If any wells exist Feet Private Water Supply Well and Le ithin 20 on site or w0 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by 01 j I� - 1 I No. `CAyy„ S Z,r Fee�V �vv THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYicatton for Migaal *pgtem Cottgtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( iPj Abandon( ) O Complete System XIndividual Components Location Address or Lot No./� r pu� / ae Owner's Name,Address and Tel.No. Assessor's Map/Parcel I A _ %.5 v o,ll_S —De .5 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. to' C)_CA F-e- tC Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 G' gallons per day. Calculated daily flow -3 Lk�) gallons. Plan' Date Number of sheets Revision Date Title ` Size of Septic Tank t S 1 04po i -; Type of S.A.S. LA c.Y r V I Description of Soil, C' A e SO Nature of Repairs or Alterations Answer when applicable) :=r lq`T-taA;>') dc.lc G " 1 �. u 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 iss h3j oar Signed x Date /"DS-00 Application Approved by _ Date 00 Application Disapproved for the following reasons Permit No. ?,,G7lU ,_��'" Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS _/Sv BARNSTABLE, MASSACHUSETTS Certificate of Compliance ' THIS IS TO CERTIFY,that they n-site Sewage Disposal System Construc-6d,C� )Rep to red:(tf )Upgraded(k'f Abandoned( )by E atSMiM has beenAcon tructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.`P.4VV "S Z'dated _Z F' r Installer I Designer The issuance of this pe ' 't sh 11� t b. construed as a guarantee that the s stem will function.as d1eigned. Date Inspector fva ✓ Wo ' No. '�1�—,� --------------------------Fee �i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Ofi6pogal Opgtem ConotVA -ton Permit Permission is hereby granted to Construct( )Repair( )Upgrade( andon( ) System located at -� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of thi .ermit. �" Q Date: Approved by -:r G U6i99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTII;TCATION OF SKETCH.kYD APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGYED PLAYS) hereby certify that the application for dis osal works peP construction permit siped by me dated it a �� conce-;un2 the property located at /� J::�i r meets all of the following criteria: "• Tne failed system is conner••ted to a residential dwelling only. There are no commercial or business uses associated rAith the dwelling. "• The soil is classified as CLASS I and the percolation rate is less than or eoual to 5 minutes per inch. �• There are no wetands within 100 feet of the proposed septic sysem V T.nere are no private wets within 1f0 feet of the proposed septic syste:n There is no incense in flow and/or change in use proposed (/T"nere are ao variances requested or needed. y i"ne bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted goundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable] ✓•.,�If the S._a.S. will :e located with 2d0 feet of any vegetated wetlands. the boaom of the proposed leaching facility will not be located less chart founeen(1 Y) feet above the maximum adjusted 0 7 undwater table e!evadon- Please complete the following: A) Too of Ground Surface Elevation(using GIS information) B) G.`N. Elevation 3�,�:the �La <. righ G.bV. .