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HomeMy WebLinkAbout0080 FLUME AVENUE - Health L= 061 e Avenue Mills 010001 I r ` Commonwealth of Massachusetts Title 5 Official Inspectio Fr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �® �6� � Ayer) ve Property Address �r A M .S' t Owner Owner's Name Uy information is (?,A r C,-N AS 1 C MAP- z I t-? required for every / per: City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your f}� cursor-do not P1 1A Ae l F (?e& use the return V key. Name of Inspector A MS JSA►`i Ct-A rti b�Q �`Company e n " �� y ' Company jAd�d�ress p P- 61A- Cityl7own State Zip Code 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 f,&Vdge digposaf sysMems. f&M d IYEPr approved 5jigfe fi"nspedfor purtiffit t'fd Sectio`n 15.34'0 of Title 5(310 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspect s gnature Date The system inspector shall submit a copy of this inspection report to the Approving AuthoritylBoa t of Health or'DEP)within 3d days of completing this inspection. If the system is a shared system or s has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit;the ~i report to the appropriate regional office of the DER The original should be sent to the systei .own 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. J i t5ins•3(13 Title 5 Md.".pection F.rtn:(Subsurface Sewage Disposal System•Page 1 of 17 I Commonwealth of Massachusetts Title 5 Official- Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address �r a Ain S iM,0a Owner Ownets Name --- -_ _.-- information is every (1/tl"�`+nylS required for eve Page-. City/Town State Zip Code Date of Inspection B. Certification (coat.) Inspection Summary: Check A,B;C,D or€/always complete all of Section D A) Syst Passes: 1 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: -13) 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): t5lns P 3/13 TW6 5 Oft-461 iiigkA fi FePifi'.gulls 666 SeWage bisposal System•Page 2 of 17 Ciammon wealth of Massachusetts Title 5 Official Inspection dorm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is ��� �� required for every page, City/Town State Zip Code Date of Inspection B. Certification (cunt.) ❑ 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 boxis 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, safely 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 86•Nis Title 9&C-list inspection form:Subsurface Sewage bisposai System•Page 3 of 17 Commonwealth of Massachusetts s Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �t Owner's Name `p� 1 9� l information is !°Y0 f S 4 A S ��ty +r ®2(oq'�� �l n h;0 required for every �1 "! a Pam- City/Town State Zip Code Date of Inspection B. Certification (cunt.) 2. System wig fail Winless the Board-of Health{anal 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: I 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 SA`or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less �I tharr%day flow t3ins•3/13 Tittle 5 Official inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address rrc C�b'1 Owner Owner's Name information is e A�� �� a ®'ZE y9 required for every f 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: 0. ❑ ] 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. ❑ !A 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 forma ❑ Imo( The system is a cesspool serving a facility with a design flow of 2000gpd- 4� 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 If of a public water supply weft 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 Title 5 Official Inspection Form Subsurface Sewage —Disposal System Form-Not for Voluntary Assessments H Property Address Owner Owner's Name _...,.._....----- -----_.........._.._.