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HomeMy WebLinkAbout0544 FLINT STREET - Health F1544 Flint Street Marstons Mills A= 102-057 I Commonwealth of Massachusetts 1Da- 06 W Title 5 Official Inspection Form EC® Subsurface Sewage Disposal System Form - Not for Voluntary Assessmen / cp g 544 Flint Street Property Address ND Alfred Bleu, Trustee, Bayview Ralty Trust, 28 Peach Tree Road, Marstons Mills, 02648 " Owner Owner's Name M. information is required for every Marstons Mills MA 02648 October 14, 2017 page. City/Town State Zip Code Date of Inspection 0.71 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 f on the computer, i /j 6 fp 6 use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. ITV Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-833-2177 S1287 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. 1 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 n:nap-N October 25, 2017 InSpecT81`sSi-g-nat5-re'4 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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 544 Flint Street Property Address Alfred Bleu, Trustee, Bayview Ralty Trust, 28 Peach Tree Road, Marstons Mills, 02648 Owner Owner's Name information is Marstons Mills MA 02648 October 14, 2017 required for every page. CitylTown 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 information contained in this report represents the condition of the system observed only on October 14, 2017 at noon and does not represent the condition of the system from that date and time into the future or guarantee the continued operation of the system, as use of the system changes daily. 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.6/16 Title 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 ,M 4 5 4 Flint Street Property Address Alfred Bleu, Trustee, Bayview Ralty Trust, 28 Peach Tree Road, Marstons Mills, 02648 Owner Owner's Name information is required for every Marstons Mills MA 02648 October 14, 2017 page. CitylTown 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 544 Flint Street Property Address Alfred Bleu, Trustee, Bayview Ralty Trust, 28 Peach Tree Road, Marstons Mills, 02648 Owner Owner's Name information is required for every Marstons Mills MA 02648 October 14, 2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 1/z day flow t5ins.doc•rev.6/16 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 544 Flint Street Property Address Alfred Bleu, Trustee, Bayview Ralty Trust, 28 Peach Tree Road, Marstons Mills, 02648 Owner Owner's Name information is required for every Marstons Mills MA 02648 October 14, 2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 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 544 Flint Street Property Address -Alfred Bleu, Trustee, Bayview Ralty Trust, 28 Peach Tree Road, Marstons Mills, 02648 Owner Owner's Name information is required for every Marstons Mills MA 02648 October 14, 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 0 ❑ 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 sate inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 544 Flint Street Property Address Alfred Bleu, Trustee, Bayview Ralty Trust, 28 Peach Tree Road, Marstons Mills, 02648 Owner Owner's Name information is required for every Marstons Mills MA 02648 October 14, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 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 ears usage d Yes 9 ( Y 9 (gp ))� Detail: 2014; 19,000 gallons, 2015; 86,000 gallons, 2016;70,000 gallons, 2017 to date; 36,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter re adings, If available. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts u W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 544 Flint Street Property Address Alfred Bleu, Trustee, Bayview Ralty Trust, 28 Peach Tree Road, Marstons Mills, 02648 Owner Owner's Name information is required for every Marstons Mills MA 02648 October 14, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of anc occu /use: P Y Date Other(describe below): General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 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 Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 544 Flint Street Property Address Alfred Bleu, Trustee, Bayview Ralty Trust, 28 Peach Tree Road, Marstons Mills, 02648 Owner Owner's Name information is required for every Marstons Mills MA 02648 October 14, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Compliance issued 6/8/2010 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade. 18feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: NA feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 3"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: Typical 1000 gallon Sludge depth: 4 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 544 Flint Street Property Address Alfred Bleu, Trustee, Bayview Ralty Trust, 28 Peach Tree Road, Marstons Mills, 