�djusmentc� _ 3° a D[17-E-.,ZENCE BETWEEN a,and E SIGNED : D a.i E. (Sketch proposed plan of sYstern on backj. a:hcaith iatdc-.: . . �, -VeL5C SR - O A I ON °'-►ti-� S E W A fE2 PERMIT NO. VILLAGE 0'jccf4a�A 5 "t (s INSTA LLER'S NAME . i ADDRESS i j co tt BUILDER OR OWNEI! M DATE PERMIT ISS-UED 10 ✓12 - � F J DATE COMPLIANCE ISSUED ^ J � y C I s Yv 66 No.. Fss....:?.A........ _ - ...- TH2*COMMONWEALTH OF MASSACHUSETTS �- BOARD qF HE � ApplirFa#iou for Dhgvoii al Works Tondrnr#ion Vamit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal y 2� � S stern t ..... ..... .. Loc,4tion.Addr or o. ------------------- ---a K...J..l.._ ..... Address W ---•......a,� tD..��.... C;Q__l.....----•..................... =' .....------•--•-•----••---•--..... a ...... Installer Address d Type of Building Size Lot5P�..4/2..Ca Sq. feet U ...................Ex anion Attic Garbage Grinder,.., Dwelling—No. of Bedrooms_________________________ p �) g aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Ct, Other fixtures ----------•---------------•--------•------------- W Design Flow............. .......................gallons per person per day. Total daily flow..........A.Z.C)..................gallons. WSeptic Tank-Liquid capacit O.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 ( /^ Percolation Test Results Performed by._I..VfI .�P C=dt J.L. f:!_ � 'Irf!1.-- Date-----9Z ----7- a Test Pit No. 1. : 5..d..minutes per inch Depth �Y Test Pit..... .rr�..L..... Depthto ground water,.___..//��� . Test Pit No. ��mnutes per inch Depth of Test Pit..J............. Depth to ground water........................ a ; .. -- - ---------------------- ----------.••----------------------------- Description of Soil..... "s ... Gl1� -•------ ----------•-•-------------------------- ----.-- w ' .............•-------------------------- -----•---- --- •-•---- . ................ -- ---- = ' - n . .. 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 iIHE 5 of the State Sanitary Code—The undersigned further agrees not to place the syste in operation until a Certificate of Compliance has be issued by the b r of health. ___,-Signed _�% -----.... . ....�. -- _ Date - Application Approved By..--•------ .._......... `_:`�..��......................................... -•-•---�•�?�ll a- ��-r Date Application Disapproved for the following reasons:-------•------••-•-------•-•-•-----------------------------•-----------------------..._---•..................._ ...........-•--•-•--•-••-•---------------------------•---------------------------------------•------•-------------------•-------•-----------------------------------------------------••----------.- Date Permit No.......... .............. ............ Issued...................................................... --------- Date No..............`....... THE COMMONWEALTH OF MASSACHUSETTS .. . --�- BOARD F H EA - T -...........OF. .. ......- Appliratiun for Dispuutt1 Works Tontrurtiun rtrutit Application is hereby made for a Permit to Construct ( Repair ( ) an Individual Sewage Disposal System,At Location-Addr or N r Owner Address •- - �. .� � - •• .................... .......................... .......'- ...................................................... Installer Address Type of Building \ Size Lot` ." _�.��._�?Sq. feet Dwelling—No. of Bedrooms......................... __...Expansion Attic t7 Garbage Grinder aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria � Other fixtures •-•-•................•-•-•---••----._.........-------._....-•---------•--.._.._..