-._._..._ n i information is s^S�$T ye m i f is V 2 110 y� � ('Z 00� required for every page, City[rown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"of as to each of the following: Yes No ❑ Pumping information was provided by th owner, occupan or Board of Health LA0 V ���� l91 PtoJt ❑ Were any of he system components pumped out i the previous two weeks? N ❑ 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 NIA) ❑ 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? LP ❑ 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: IFf A^S C i tf 6 ® 1-' ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part.0-is-at_issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information -Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): - y t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Addre I r°1'8 n Owner Owner's Name _....... _..,..._. _._......_..-____-- information is ,>ry' 'k �� 1'� /t- '2-(0 yg 10�.l�� required for every 4/ , ' f page: City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes Pj 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: 2013 3 -00 SA IS = 19 2. Co Pb 2-019- Sfv 000 SA4 W2, G,P' ')' loll 12910,00 5+1- 1 � �, ' J Sump pump? C `e 1'�S /� Aive9v� �r`� � ❑ Yes No Last date of occupancy: Date i Commercial/Industrial Flow Conditions: Type of Establishment: -- Design flow(based on 310 CM 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 Trde 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth,of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments TAO _F1 Vie -e Property Address t "I Cie) Owner Owners Name information is //!S �� 0U jYY I!O� ® �5 ! / required for every /* 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: ; p 13 1"'uK.As '450 Was system pumped as part of the inspection? Yes No If-yes, volume pumped. gallons How was quantity pumped determined? Reason for pumping: Typ� 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/Altemative 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 VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. -Other(describe): t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments go -Ptvme A" Property Address Owner Owner's Name information is .5to A 1 f U f1l A- O (04 '!-Z 113 required for every page, City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all componeelnts, date installed(if known)/hand source of information: I C-O C r DA S- ®'o Were sewage odors detected when arriving at the site? ❑ Yes No Building-Sewer(locate on site plan): Depth below grade: 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.): Septic'!rank(locate on site plan): it A 7 4 Depth below grade: i feet- Material of construction: IN concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) J If tank is metal, list age: Yew' Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Dsposal System•Page 9 of 17 01Y11 UI 119,Il'11stiluju pernrtment of Ileallh,Safety,nlld l;nvironrnenlnl Services . t)nte I'tlbuc He.>Illh t1)ivi�6ul! of t►u rht� 't ,In eel, 1AMMAMPAUM Fee Pd.— Dale Scheduled Tlnte_-/O-4-44t- I . c tnliilit ssc�ss�»ent,fo!� Sewage DISP, Soil Sc y � riytN�; V�iJII� Wllncsserl Uy , Performed By: 1 u� ) OCA'1 IQN & GEN1:RA, to Ite)IrlYxtA nd ark Lalces Dev. r. N. . Location Adq,es; Lot Flume Ave Address.0. Box 95 AA Al Celzteryille, Ma. 0263 Gnglnecr's Name Assessor's Mnpff Arcel Map (1 Pcl_ 10 (Part) ;Oax.tex & Nye Inc. - Telepholrc N 2 8 .9 l 3] Nt,w CONSTRUCTION X_ RV-PAIR 4 Slopes(°/a) Surface Stones Land Use __=t f���►1T I,Lt_� > .` ()pen Wnlcr,podgy© n '('ossihle Wet Area_ '� R Drinking Water Well ove> R Uistnnces from. P Y.--""' n Drainage Way Property Line -n Other SICC'I'CI1:(street na me Junenslons of lot,exact locations.of test holes,&perc Icsls,locale tvetlnnJs In proximity to liolcs) - 4 43,561 sq.ft. shape fac / ..Q"E S 89'08'49" E' r<v 1.p7_02' .. iA/ 4:6,.026 .sq.ft__upland ft. wetland �ry 3 4,762 sq. oo. _ 50,788 sq.ft.: total a ;� V- o ` ( 1.17 acres te i ^ :j ��SSg 26 322 sq ft. u) / o iri _., .N _ o 0 �c� .ham N R:':= 1Z6:93" -� C.B. FND CID 1.03.32 20.6 1.6 Oh 58 ^ , �g68 QU •- r Pnrcnl material(geologic) Ucplh to Groundwater. Sw (IIng Wnlrr In 110Ic we phig Gstiutatcd Scasonnl I ligh Groundwalcl — l�tr;�l;:ltnitt�i��a lu^iv A. It 1v.