02648 Owner Owner's Name information is required for every Marstons Mills MA 02648 October 14, 2017 page. City/Town 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 38" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent level with outlet tee 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 544 Flint Street Property Address Alfred Bleu, Trustee, Bayview Ralty Trust, 28 Peach Tree Road, Marstons Mills, 02648 Owner Owner's Name information is Marstons Mills MA 02648 October 14 2017 required for every , page. aty/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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 544 Flint Street Property Address Alfred Bleu, Trustee, Bayview Ralty Trust, 28 Peach Tree Road, Marstons Mills, 02648 Owner Owner's Name information is required for every Marstons Mills MA 02648 October 14, 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 Level with outlet invert 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.): Riser is 6" below grade. Used camera to observe. Evidence of solids carryover. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 544 Flint Street Property Address Alfred Bleu, Trustee, Bayview Ralty Trust, 28 Peach Tree Road, Marstons Mills, 02648 Owner Owner's Name information is required for every Marstons Mills MA 02648 October 14, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ 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.): Chambers are 46" below grade. Riser is 4 inches below grade. 12 inches of effluent standing in chambers. Evidence of solids carryover. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 544 Flint Street Property Address Alfred Bleu, Trustee, Bayview Ralty Trust, 28 Peach Tree Road, Marstons Mills, 02648 Owner Owner's Name information is required for every Marstons Mills MA 02648 October 14, 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 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 ,M 544 Flint Street Property Address Alfred Bleu, Trustee, Bayview Ralty Trust, 28 Peach Tree Road, Marstons Mills, 02648 Owner Owner's Name information is required for every Marstons Mills MA 02648 October 14, 2017 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 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 544 Flint Street Property Address Alfred Bleu, Trustee, Bayview Ralty Trust, 28 Peach Tree Road, Marstons Mills, 02648 Owner Owner's Name information is Marstons Mills MA 02648 October 14 2017 required for every , 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: 124 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: As Built card dated 6/8/2010 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Groundwater contour map ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Utilized information on file with Board of Health. As-built card specific to this property indicates no water at 12' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 177 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 544 Flint Street Property Address Alfred Bleu, Trustee, Bayview Ralty Trust, 28 Peach Tree Road, Marstons Mills, 02648 Owner Owner's Name information is required for every Marstons Mills MA 02648 October 14, 2017 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 ® S stem Information—Estimated depth to high groundw ater ater P 9 9 ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-ree.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION Sys fLi�T `r� SEWAGE#1 VILLAGE, 5U4X7-a-0,0-1"ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) o�JFX1 Vr�,�r NO.OF BEDROOMS 3 OWNER -efM c-.O BZE"!/ PERMIT DATE: 6'1,O COMPLIANCE DATE: —moo Separation Distance Between the: ,V v Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility A T /.$ 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 0 o y /A B ol_3y. 6 ��- 38•� o -3 9 3- a8. 3 ax l http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=102057&seq=2 10/11/2017 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppliCAtion for 30ispo8Ar bpstem ConstrULtlon permit Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) []Complete System X Individual Components Location Address or Lot No.S� f�i�T J`T. �,/�� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel /O o� S� i4Gi��2er`� •/8� v Installer's Nam9kddry,and Tel.N�` Designer's Name,Address,and Tel.No. O O Type of Building: Dwelling No.of Bedrooms '3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building f' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 C gpd Design flow provided D gpd Plan Date Number i'o Number of sheets / Revision Date Title Size of Septic Tank—`0-Y,"P7"'2' &r 1c)'10 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed �0 A Date Application Approved by ^ 3 6' Date Application Disapproved by Date for the following reasons Permit No. 90 1 G — 16 6 *.._� Date Issued r ,t 0 No. auto (0 ��r . 