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0069 JONES ROAD - Health
69 JONES O ... CL 1 In L�S 'T4JWi1d OEi3 "i~�,EL X.00 'A'IgN SEWAGE#t ,.. �. `ViLLA�ESi;Ssows M.A. &1.4x__�__ I INS'£A49R'S NAIL 8z.k��KQNE No xNr c,PAcr3r BUILD oR Co tt PERM Sdprat�ttopt�cst�Ge�stv�eeta ci�a ,�:• M�xlmum��just��Gtaut��watet.'['ablo�o tltc Bottom of�aac;hing l�r�r��lity. ...�. .�-�- 1 lv�te l�4ei Supiaty Wd1;Wd Leactaios Padttty Oy��el9s cxisi Oil,gigs 6c within 200;feat oi"taach►og'f pWTy) -- �.� -�- --r- aa' t i4 cy '6Vet�ae►d aid i.eac164 oii flhy(Yt'1My tWhOd5 exist o � 3 A L" r �f („,.,C� TO OF ARNSTABLE ' LOCATIOIV� ` � � V EGGE # VILLAGE Z-; l ASSESSO & g��f j44 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 66 LEACHING FACILITY: (type J (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facili Feet Furnished by ��-'" AA mOlt� Ac IL No. (emu(5 — 3 Fee /00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Nsposal *pstpm Construction 3permit Application for a Permit to Construct( ) Repair(4) Upgrade( ) Abandon( ) ❑Complete System Lndividual Components Location Address or Lot No. �C.� ��tJ�s #(d it s Owner's Name,Address,and Tel.No. d V_% � Assessor's Map/Parcel 1 i axe 04 I r Installer's Name,Address,and Tel.No. Designer's Name,Addre s,and Tel.No. v� i\i'�rov.��• c�— c�1�y IS3� rwlv�ov n vlk,tt"P. Q-(O?6f-y 17114 t MIA OZ G Type of Building: Dwelling No.of Bedrooms 3 Lot Size 5\ sq.ft. Garbage Grinder( ) Other Type of Building tgvax. A%'_ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.reequir d) O gpd Design flow provided 3�JC?„ C) L1 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank a Q q, 4&x S 1L�Type of S.A.S._ `A,; SRO 4 rt L \�•Q u� � _ Description of Soil Nature of Repairs or Alterations(Answer when applicable) V-4C JN�_age !;6 s 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 d Date Application Approved by Date ® �[ Application Disapproved Date for the following reasons Permit No. j,015 Date Issued tof zw/! `1L s f 4 4D a0 Fee /0v / No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:/ PUBLIC HEALTH DIVISION - TOWN O BARNSTABLE, MASSACHUSETTS YesOF 21pplication for Di8f o016pstem Construction Fermat Application for a Permit to Construct( ) Repair l") Upgrade( ) Abandon( ) ❑Complete System Vndividual Components Location Address or Lot No. bV TO"e-S Midec�oNs Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 4 b o2cA wke_ �Jl�v l la H v l T' Installer's Name,Address,and Tel.No. Designer's Name,Addre s,and Tel.No. %NC�_'C lam. �` ��� 15 3 3 t&1 vv,ou l r Ie N G.G�jj''�� vi 1J 1a 6AA QZ(.6 k e3i _b 7 Type of Building: Dwelling No.of Bedrooms 3 Lot Size . 5 sq.ft. Garbage Grinder( ) ~ Other Type of Building �2S�Gr,t.v4 L No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.requir d) -7 3 O gpd Design flow provided *3!)o , 0 �-- gpd Plan Date \ Number of sheets Revision Date Title S' V"iL \Q\CA ram? Size of Septic Tank <10 q! gi,.%S��ul Type of S.A.S. .�; sc�o q L ��•! p I Description of Soil •� Nature of Repairs or Alterations(Answer when applicable) Y—C 1!t i Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of e'th.Z,7, r^ d t` f t ' ' .J Date .° Application Approved by Date 7 t 0l) Application Disapproved Date for the following reasons Permit No. 1?w ��� Date Issued W LQ 071! 1-1 --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate Of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(-4 ) Upgraded( ) Abandoned( )by at �, ! ';S()u f, t�'� 1p(JS Val MI has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.Z'T -398 dated I(I Tom+,r- Installer \ V p�V\,\ _D\t.3 s;c Designer F CO- #bedrooms Approved design ow b•f U y gpd The issuance of this pe �it shill not be construed as a guarantee that the system will cti n sdesign d. �J Date ' Inspector tti--------- - --------------------------------------- --------------------=- ------=-----------Fe--O-------------- N JJ _ Z THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pste u Construction 1Prmit Permission is hereby granted to Construct( ) Repair(�/) _Upgrade( ) Abandon( ) System located at �p� �Q �_� ' t1kAl-s J O ri \� 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��b ��(� Approved by f+ Town of Barnstable Regulatory Services Richard V. Scali, Interim Director • BARNSfABLE. MASS. g Public Health Division 1639. ♦0 A'Eo►++p�°' Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 11 3 15 Sewage Permit# . l.