�t.�il'z?;.� 'I'�UI.,I�, Method Uscd; _ —_ In Iirlil.lt Io soil inolllcs: _ __.—n. Ucpth Observed sl�nding In ohs.hole In, OlEn+nt(wster R I)eplh to weeping(Ioijl side of ohs.hole• _ — A, .f+clor— Adj.Ciwunthenler l.evcl•_-- hulc.e IN N_.` •Rriidht ,pate Indcx Well levt l ll.., — to 4w . I'I;X�L(31L!1'Irrt)N `t It�'1' : Date ; . Ubscrvation line at 9" — 11VIc N --— r' tl— I Imc at 6 Depth or Pcrc L•nJ Pre-soak Itntc.T4in./Inch --. ; Sitc swhbtlity AsscsspMit S+lc l'r+asul _ Sllc Original. Public ll MO'ulvlslolt UUsel'vutloll,]tole Uatl) Co,lfe(,oniplc(cl on 1)nclt Copy: Applicant 1)rEl' OUST,RVATION`1IOLE LOG, :fYnte # Depth from Soil I lorizon Soil 1•6ture soil Colnt Sall Utlrcr ; Surfaco(in,) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes, e 11 r1 ' C) oru bpi 1= s Its t2 lop-t d,�, to) ►2 6�¢ Jjr.. DEEP OBSERVATION I'IOLE LOCI::: e # Olht r Soil Color Soil Depth from Soil Horizon Soil Texture ra (Munsell) Mottling (Structure, loges Boulderes. Surface(in.) Consist V five I Id vu v,� � s b �-slz• f / u r " Sr4 l 1 a. , DEP Onst,RVA.TiON HOLE LOG I�ol�e # _ Soil Color'. Soil Other Ucplir from Soil I lorizon Soil'fexlure M nsell Mottling (Structure,Stones,l3oulderes. Surface(In.) (USDA) ( y. J v.e — ?? -��. _ r, DEEP OBSEItVAT10N tTl�l # Depth from Soil I lorizon Soil texture ., Sou other Surface(in.) (USDA) (Munsell), Mottling (Structure,Stones,Boulderes• • v • s ;t - r ------------- t Flood Insurance Rate Man:- ` Above 500 year flood boundary No Yes Within 500 year boundary No Yes Within 100 year flood boundary No Yes Dc tl f 'aturall Occurrin P rviou Material Does at feast four feet of naturally occurring pefvious aterial exist in all areas observed throughout the area proposed for the soil absorption system? ^—} If not, what is the depth of naturally occurring pervious material? _A_7 ('ertlRcatlon - 1 certify that on < Gate)I have pa§sec the soil evaluator exajnination approved by the Department of Enviro mental Protectton an that the' above analysis was p'erfo ed me r risistent with the required training, expertise and experience described rn 31Q CMR 15.017,. , ),90 l(�/ G� f Commonwealth of Massachusetts Title 5 O icial Inspe ctionForm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9V F f V'YLe- V-e Property Address f 6'1't OY$ Owner Owner'-s Name information is �� �'y1 1s MA required for every U a � 3 a 6 q page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Septic Tank(cunt:) !f Distance from top of sludge to bottom of outlet tee or baffle Scum thickness �o ���e t��� 2. y u-t (.el` /1 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? f»eAcvPeJ 03#nS Aod TA- pc Comments(on pumping_recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): OOP- W l I I C e A--, &t L( " 'b ov— 1t1A / r�r Grease Trap(locate on site plan): Depth below grade: feet Material of construction; ❑concrete ❑metal r ❑fiberglass ❑polyethylene El 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 bafflo Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r V T vrne v­e_ Property Addres Owner Owner's Name information is U ° r AP,�1� N t h M� 0 Z(PqY �/�2/a required for every l page. CitylTown 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 I I 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 f5lrns•3/13 Tale 5Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 CdMmOnwealth of Massachusetts . Title 5 Official Inspection. Form' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Tfulme Ave— Property Address Owner Owner's Name—S� _.......