4 \ Fee computer:Entered in THE COMMONWEALTH OF MASSACHUSETTS F PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Misposal 6pstent Construction i9erntit Application for a Permit to Construct( ) `Repair( ) Upgrade ) Abandon( ) ❑ stem Complete Sy stem y ;K Individual Components Location Address or Lot No.S"�je f.//,ivT 1`T. /li,/l�� Owner's Name,Address,and Tel.No. Assessor's Map/Pai•cel %O e; Installer's Names d s,and Tel.N Designer's Name,Address,and Tel.No. l n � D�U -�7 S-o d 7Z /!>ill�' _� t ' Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building .1e de-r No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) C gpd Design flow provided 3110 y gpd Plan Date y i'o Number of sheets Revision Date Title Size of Septic Tank�-�"�r1"" d6-* Io®® Type of S.A.S. Description of Soil * Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date do,"'Z��� Application Approved by - Date —} o Application Disapproved by V Date for the following reasons Permit No. PO 10 ^ Date Issued — 1 0 --------------------------------------------------------------------------------------------------------------------------------------- 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 �/yJ' at r�'1 Fd�r'T J'T w,,W, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 010— 6 dated 6 —-2 —1 0 Installer V>.oW L�'.6'oa�`Ui� Designer.Oil 4*i4 4—or �J1AJ's+� R✓'_ #bedrooms Approved design flow a 3 3 gpd The issuance of this permit shall not be construed as a guarantee that the system will(function as designed) Date q f I.( . t) Inspector _ -------------------------------------------------------------------------------- ------------------------------ No.c2o D , f ICJ 6 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction permit Permission is hereby granted to Construct( ) Repair) Upgrade( ) Abandon( ) System located at �y /�—�i^"T J' /I9,-409. and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 permit. Date V Approved by Town of Barnstable y��OpYHB ilk "�Z Regulatory Services t Thomas'F.tieilcr,Director m+ax,�rnu�r. • MAM °' Public Health Division '°rFu�rN•�e, Thomas McKean,Director 200 MI"i"Street,Hyannis,MA 0260.1 Off-ice: 508-862-4644 Fax. 508-790.6304 Installer&DEsigner Certification Form Date.- 10 Designer: rlT�' j Instauer: Address: S7' '`� )(C �_ Address: Oil _ CIA4 . c. �'iC was issued 1 perncit to install 11 (date) _ _— (installer) septic systeul ate t,t based on44_! 1 design draw,,by (address) ,� '^ a6CL�, dated ✓.r •certify that the septic s �tecll Keferp,11ccd 1 P ys cove was installed substatitiatly o.ccordin to .he design, which may include, minor 24)proyed•chiuiges such as litters+ relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was install-W with-'nujor changes greater than 10' lateral relocation of the SAS or any vertical revocation of any component of the septics5ystein)but in accordance with State&Local)tc:getlataons. ply fomport o> certified as-lnif by designer to follow. Of { B.litstalle�'s DnAAVI Signature:) MASON �? .�•N0.1066 U y _ SgN1UM " o,= ier s ignature} (Afrix• pk's Stamp Sere) PLEASE RETURN 'l'O BARNSTABUZ-PUBLIC HEALTH DM-SION. C ;RTiX+�C A7'.E DX<' C�UM[P1L,XANCF, WILL N4�T • SSUED >s]N•'�, X3dT13 .TfIC►�X+ORM ANC)MALT AS- CA RD AXtE REC`EI +`b WYN RAR� ARI.F.pjnpty IC Y��. MViSFON. THANK Y01I. Q! I lcoltNSeptic/t)esiy,,icr C utitic.-Am Fprrr, TRANS. NO.: CITY/TOWN: APPLICANT: ADDRESS: 517 DESIGN FLOW: gpd REVIEWED BY: DATE: N/A OK NO GENERAL Legal boundaries denoted [310 CMR 15.220(4)(a)] Street, Lot, tax parcel number and lot number noted on plan[310 CMR 15.220(4)(u)] Locus Provided [310 CMR 15.2204(t)] Plan proper scale? (1"=40' for plot plans, 1"=20'or fewer for components) [310 CMR 15.220(4)] Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for upgrades]-if not, a variance is required [310 CMR 15.412(4)] Location of impervious surfaces (driveways,parking areas etc.) [310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR 15.220(4)(c)] Location and dimensions of system components and reserve areas. [310 CMR 15.220(4)(e)] Svstem Calculations [310 CMR 15.220(4)(f)] daily flow septic tank capacity(required andprovided) soil absorption system(required and provided) whether system designed for garbage grinder North arrow [310 CMR 15.220(4)(g)] Existing and proposed contours [310 CMR 15.220(4)(g)] Location and log of deep observation holes (existing grade el. on each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h) and(i)] Location and date of percolation tests (performed at proper elevation?) 