----------------•-------•- • WDesign Flow............... ..:...................gallons per person per day. Total daily flow.............................................gallons. g Septic Tank—Liquid capacity ?gallons Length................ Width................ Diameter................ Depth................. Disposal Trench—No. .............. Width.................... Total Len gth---------- ._.......: Total leaching area..................... ft. 3 Seepage Pit No..................... Diameter.................... Depth below,-inlet..........., Total leaching area.____- /, .sq, _. ft. Z Other Distribution box ( ;') Dosing � aPercolation Test Results Performed by.- _..... ,. ,......_.. ..... ................... Date....................................... Test Pit No. 1. �`� ____minutes per inch Depth o Test Pit ,,�.. _. Depth to ground water..-__. _±� _ f=1 Test Pit No. `r P%iinutes per inch Depth Of Test Pit ................Depth to ground water .___..... x Description of Soul Cr+ , �J...5R .r, ........ ............••---•-•••....--••....._ .......-•--.._.......•--- 71, 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 T ITLL 5 of the State Sanitary Code—.The undersigned further agrees not to place the syste .in operation until a Certificate of Compliance has bee ssue'd by the b )nrrof health.ed _ .- ---...... --••.................. ................. .... •--• =«� V'�ivYc .�a" " .w.• Da ApplicationApproved BY 3e� . .. _...•-____-• ......... ......••- -_____-__ --......._.._...... - 1( l -- Date Application Disapproved for the following reasons_........._................................................................................................___ ....................•-••-•---••••----••-••.......•------••-••----••--•--•--••---••-•••--....-•••---••--•....•-••---...._..........-••••••••-...._..----.....•---••-------......__----............_------ -1• Date PermitNo...........: ........................_.... Issued......................................................_ te THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT �. Trrtif irate of Tuutphanrr THIS IS TO CEIFY, That14e Individual Sewage Disposal System constructed or Repaired ) by....... . .. ....• _ °.t. Q---•••.................. ..... .... .................................._...._ ; Installer at. 1 4?.................................. .....lr'` t G,` •_•t,°�.r7 F �' - has been installed in accordance with the provisions of TITLE 5 of he State Sanitary Code desgrbed in the application for Disposal Works Construction Permit Noz 5_._._ 00....... dated_--... _ ? r'?........:............... -a.,THE,ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON TRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................. ..� a.�. .............................. inspector............ ..................bccpj�- --••----- THE COMMONWEALTH OF MASSACHUSETTS • �' BOARD jQf HEALTH - : .........- !' k ......oF...... ~� .....-•............... ..................... -- . i ..,�,. No.... Fu...... .. Disposal urku nstrVt yn f rrutit Permission is hereby granted....... . t° ?................... .. to Construe qr Repair ( ) aj•.Individual Sewag Disposal�Syste n -�~�-- at No......... ......Z._,.�'......60V!'±x..- =-s...-----F::"t? _ ?, /,! .�.., ..................... ... ............. . ..