__-- information is r-&-6V% 01 1 �� g required for every �?26 q�, �j '•Z '3 page: City/Town State ZipCode s� Date of Inspection D. System Information (cunt.) Distribution Sox(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.): e-jY, 1 LOA I-ev-e (fl `j ` 0 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: Sail Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 5.ns•3t13 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 u rn e A Property Address Simon Owner Owner's Name ji information `r.S��15 �t 03 MA 024�required for every y r3! page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Type: ❑ leaching pits number: ❑ leaching chamfaers number: 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.): t1 "tree Mc k I'Z- x 30 ` 2 C har 4tr IA M hP'Ai (AJ AS t-e(® Cesspools(cesspool must be pumped aspart 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 Mns•3113 Title 5 official Ire petition Form:Subsurface Sewage Disposal System•Page 13 of 17 dofnmonwealth Of Massachusetts Title 5- Official., Inspection dorm. Subsurface.Sewage.Disposal System Form -:Not for Voluntary Assessments Property Address �i V�1®Y1 Owner Owner's Name information is required for every page Cityfrown 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•3113 Title 5 official Insp ection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Ins, ectton For . la � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °rf Ume. Ave Pr operty Address Owner Owner's Name information is ��`�°'��S required for every page: City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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 1> jq if coAf A32- 02 r D-ePvL\ "ft r0Vei 63 4 t5ins•3/13 Title 5 official I nspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f , Commonwmalth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V•y V'O F`yate \t-e Property Address- 1 won Owner Owner's Name information is ,�),&r&+0yu a( 1 t �15 P1 A � required for every �J"� U page: Cityfrown State Zip Code Date of Inspection D. System Information (cons.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells i � 12 Estimated depth to high ground water: 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) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: (V/f�� �- J� hld1n � A ?/A" Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 T&5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is �y) ] f required for every /f ,—A S�os (J " `i '`S f�)A 02 6 i(,f /1_2 page. City/TdUn State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked rInspection Summary D(System Failure Criteria Applicable to AH Systems).completed System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ms 3/13 Title 5 official I nspectlon Form:Subsurface Sewage his MI System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION t' I-timr- Atlenwc SEWAGE # 010 VILLAGE Ma161,411 M I15 __ ASSESSOR'S MAP&CLOT 007. �r INSTALLER'S NAME&PHONE NO. (�YY1 �K n - C u-- V (.00, SEPTIC TANK CAPACITY Sn Qial 7aatK LEACHING FACILITY: (type) RLG� (size) NO.OF BEDROOMS ff BUILDER OR OWNER !� PERMITDATE:fjlilb! COMPLIANCE DATE: 0 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 tq 15Jot _ �S3 TOWN OF BARNSTABLE F—C- LOCATION FO `T L ' SEWAGE # 7 / � 1 4 VILLAGE 4!l 4—<"ZO/15 iff/llf ASSESSOR'S MAP & LOT Ur -D U—fb INSTALLER'S NAME&PHONE NO. 7/�/�/7L" � SEPTIC TANK CAPACITY LEACHING FACILITY: (type) j e r 6 . S (size) I i NO. OF BEDROOMS_ BUILDER OR OWNER PERMITDATE: /3 Oa COMPLIANCE DATE: /(1 k Separation Distance Bet ween 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 Ru,, A1'QAue-. -57 A H fNn�" r e TOWN. OFBARNSTABLE EC- (� LOCATION Fl- u van e— a-1/ SEWAGE # / 1 VILLAGEJ&,9 /y21 ASSESSOR'S MAP & LOT -D,v--00� INSTALLER'S NAME& PHONE NO. � y�?f�/�e' X• . SEPTIC TANK CAPACITY LEACHING FACILITY: (type) d; (size) r t NO. OF