310 CMR 15.220(4)(i)] Percolation test results match loading rate? [310 CMR 15.242] Certification statement by Soil Evaluator[310 CMR 15.220(4)0)] Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)] Address �"`+1 iJ► . Sheet 1 f 0 7 I N/A OK NO Location of every water supply,public and private, [310 CMR 15.220(4)(k)] within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply within 250 feet of the proposed system location in the case within 150 feet of the proposed system location in the case of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins located within 50 ft. [310 CMR 15.220(4)(1)] Water lines and other subsurface utilities located [310 CMR 15.220(4)(m)] if water line cross see 310 CMR 15.211(1)[1]) Profile of system showing invert elevations of all system components and the bottom of the SAS [310 CMR15.220(4)(o)] Stamp of designer[310 CMR 15.220(1) and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] Test Holes adequate(two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2) or as approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] Test hole adequate to demonstrate four feet of suitable material? [310 CMR 15.103(4)] Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.103(3)] Benchmark within 50-75' of system [310 CMR 15.220(4)(q)] Materials specifications noted? [various sections of 310 CMR 15.000] System components not> 36" deep (unless Local Upgrade jApproval or LUA requested) [310 CMR 15.405(1(b)] Address -4 t ru"4—, i . Sheet 2 of 7 N/A OK NO SEPTIC TANK Size OK? [310 CMR 15.223(1) Inlet tee located ten inches below flow line [310 CMR 15.227(6)] Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR. 15.227(6)] Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)] Note regarding installation on stable compacted base [310 CMR 15.228 1 Separation between inlet and outlet tees(no less than liquid depth) 310 CMR 15.227(2)] Inlet/Outlet elevations at least 12" above high groundwater / (except as described 310 CMR 15.227(5)) or permitted for V/ upgrades under LUA [310 CMR 15.405(1)(k)] Minimum cover 9" (Tanks buried more than 9" must have risers on all openings and on the d-box) [310 CMR 15.2228(1) and 310 CMR 15.232(3)(0] Three access covers (inlet and outlet must be 20" or greater) - middle access at least 8" (by 7/07) [310 CMR 15.228(2)] Access to within 6 " of grade - one port for systems<I 000gpd, two for systems>1000 gpd [310 CMR 15.228(2)] All at-grade covers secured to unauthorized access? [310 CMR 15.228(2)] > 10 ft from building foundation [310 CMR 15.211(1)] Buoyancy calculation Required/Done [310 CMR 15.221(8)] H-20 Where appropriate? [310 CMR 15.226(3)] Setbacks from resources [310 CMR 15.211] Multi-Compartment Tanks Required when other than single-family dwelling or flow>1000 gpd [310 CMR 15.223(1)(b)] First compartment 200% daily flow; Second compartment 100% daily flow [310 CMR 15.224(2) and 3)] "U"pipe through or over baffle, outlet of each compartment with gas baffle or approved filter [310 CMR 15.224(4)] Address Sheet 3 of 7 N/A OK NO BUILDING SEWER AND OTHER PIPING Located at least ten feet from any water line? [310 CMR 15.222(2)] Disposal piping at least 18" below water line(when water and sewer cross, see 310 CMR 15.211(1)[1]) Cleanouts required/provided? [310 CMR 15.222(8)] Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable / [310 CMR 15.222(6)] Proper pitch on all runs? (.005 within gravity-distributed trenches and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c) Siphon problem/(leachfield below pump chamber) Endcaps or vent manifold specified? Size and orientation of discharge holes specified? (not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) DISTRIBUTION BOX Stable compacted base [310 CMR 15.221(2) and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided? (when / pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a)] Riser if deeper than 9" [310 CMR 15.232(3)(f)] Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum sum 6" [310 CMR15.232(3)(e)] Watertight cover if<2000gpd); waterproof manhole if>2000gpd [310 CMR 15.232(3)(d)] PUMP CHAMBERS Capacity(emergency storage above working=design flow)? [310 CMR 231(2)] Proper setbacks [310 CMR 15.211 (same as septic tanks)] Watertight 20-in minium access manhole at least 20" MUST BE TO GRADE [310 CMR 15.231(5)] Service components accessible (not too deep with piping, disconnects accessible) Alarm floats - alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [310 CMR 15.231(6) and(8)] Stable Compacted Base [310 CMR 15.221(2)] Buoyancy calcul tons�nneed�edd?Provided? [310 CMR 15.221(8) Address f �'�"'� cJ( Sheet 4 of 7 N/A OK NO SOIL ABSORPTION SYSTEMS (SAS) GENERAL Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240(1)] Required separation to groundwater? [310 CMR 15.212)] Aggregatespecified as double washed 310 CMR 15.247(2)] System Venting required/provided? (system under driveway or >36" deep) [310 CMR 15.2411 Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] Breakout requirements met? (No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] GALLERIES,PITS,CHAMBERS 310 CMR 15.253 Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR 15.253(6)] Each structure with one inspection manhole (if>2000 gpd must be to grade) [310 CMR 15.253(2)] Aggregate I' minimum-4' maximum. [310 CMR 15.253(1) b ] 2' sidewall credit maximum [310 CMR 15.253(1)(a)] In bed configuration, inlet every 40 sq. ft. [310 