- Street / / as shown on the application,for Disposal Works Construction Permit No. `_ : Dated.._Y......... '°f: --��_ n n DATE.. Board of Health _�6 FORM 1255 A. M. SULKIN, INC.. BOSTON - t. wsfa y l.: ROBERT �� y K gELEWDGE . C3. P 17. x too. 1 3o7 l LA1i� 6 p pv6 Lr a� � v 'ALBERT. 01 .o G I ' t 2' + u, VZ vl x s„" r'firntf' ' V 0 . � 11`` � 3 . C_5 ER Wq­ .. n/sT- /o N: zo tQ ol,� .Tow_nr__� W'G• J flC�� ''s� iISv FRo nrT/t G P. ,tZo 4/ h //OTE : ASS UMG7� Lo'T 6q C Lo PRO7 CT/Di✓ T� AR Z o, St7 Xf 13 01v c0 LEGEND jENIGTING SPOT ELEVATION OAO CERTIFIED , PLOT PLAN V;EXISTINQ."CONTOUR --- 0 -- �¢ :R� ISI�ED SPOT ELEVATION L07 -It NED .CONTOUR 0 rel��r- A%t�� A,1 2-.LS IdO7Tl:t The location of any existing under 1`ound sewerage, -- 1 N lls,rvor�othe'r.utilities shown on this plan is approx- me�te only ;as determined from records and/or verbal Jg A�3 A S-140�I j bI ASS = �nfa�rination ;The contractor is responsible for the uer',if c4tion• of .the existing locations in the field. SCALE, / `� 4'O DATE i � // `r�/�-9 C6.IENT:...�..._ 1 CERTIFY THAT THE PROPOSED E®ISTEI�E REGISTiREO JO9 NO. 851 4.. BUILDING SHOWN ON THIS PLAN # CONFORMS TO THE ZONING LAWS I CIVIL LAN® DR. .f�. R OF BARNSTABLE , AAA h ?i2 MAIN STREET' CH• QYl e*TE � �HYANNiS MASS. 2_, 9HEET_.L. OF D REG. LAND SURVEYOR _ E /Y07"E /F EITHER THE SSPT/C TANK OR 7r 20 FT. M//1l• i_Ei4CN/NG P/T ARE /"JORE T.'lA:'J /2"BELOW 1,4A OEM �4 2¢ 'O1A Al E TER CONC'R c TE CO NE.p r7" /O � M/N- 4�PYC Pi Pr 5/,/.4LL BE BROUGHT TD G)gAOE. �c+.y EXTRA CONCRCTC /-/E.4VY CAST /i?O/Y COV—",T Sh�ALL OE USED M/N. P/TCN L�IR1 vEWA Y I :• — 2 . Mini. CO/Vc'RETE CU VEF� CL EAN -5A/V / 45AC.+IFILL q.^CAST� - - ! .��.� 2•Lf3YER IRO N PIPE' / 0 0 O o 0 0 • o e n 'd MJN.PITC/d OA1- D/ST, • r • • • • r ' •e WASHED S72�NE Rex /°r. S,EPT/C TANK • • r e . ;.a BOX v rl � • a • • e � �•• • I i Ir qv p EFFECTIVE • • WASYFO STONE 00 Z.S = 377 • e a r / • • • • • r r v o 4� D y • e o , � r m • .s • • a r p ,•p PREG4.5 T SE.EPAG E 49O CAL/O` / SF 10 CD . r s o • • . a e a P/7 OR fVU/V• !,Vp-e q r C`L zYA7,1,oJv 5 T'17 �nf'c, r7 _ . a �L 9 Z.9 �. i 1NYER'T AT Q!1/4101NG ��' D FT � 3` _G FT D/AM. INLET SEPTIC 7 4,VK 9-7 5- F T 7 F 0/AM. � � SEE TABULATION, 40U Ti-E'T SEPTIC 7"ANM 7.3 FT INLET 01STR140UTI0N BOX 9 G •8 PT SHCT•1®N OF GROUND WATER TABLE OCITLETDJSTR!®CIT/O/d B60X 9,6 PT /NLE•T I-EACNIMG P/7- 7� v_/�T,. S =;-VAGH KS A=-/W "7A46II1-AT140N LEACHING P/7- SCALE % _ /= O" DJME/V3/OA/ A FT AEa`a/G1Y CR/7E�/� D /®N a-4FT. N[1/�98ER OF BED'ToomS 3. Dlr�9ENS/ON Cs�F7� /"�/N• u Gs4ROAOE-D'l5P0-5,4, . vlT /�/y//C SOIL LOG TOTAL E3 T 7•//rsAE0 F1-0*V 33 0 0A1.1OAY S01 L TEST A/ SOIL TESTOAP _ q� NUA19ER OF 40ACHIn/Ce P/Y'S_ I f^FLG`Y. �9S /-40LA Y, PATE OC" SOIL TEST / Z ` -7 S/OE LEACHING PEFt ®/T l s SC,9 FT. U _ Z R,E3ULTS dV/TN�SSED DYE# 0� ,a0TTO/NP LEACHING p&R P/T I !3 $Q. 'A77 z u A.m P4FWC0,4A r101v RATE At/ LOSS ^11)VlJNCH z6 FLGR'COLA-"/ON RATE TO 2 Tf� /*/IN.�/NCH TAL 4 e4CH11V6 AREA SQ. FT. S, v 0.50/L- RESFRYE•LEAr'.'/l/YG'ARFi► zU SQ. FT. � _7 / / 4Z, a, Of '1gSJ9�+ THOF.4.q, 12-. Z 1,�T1 / .9T�1�S A9R ROSERT yG� 1 AIBERT �u lip E5P/0m - i"//,4 I-e,9 TO 1✓.S M/ L L S oA B_ �, g A. ELDREDGE MORSE � /� 9 No. 19367 a No 10951 p S�/P fl s�� E�►Sf4����@�' 9o� isT �� / EL J2'I69�9(N ST .Af$6q V., �h+9L LM ;,� .. �, .NO GI�OUKf��`Y6�i�TLaJ$. 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'�.� ,..-., s.' � ::,: -.;;;•� _."_,_.' :.i'k...._..._.._...--_.._ t' _� e. :^•�'_c�'s.`" 4.�"'� � _ °�' �•rc'!�''' r .x/`: .is;' k•5.i _ _-