BEDROOMS_ BU L, DER OR OWNER. FJ lc%� PERMITDATE: O COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the.Bottom of Leaching Facility Feet Private'Kater 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 j 'Fronk a \ t 01• � No. Fee THE COMMONWE TH OF MASSACHUSETTS Entered in computer: ✓✓ Yes PUBLIC HEALTH DIVISION -TO OF BARNSTABLE., MASSACHUSETTS oA Z(pprfcatton for Oigpozal *pztem Cow6truction 3permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Lvl Complete System El Individual Components Location Address or Lot No8''D F 1 ume A V e Owner's Name,Address and Tel.No. s \� Assessor's Map/ParcelMarstons Mills Bayside Building Co. Inc. Mag 61771 -1041 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Baxter & Nye Inc. Q5SVI-AA / /9k�k 812 Main Street Osterville 428-913 Type of Building: Dwelling No.of Bedrooms Lot Size -26, 90R)- sq. ft. Garbage Grinder(/✓O Other Type of Building F91,4119 No.of Persons Showers( ) Cafeteria( ) Other Fixtures //�� Design Flow eU gallons per day. Calculated daily flow gallons. Plan Date 5 Number of sheets Revision Date Title f Size of Septic Tank 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 Certifi- cate of Compliance has been issued by this Board of He Signed Date Application Approved C2 Date �- � Application Disapproved for the following reasons Permit No. !' Date Issued No. -Fee a THE COMMONWE TH OF MASSACHUSETTS Entered in computer: ✓ Yes ^{ PUBLIC HEALTH DIVISION - T_OW OF BARNSTABLES MASSACHUSETTS Zipprication for Mi-qpogaf *pgtem Con!5truction j3ermit A` Application for a Permit to Construct Repair Upgrade Abandon JCom lete System ❑Individual Components Location.Address or Lot Nod''D Flume A V e Owner's Name,Address and Tel.No. Marstons Mills Bayside Building Co. Inc. Assessor's Map/Pazcel Centerville Ma 61 Pcl 10 Part P.O. Box 95 Installer's Name,Address,and Tel.No. y Designer's Name,Address and Tel.No. Baxter & Nye Inc. 812 Main Street Osterville 428-913 Type of Building: Dwelling N,ccp Bedrooms ' Lot Size a26� 3°?'� sq. ft. Garbage Grinder(/✓V Other Type of Building 910OD FAf F No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �__e 6) gallons per day. Calculated daily flow y gallons. Plan Date 7 / 5 Number of sh&ett�s Revision Date Title ( ) Size of Septic Tank 5 V r Type of S.A.S. Description of Soil rx f t. r' Nature of Repairs or Alterations(Answer when applicable) r Daie last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Hea Signed Date Application Approved !' Date Application Disapproved for the following reasons Permit No. i' Date Issued "- -------------------------------- 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 JQe b/C at �?d FL V R F /9 V9_ - W 4 9 5 TiJw5 N1 14-4S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated *- Installer Designer The issuance '� emf 's permit shall not be construed as a guarantee that the s will functio a igned. Date rf• Inspector . No. Fe THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Di$pool *p!6tem Construction 3permit Permission is hereby granted to C nstruct(✓>Repair( )Upgrad T Abandon System located at &I F 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:Co struction must be completed within three years of the date of this t. Date: 2 T 3 A� Approved by � � BAR I 1ABLE 2 1 SEP 4 PF t,: 03 �. . I IL RaON_ 0�:: ��1�.[�Sro:+.1 N ,, RCOF-n__ Ic:_ _ NI - 2st VUc op T7LA w --- u 2d.a s•• . .g"il,✓.�vn�ug_ouJ4:Ciz:E.�'71w.::KIYU]:E�.S::�Ckva7c.N G<tS7�4�:_-___-:. i ITJ� Ex�--- - , I i y - �• �i it I I C° I i . I i L VzV65 DEg IM,DEMO •���q�:l o� Pao Eoo.. eo_���:-:nyE:.�A�ISfQUS°ti1i(sS /tios2. ► � . I II 11 ' ll (� f I _ I I I i N I i I - 1 -��cnrv7 j >J. � SNEtTBf14lS. �-. I dw4 Pc�3Y�5tB"I+t'IGTcRED_ - .. • i ' .. _ -._. - _ - TAY-OSFEr'.ER-SC�BEP_ERS- 1 , Z: J 2a63YofTf-w�(9_WSO.t { { i I I .. - ... _;DP_E� I .