CMR 15.253(6)] TRENCHES 310 CMR 15.251 Width T minimum 3' maximum [310 CMR 15.251(1)(b)] 100 feet-maximum length[310 CMR 15.251 1)(a)] Minimum separation 2x effective depth or width whichever greater(3x if reserve between trenches) [310 CMR 251(1)(d)] Situated along contours 310 CMR 15.251(2)] Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document] BED SAS (Maximum size of bed or field 5000 gpd) minimum 2 distribution lines [310 CMR 15.252(2)(a)] Maximum separation between lines 6' [310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6" minimum, 12" maximum. [310 CMR 15.252(2)(g)] Separation between beds 10' minimum. [310 CMR 15.252(2)(0] Bottom area used in calculations only [310 CMR 15.252(2)(i)] Address ���"� �� Sheet 5 of 7 I N/A OK NO DID THE PLAN INVOLVE Pressure Dosed System ? Provided pump and piping calculations as required [310 CMR 15.220(4)(r)] Pressure dosing required on all systems>2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and I/A Remedial Use Approvals] , /A I If used in gravelless system-make sure jet is directed as not to scour soil interface [Guidance Document] Inspections once per year(systems<2000 gpd) or quarterly (>2000gpd) good to note on plan[310 CMR 15.254(2)(d)] Construction in fill - Did the plan specify that the fill shall meet the specification of 310 CMR 15.255(3)? Impervious barrier and/or retaining wall? [Guidance Document] Impervious barrier installation must be supervised by designer [310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer[310 CMR 15.255(2)(a)] Side slope not exceed 3:1 ? [310 CMR 15.255(2)] Breakout requirements met? [310 CMR 15.252(2) and Guidance Document] At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended) [310 CMR 15.255 (2)(e)] Gravelless System[UA Approval Letters] Check DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scour soil interface Alternative Septic System[I/A Approval Letters] Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant submitted a copy of a maintenance Variances Are the variances listed on the plan? [310 CMR 15.220 (4)( ] RLS Stamp necessary on plan if a component is within five feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed- [Refer to 310 CMR 15.414] Address "I rLtwT Z:)-Uf b Sheet 6 of 7 N/A OK NO Nitrogen Sensitive Areas Is the system in a Designated Nitrogen Sensitive Area(Zone 11 for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such ✓✓✓ existing systems] Is the system proposed on the same lot as served by private well ? [310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR 15.216(1)] Miscellaneous Pumping to septic tank? [ 310 CMR 15.229] Shared System [310 CMR 15.290] Address I ' ` dd ess � Sheet 7 of 7 TOWN OF BARNSTABLE LOCATION, SEWAGE# Vf ,LAGE�l1,(a-^7®1-`0,-;I'/,& ASSESSOR'S MAP&PARCEL/,)-2 INSTALLER'S NAME&PHONE NO. 0, O'er SEPTIC TANK CAPACITY `x�!'i LEACHING FACILITY:(type) (size) �-3 Xa rXoT NO.OF BEDROOMS -� OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: ,y o stiXT�4� Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility A 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 c . s Ui �� e �1sea,r O ov � a No. C�o L 0 - Fee ( v v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Rpplication for Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) UpgradeV Abandon( ) ❑Complete System Individual Components Location Address or Lot No.S fL%�vT J`T. ./n- Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name d s,and Tel.Nc� Designer's Name,Address,and Tel.No. -7.7S—o,7o7- Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building � J' No.of Persons Showers( ) Cafeteria( ) Other Fixtures j Design Flow(min.required) gpd Design flow provided 3 `{ 0 gpd Plan Date —may i o Number of sheets l Revision Date Title Size of Septic Tank�,+'��� Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the'system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date Application Disapproved by Date { for the following reasons Permit No. 90 1 D — I G 6 Date Issued —t o s -------------------------------------------------------------------------------------------------------------------------------------- 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 S"�y f���� v"T ./�l. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ,2 010 - 6 dated Installer 0>.-W L t.�'oe�`�" Designer .z7i/yr p 8 �'VXV!e--ti, 4�✓'- #bedrooms -s Approved design flow 3 3 gpd j The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector ----- ----v-�--_-_•--��------------ ------------------------__ .---•--•---------_---•---------•----•--------Fee--- ---- No. r � 1 v miiT I-I Al R11 W-v- 1 T T /lT T T 1 C1 ♦/ TYT TV T, TTCl Town of Barnstable P# Department of Regulatory Services . Public Health Division DateS l o 200 Main Street,Hyannis MA 02601 z Date Scheduled -A. �'3 T Time Fee Pd. �Of Soil Suitability Assessment for SewagePisposal Performed By: o _q-s 2LQ` I Witnessed By: V t 1V. f yr LOCATION& GENERAL INFORMATION Location Address Owner's Name J J— Address Assessor's Map/Parcel: �d/� G� �'� Engineer's Name d4dVI O NEW CONSTRUCTION REPAIR Telephone# O' 3 3 aG 1�7, Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetland's in proximity to holes) �C) M a L Parent material(geologic) Depth to Bedrock �± )VV Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater Zt� DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: - —- Depth Observed standing in obs.hole: ___ ___In. Depth to soil mottles: In. Depth to weeping from side of obs.hole: in. Groundwater Adjustment fr. Index Well# Reading Date: Index Well level , Adj.factor Adj.Clroundwater Level 1 PERCOLATION TEST Date Thne.� Observation I Hole# Time at 9" Depth of Perc Time at 6" Start Pre-soak Time @ Time(91'4") End Pre-soak �f Rate Min./Inch fu Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:XSEPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency,%Gravel) D r W DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. C nsi to c Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders. Consi ten 1 Flood Insurance Rate Mao: Above 500 year flood boundary No_ Ye Within 500 year boundary No✓ Yes Within 100 year flood boundary No.. Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi u m to 'al exist in all areas observed throughout the area proposed for the soil a orption system. „ r If not,what is the depth of turally occurring pery ous material? Certification I certify that on i� isat (date)I have passed the soil evaluator examination approved by the Department of Enviro motection and that the above analysis was performed by me consistent with . the r ning,a px i a described in 310 CMR 15.017 f afl Signature Date Q:\.SEP'nMERCFORM.DOC ASSESSOR'S MAP NO. PARCEL L-0 CAT ION SEWAGE PERMIT NO. S'y5� �ot3/ F/i77Sr V-! L L AG E I N S T A LLER'S NAME A ADDRESS rh� a U I L D E R OR OWNER e p,rk4� ra DATE PERMIT ISSUED ..7_ > � �� .DATE COMPLIANCE ISSUED -7ll l .... _ .. .. .. '� Jq� � � �� ` � 6® � 1 ASSESSORS MAP NO: J C) t ' PARCEL NO No.... a' F .............. eti THE COMMONWEALTH OF MASSACHUSETTS Y BOARD OF HEALTH � . . ........OF.........� 1V�S ---- Applirution for Dhip i al Works Tumtrur#ivit Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage.Disposal System at: .7........1 '.�? X.. a1..�------......•.... --•••••-••-•...•-----....... .:�...� / ...----- - o..... . ' Location- ddress or Lot No. ..... ----.--••-•••-•••. -•-•-- ............. Owner Address a ..................... --_-____--_.._-_._.___--_-_-•------------ Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms..._ ..................... ......Expansion Attic ( ) Garbage 'Grinder Other—Type T e of Building No. of persons............................ Showers — Cafeteria Pa YP g P ( ) ( ) a Other fixtures ...................................................... W Design Flow...... j��.............................gallons per person per day. Total daily flow____ _._._____-....................gallons. WSeptic Tank—Liquid capacity._j)V.gallons Length................ Width--------------.. Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.._._.._._.____ ... Total leaching area.....................sq. ft. Seepage Pit No------(------------- Diameter.__.....�Z Depth below inlet........6........ Total leaching area................�.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date.......................•----••-•--•--- aTest Pit No. 1................minutes per inch Depth of Test Pit------------------.. Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.................. ..� SO Description of Soil------- -------•--• -----I........................................................................................................ x W ••••-•-•-•-----------•-•-----•-----•------•------•-----•---•----------------•-----•--•-•----.....--------••---•-----------------------•-------------------=--•••-----•---•--•--•---------....--••----••- VNature of Repairs or Alterations—Answer when applicable............................................................................................... -•-------•------------------------------------------•----...-------------------------••-••--•_•....-•••----•-••---------•-••---•••-••-•---•---•-•--•-••-------------•-•----.._......................... Agreement: The undersigned agrees to install the aforedescribed Individ ewag isposal System in accordance with the provisions of iITL 5 of the State Sanitary C e—.The un ersig d f t .er agrees not to place the system in operation until a Certificate o C mpliance has b issp by t oard f h th. D e ApplicationApproved By............................................ ... .....• .--- ..................... •••=---s -Q ---------------- te Application Disapproved for the following reasons . --•-•-----•-•-•--••-•-•---------••-•-•---•--------•--------•---------••••---•------•----••--•••--•-•---...