� ...._.-_____._..__ -_ _.__--_.. a _54rrrrw ..._.. • 31, IN t" '1TG.�FOOIJTPC'i'1D�7 Ll - �e4- Wee MUN DESIQN7 CHAiHAM, HA. i P.o Fl i'ME--�(yE;/;<iXRsroRs-r�{l� . 7C2oa"2.— I NOTES: 4 TOTAL UNITS 1 STARTER,1 END, & 2 INTERMEDIATE. ? 1. THIS PARCEL IS NOT LOCATED IN THE FLOOD PLAIN. 330S TYP. 3301 330E 2. THERE ARE NO WETLANDS LOCATED WITHIN 100' OF THIS LOCUS. 7.5'6.256.256.254. 3. REMOVE UNSUITABLE SOILS BENEAT H PROPOSED SYSTEM, BACKFILL ,-1s WASHED STONE 41 WITH CLEAN GRANULAR MATERIAL FILL TO BED' GRADED AS FOLLOWS: NOT o i f: fit. � (.0 MORE THAN 15% RETAINED ON No. 4 SIEVE,' NOT MORE THAN 90% RETAINED ,. I f,, ~_" ' ON No. 50 SIEVE, OF FRACTION PASSING No. 4, 10% OR LESS TO PASS No. 3s'oo' �L \ 100 SIEVE.AND 5% OR LESS TO PASS No. 200 SIEVE, SOIL TO BE APPROVED f-- _ FI fr F /'96.62' :S 15"r8 BY ENGINEER FOR COMPLIANCE PRIOR TO PLACING ON SITE. vEr�S rj ,` 36" �, \ \ LIAN CE LEACH ICCFIAMB cn 4. LOCATION OF UTILITIES NOT SHOWN ON THIS PLAN, AT LEAST 72 HOURS - —, 226•Sg' \ oD PRIOR TO ANY EXCAVATION FOR THIS PROJECT CONTRACTOR SHALL MAKE N.T.S. 54 I °' THE REQUIRED NOTIFICATION TO DIG SAFE (1-888-344-7233) AND APPROPRIATE _ 56 I �+ WATER DISTRICT TO DETERMINE UTILITY LOCATIONS. °' S8 60 ,� 129 96" o 4> f cV �\ i`ti (SI _f _ DO CD 62 _ �v po DO 00 'Lon I 29.2' �� of 66 � �7 JIB 12' --• ... ' / E N I AA�� DATA - �- 26,322+ SQ. FT. 3 0 C �;iV L•A.I A > - FINISHED GRADE t _ _ ROOMS \ `\/\�� \ \\ \/ \/\\/ COMPACTED FILL } "0: 0+ ACRES o 36"MAX.- 12"MIN \ //\\/ Ell \/\//\//\�\\� \//\ 1___ / r ' Z�= U'. SINGLE FAMILY- 4 BED z_I _-_ _ -- -- PEASTONE - / O U I t NO GARBAGE GRINDER a 3/4" TO 1 T/2q"A DAILY FLOW = 110 X 4 = 440 G.P.D. 30.5" .a DOUBLE t r I )Z SEPTIC TANK 44 X 200% = 880 WASHED STONE CL O o 210 '`ti r ; USE 1500 GAL. SEPTIC TANK ; I CULTEC LFACHINaG CHAMBER DESIGN SECTION N.T.S. RECHARGER 330R OR EQUIVALENT ALL PIPES TO BE SCHEDULE 40 PVC PERFORATED -- -- 20.53' t'r t :`t 158.48' WITH CAPPED ENDS -`"- - USE 1 - 4" DISTRIBUTION LINE IN 4 RECHARGER UNITS I CERTIFY THAT THE PROPOSED FOUNDATION _ \ _.._, � IN 05'09'55 E 179`©,1' IN A 12'X .55' WASHED STONE TRENCH AS SHOWN COMPLIES WITHrTHE TOWN OF BARNSTABLE SIDELINE 1 pit- IN LEACHING AREA REQUIRED AND SETBACK REQUIREMENTS AND IS NOT LOCATED ( f r7r " 440 G.P.D./.74 = 595 S.F. WITHIN THE FLOOD PLAI� F ���_• � LQ_l �. - t ' DATE: 04 'L.- - �-.� _e..? - R.L.S. \. I 2(35 + 12) X 2 = 188 S.F. -SIDEWALL AREA .-41 - , (12 X 35) = 420 S.F. BOTTOM AREA - ryT'� O �'_'� THIS PLAN IS OT BASE ON AN INSTRUMENT SURVEY AND � �IJL; D P FILE NO. S&� --33'72 � 608 S.F. TOTAL PROVIDED THE OFFSETS _ ULD N BE USED TO DETERMINE LOT-LINES. I R' ALE: 1" _ 40' PERCOLATION RATE 1"IN 2'OR LESS 8/14/98 ~+; CERTIFIED 'PLOT PLAN a'�, SOIL CLASS 1 TEST MOLE .ate � `�sv /� eI � F¢� BAXTER & NYE INC. / \`'JF1 s\ LOCATION •; r LOT 1 - FLUME AVENUE \� r� #P-9221 i� ��, MARSTONS MILLS COVERS LOCATED TO WITHIN �a97 f I a �' DATE: 6" OF F.G. �. L`s PIT #1 PIT 2 i .� c` ELEV. = 65.2' # ELEV. = 65.5'0 HUMUS �; JANUARY 29, 2002 O HUMUS ' F.G.=65't -2„ -2" r3.Gl/ C�t TOF = 67.0' -G•= 65 F.G.=EiS' E LOAMY SAND E LOAMY SAND C7 *r� C-' G T REFERENCE -6 -6.. .c FLAN REY ERE�Cr' LEVEL HERRING RUN AT INDIAN LAKES B LOAMY SAND B 3 LOAMY SAND J'�� INV.63.0' INV. = 1500 GAL. 4"DIAMETER LEACHING Cl,-.AMBERS -5 " )� 62.8' INV = DIST. SCHEDULE40 P.V.C. --"y-T :;? -5' PERC TEST // / SUBDIVISION 762 SEPTIC TANK 2 5' INV. 62.4 eox -5' 10" PERC TEST / Zy, �- ......::::INV. =62.2' - INV. =62.o ASSESSORS MAP 61 PARCEL '10-1 10.00' s"`` '''"�"""-6- STONE BASE MIN. C COARSE Cl COARSE BAXTER NYE & HOLMGREN INC- BOTTOM ELEV. EL =60.0' SAND SAND LAND SURVEYORS ,CIVIL ENGINEERS 10YR 6/4 1OYR6/4 CIS TERVILLE,MASS. C2 COARSE SAND !A PPLICA N T- PROF I.LE " l 10YR.7/6 �f'S _ ! `. -12' NO WATER U-12' NOV. =WATER 53.5' BAYSIDE BUILDING CO. INC. � f ; ELEV. = 53.2'