••- ...............................................................................................N....................................................................................................... Date PermitNo......................................................... Issued....................................................... Date ��� �� � �� -_ ~� �� �� zHE ooMMomvvsxcr* OF MASSAoHussrTs � | | ,-�-/)\*/ «������ ���� ` - ." .~ 91 ` . ' . ~- -- --�----- ...................OF............................................................ . . � �~�� �� ��4���lir�uti4u�� ��x� ���i����tim� Vo4kxi (foumitrurtwwn run4»t Application is hereby made for u Permit to Construct ' or lonair � an S?W ^ T 'p° System at&Y�/ / / 3 / ` ...... ' _--_'-- '--___-' � No. C.,Afe Or4L --��'_---- -'--'_-----��_-_- ------------------'_--�����_'-'-'_-'--'_---_--_'- ^ ........... z�uue �� Address . , ) � Type of Building Size Dwelling--Nu of Bedrooms............................................Expansion Attic Garbage Grinder Other - ............................ No. cf persons............................ Sb ) -- Cafeteria ( \ Ltuer -�xtuceo ..-'.--_--.-_-_—.-_.____________________________________ Ww / ..gall.ons per person per day. Total daily' Design �xD �coctb \��]d� D�n�ct�� D�n�b � Septic Tank f '' -----' ^-------- Disposal Trc���--�o.-.-_---_- Total Total area....................uq. f t. Seepage Pit No..................... Diaozetcc------' Depth below Total leaching area..................sq. h' ()tb�rZio�ibnti�obo� ( \ I]ou��otao� ( \ �� ` ^ ~ ` ' ~~ Percolation Test Results Performed by..-------.--------_''--------------' Date........................................ Test Pb No. l................minutes per inch Depth of Test Pit.................... Depth to ground water........................ _ [� Test Pit No. 2___ per inch th of Test Pit.................... Depth to ground water........................ P4 O Description of ---- --------- ' �.--__----_-.---_--'--.----._-_-'.____-----'_---._---. [] Nature of Repairs orAltcrutiom--Anawerwbco -'----'-_----_--'-'_-._-._-_-_---_ '----'-'----------' ----''-''''----'---- The undersigned agrees to install the f d c d Individ al S ag sposal System in accordance with .,,he u rsign f er agrees not to place the system in Date � 6n the ru�mmx' /�p9ucuuouumayy�v,cu ' /v°"""°~x reasons:................................................................................................................ � __--____-_-'-__-_----.-'-__-----____-''---_-_---___'-'---'-------'_-----_-'_-'-------- � ' --' Permit ' � Date . ' ' THE comMomvvEALrx or mAssAonussTrs _=~ | K > BOARD —pp ' ..........................................OF................... ................................................................ THIS IS TO CERTIFY, That th Individu—Z I 60*NDisposal AtAniii0ructed or Repaired has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in tl,ie THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE � SYSTEM WILL FYNCTION SATISFACTORY. DATE ' &� � ��5� THE COMMONWEALTH o= mAssxo*usErrs LOCATION MAP add s g °60 0o ---- /047•0015 ' --� -� - �6L L---I ASSESSORS MAP? jD,, TEST HOLE LOGS NOTES: PARCEL: SOIL EVALUATOR : ' V � FLOOD ZONE: /tw% J�f"��G�Cg _ _._.. _. _:_ 1) The installation shall comply with Title V and Town of Barnstable Board of t WITNESS : Health Regulations. REFERENCE: — h- G �4^ - -- --,_----- -------- DATE: gA 1 2} The installer shall verify the location of utilities, sewer inverts and septic - j PERCOLA I 0 RAT G IM , l , components prior to installation and settingbase elevations. ere .v. ^ _E ,�1 11, 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot.The first IZE H- 1 TH-2 two feet out of the d-box to the leaching shall be level. 4) This plan is not to be utilized for property line determination nor any other I' ,( purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. LvAxk 6) Parking shall not be constructed over H10 septic components. �,, c� ��, b� :/� 1 ►2�� p�+ 7) The property is bounded by property comers and property lines. 8) The properly owner shall review design considerations to approve of total LOCATION MAP design flow and number of bedrooms to be considered for design. Receipt �V- ) `5 of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. 9 The existing leaching or cesspools shall be pumped and fill ed with material per Title V abandonment procedures. Those within the proposed SAS shall 1 ' be removed along with contaminated soil and replaced with clean sand per Title V specs. O o' �� -t'�' -�- 10)System components to be 10 feet from water line. Sewer lines crossing the 2n Z9 water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if �6d - applicable. The proposed SAS is being installed below the water service SEPTIC SYSTEM DES I G N line. The line is to be sleeved as aforementioned and maintained in place. 11) If a garbage grinder exists it is to be removed and is the responsibility of the I FLOW EST I MATE owner to ensure such. 1 12)The installer is to take caution in excavation around the gas line if such ( I BEDROOMS AT rO GAL/DAY/BEDROOM •%'/V GAL/DAY exists. S S 1 °6o co — 13)The installer shall verify the location,quantity and elevation of the sewer I /D .1p0 lines exiting the dwelling prior to the installation. - SEPTIC TANKI WZ - d GAL/DAY x 2 DAYS - GAL , USE Ln GALLON SEPTIC TANK 'fit 5'T L-4 ( 1 J SOIL ABSORPTION SYSTEM -tJ ( 5 I DE 'AREA: �J :_ Z�C ;� � �Z D A D i rt q BOTTOM AREA: B1 . MASON TIC SYSTEM SECTION • _ r _ -Z7-- - mot''VC 14 ID 0 GAL SEPTIC TANK 2. Lam/ a r wl��r ---I i3 6 WCUU14 buIVA + SITE AND SEWAGE PLAN LOCATION : 0 0 PREPARED FOR : SCALE: -a - DAV I D B . MASON,ZS DATE: 5&41wo o DBC ENVIRONMENTAL DESIGNS EAST SANDWICH . MA W DATE HEALTH AGENT ( 508 ) 833— 2 177 W Z __ -; ' ,, . ..�,.. . ,,,..,-<.r w'a<* r c•✓ -a v;v'.>...; , ,4 .r r%e __.,, , .„ , , r.. ,. , ,->r >n .. _..: -< �. '.� _,. w 3,'ff. 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'ea.d. o.:o'.:o'..: P. H- 0 REINFORCED I b• CRUSHED a CONCRETE '_ 4 d: 9•00 :4;ao':q'.o9 c : o-:o e,p.p,p•,Q•,.Q,a•Q.a::::.a•: d 'o. b 000: NE o,o •: , ,;o o;.•;o:. o:. o b: STD I• d °! �:. b::o.•o.o:.p.b• •d1 ¢ .o.de:•'A:a . . . .:o, . . . . H- JO REINF. ; O. D :O , 6:.• .a :4. e'* o• a,: .SEPTIC SEPTIC TANK bo INSTALL ON LEVEL BASE NOTE.' EXCA VA TE TO ELEV.- `` ©R o'.' ''a'• •a ;'� a , .o..�. '_'P' _ d �_ •DJ LOWER TO REMOVE ALL IMPERVIOUS = `' '-`- MA TERIAL BENEA TH. THE:L EA CHING AREA . REPLACE EXCA VA TED MA TERIAL WSTH ''® "0 _ CL EAN, CLA Y FREE SAND /11- Q i 52 EFFECTIVE DIAMETER 1 , , , 4 87100'00.E 00 LEACHING PI T GENERAL NO TES - , y INSTALL " ON `LEVEL BASE . .6 7C 1. AL L. EL EVATIONS SHOI✓N ARE BASED ON u f A -:- , '. 7 2. ALL PIPES IN THE SYSTEM MUST BE CAS T: IRON x V .-, ,.,, „ OR 'SCfHE 1 E 40 P C. Q ,. OBSEfa A ION PI . . `_; i H UST BE NOTIFIED.-a`._-, H BOARD OF HEAL T M 3. T HE BOARD . 3 , ' ...- ,.._' . O P, WHEN`` CONS TRUCTI N IS COM L ETE PRIOR _ . ., . ERC A T O RA_, _ a P DL I N TE. < , h, , TO BA CKFIL L ING ' GALLON' aao x MIN. IN. ; N N E E Y CHANGES I THIS PLAN MUST BE APPROVED < , ., 1 RECAST CO A T < W . �LI_ W TNESS O B Y. ARD OF A T I E . . .rr.._.:_ l�'h'7"E�' PTIC TANK: BY THE BO HE L HAND CAPE 6 ISLANDS Q o _ _,; ' I< o ' ` c SURVEYING CO, INC. c , , io " ,. o a � r 5. _MA MATERIALS AND INSTALLATION -SHALL BE IN C, , ..y - _ ! 1 g / hr BRD. OF HEALTH'� g f . � DESIGN _VA TA , o CQMPL LANCE WITH .THE STATE SANI TARP o , T . . CODE TI TL E V AND LOCAL APPL ICABL,E . ., w � Q. as - , .` . : - ` .�J o S AND REG L A TIONS " .. ti RULE U ... ,3 ., o .' NUMBER OF, BEDROOMS RTH ARROW IS FROM RECORD PLANS AND - :. I' r, 6. NO t © GARBAGE ,;DISPOSAL IS NOT TO BE USED FOR SOLAR PURPOSES a }® y D G , 7. FL ODD HA2AiR0 ZONE .,,, ., DA IL Y FL ON l r 7 x' 4 l 7--- B. WA TER 3UPP.L Y 7` J.:vaO o�� c . . SEP TIC TANK RED D. , 9 T_ rr"''«F`,F. - N �„}r'(..d'e'2o$' awn '''. 1l '"- 'S' ., 'y, SEPTIC TANK PROVIDED ltc _ .,. ._ i/ ?r. I 01 .. I }. ,4 „' , .r, 1 I LEACHING REQUIRE C , x S• I" PRECAST CONCRETE : xL EACHING PI T j] `. SIDEWALL AREA = J.�� S.F. t ' ,�II 1�.I�1 III I I,�,:.I,I II'�:I I I1,�.I,I I,.II I I:I1"�..­1�'1:�I.I�*-I�II I I.,.'1 y',III.I I1.I I�I�1�-I�;.I,I.�::.�I­1 II1I�.�.I�I'I..I.-1,�I 1.I�I­1 II�I:1.�'-1 I1I_.-..I'.'-._....1I.--.,�.'V.Q.%:I.:..I-....I.:I.*..*w.I..�..P.r-0P.�T� ..*.':*.-.�.I'...Z.I.I-1.I._..­?III�o.I.:,l 67.�--..*�.I.I�..I.,,,I..:I�'*-.I....0,II�.�,,.'�.1,v I-',-�-:,t�iI-I.I I':-0-..1*:I-:�'�I.�,I 9 I-..-.�:,I"1:,A II�1 OI'*:.�_I--I0.o 1I�0t"16*-I.- a­�­�I1-I-�-.,----,.�,.-�'".41 I1,��,�1�­��II"�Ii I, '�, F ``' J d. �'S F.X .•, -- G/S.F. _ �3 ' ' GPD } , m BOTTOM AREA � L EGEND7 .l ,.j S F. X r. G/S.F. /f.3 GPD `,,.; N�`•'Teti LEACHING PROVIDED = GPO 'Q 72.6 ,,,, t • .' : _S 86 27 „_ , ,., PROPOSED EL EVA TION f4 ,,.� y , . ,. , v ._ _ .. E R ,, �.: .. , , SID _;.,<�ax_ , , EXISTING 'CONTOUR _w . . a KE �,.. ,, . L ____ , v . , _ v SINGLE FAN1aIL x. . „ , ,O SERVA TION' PI T } . ,. _.. .....: : .. 1:., k .. < _ ,._ _ � _. _ T N BOX f r . x ,,, DIS R1 BUTIO . , , .< -� .. �- ,. ,.,_ _ < r,. . < W G ISPOSA L_ SYSTEM ... ,_ Y�. _ PROPOSED SEA E D (y Vie,>€,,�, n ,:.,, .. ::.x.-.. f,. _. ..: q 2 y , .... - ,CM1s,.,.. - , :. , 0:, u( "., . ,, <.,_. ,, ,-a _rt. I _ O _ :LEACHING PI T .. _ x .. ''FOf O PREPARED . " .. t .,, ✓' r ,. ..,. , .,. , 1 ..> a,'r 0 o SEPTIC TANK- : y. x<, ,� � , �._ S .ICfEY..,« �y . SW YER & D __._ :r- v ..+mom'...:. - I , t RP 'RESERVE ` EE T , :� � L Q T 3� F'L INT S TR - ��� _ �, ..� >~ - NSTABLE M. MILL S MA SS. _ /^'' g : BAR .� .. a ). L vA rroN PIPE INVERT E E _ T_ DA E � x V C_ 6 ISL ' NOS SUR EY NG IN_ ° , CAPE A I PL O r PLAN . s T - _ SCALE AS N D 34 .3 _ P. <O. BOX_ 3 C LE. _1 '. u ;, . S A _„ ,. e ASS TE`A ICKET M 4 . T - .. _, O , _ AN_ N_ .._ _w , w _ __ �, , _. , _.x . x ,_- , . .r w m S C PCL LDT, _. _ _�• , , � _. . , ,. MAP. E ., a«�.,, _ -., M , ;,I. -.s: . ,,: .t. r,. .t4 ,- ✓ ., i. , r, , A i of ,f tr N, ,