� �3`f� Assessor's Map\Parcel 46/29 Designer: David Coughanowr Installer: (0a l4N,\�iwc � Address: 155 George Ryder Rd South Address: at, %Nv rr g_ s'T Chatham, MA 02633 On t 3 r j�c� was issued a permit to install a (date) (installer) septic system at 69 Jones Road based on a design drawn by (address) David D. Coughanowr, RS dated November 3, 2015 (designer) X I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. 1. certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructe ce with the terms of the IIA approval letters (if applicable) �1L� r"�SS�� DAVID yGN; t D j. �a COUGHANOWR T (Instal le ign re) Nt . 1093 o z"t �STE V). S� \P �S N17AR (Designer's Signature) (Affix Design amp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc f L .Z _ Town of Barnstable Barnstable kgftd Regulatory Services Department MASS 6A� Public Health Division 200 Main Street,.Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7014 1200,0001 0358 7542 August 26, 2015 Lyn Rosado PO Box 294 Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 69 Jones Road, Marstons Mills, MA was last inspected on 8113/2015, by Shawn Mcelroy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Leaching pit or cesspool with high liquid level, <12" below inlet (per Town Code 360-9.1) You are ordered to repair or replace the septic system within Two (2) years from the date you receive this notification Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH s c ean, R.S., CHO Agent of the Board of Health Q:\SE:PTIC\Letters Septic Inspection Failures or future Evl\69 Jones Rd MM Aug 2015 11125/2015 Parcel Detail ti©4 _THE 71 RA"."YAi#LE, Logged In As: Parcel DetailTuesday, August 25 2015 Parcel Lookup Parcel Info Parcel ID 046-029 Developer Lot LOT444 Location 69 JONES ROAD ' Pri Frontage 1158 Sec Road BLACKTHORN ROAD sec Frontage '120 Village MARSTONS MILLS Fire District C-O-MM - I Town sewer exists at this address No I Road Index 0808 ~4 f Asbuilt Septic Scan: Interactive Map ♦` r` � 0460291 I t,,. - Owner Info Owner ROSADO, LYNN DO _ I Owner streets PO BOX 294 street2 City MARSTONS MILLS I State MA zip 02648 I Country Land Info Acres '0.51 l use Single Fam MDL-01 a zoning RF (Nghbd '0105 Topography Le\el Road P8\ed Utilities Public Water,Gas,Septic Location I Construction Info Building 1 of 1 Year 1977 Roof Gable/Hip Ex Wood Shin le Built Struct• wall g Living 1053 Roof Asph/F GIs/Cmp AC None J Area Cover Type Int style Saltbox wall Drywall RooBms 3 Bedrooms Int Model Residential J Floor Carpet R oms !1 Full-1 Half Grade Average Type Hot Water Rooms 5 Rooms stories .1 1/2 Stories Fuel •Gas F Heat atio� Poured Conc. Cross 1 � - Area 180 Permit History Issue Date Purpose Permit# Amount Insp Date Comments 4/11/2006' Out Building 91414 9/11/2006 12:00:00 AM 48SF SHED 4/5/2002 New Roof 60545 $2,500 7/2/2002 12:00:00 AM 5/1/1977 1 Dwelling IBI9227 $0 11/15/1978 12:00:00 AM MM 11/2 S http:/Iissq]2fintranet/propdata/Parcel Detai i.aspx?ID=3069 1/3 Town of Barnstable BA"S ABL& Regulatory Services Department fp µp'l Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director - Thomas A.McKean CHO FAX: 508 790 6304 , Feb 6, 2007 Rev. 7/6/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑Any.portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts /."�P ��1� "��/ J 0 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments M 69 Jones Rd Property Address Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 8-13-15 page. Cityrrown 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Ev on y the Local Approving Authority 8-13-15 fftp—ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 40 �S t5ins•3113 TiNe 5 Official Inspection Form:Subsurface Sewage Dis System•Page 1 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 69 Jones Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 8-13-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 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): r t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Jones Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 8-13-15 page. City/Town State Zip Code Date of Inspection B. Certification (cost.) ❑ 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): I C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Jones Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 8-13-15 page. Cityfrown 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 P system asses if the well water analysis, performed at a DEP certified laboratory, for fecal Y 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 ® El clogged 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-3113 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 69 Jones Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 8-13-15 page. Cityfrown 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 16,000 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM '< 69 Jones Rd Property Address Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Marstons Mills MA 02648 8-13-15 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes ' No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑. ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 a t5ins•W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Jones Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 8-13-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ® No Last date 2015.of occupancy: � 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? r ❑ 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 69 Jones Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 8-13-15 page. Cityrrown 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: N/A 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 69 Jones Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 8-13-15 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: 1970's with pit added in 1990's. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 12" 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.): Good condition. 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: 1000 gal Sludge depth: 12" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 69 Jones Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 8-13-15 page. CitylTown 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 20" Scum thickness , 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts - Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Jones Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 8-13-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ` Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): s it *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments" M 69 Jones Rd Property Address P Y Bank Owned (Contact David Hon @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 8-13-15 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 N/A 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.): 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.): d * 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•3113 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 G M 69 Jones Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) . Owner Owner's Name information is required for every Marstons Mills MA 02648 8-13-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers 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.): Leach pit holding water at 6" below inlet invert with stain lines above inlet invert. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 I i Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 69 Jones Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 8-13-15 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Jones Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 8-13-15 page. Cityfrown 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 stpply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 0u " 0 f t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' b 69 Jones Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 8-13-15 page. CityTTown 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: 20' 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: USGS and town maps show groundwater at 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Jones Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 8-13-15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked Z Inspection Summary D (System Failure Criteria Applicable to All Systems) completed Z System Information—Estimated depth to high groundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION�� �tJ�. � SEWAGE# 3 1) VILLAGE ASSESSOR'S MAP&PARCEL 0 ' G"2. INSTALLER'S NAME&PHONE NO. S02�-6'a S 8� J SEPTIC TANK CAPACITY LEACHING FACILITY.(type) g�1.. i �1���IS (size) NO.OF BEDROOMS OWNER *Jkt ikpte— PERMIT DATE: - 1 O - f COMPLIANCE DATE: (Z Separation Distance Between the: 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) 0 , Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) °Pt Feet FURNISHED BY ,s a® - c* N f- o Town of]Barnstable P# EVE � Department of Regulatory Services 1 ,J►nNaT��, O�fi�j Public Health Division Date 1 MASS. 200 Main Street,Hyannis MA 0260I •> rFunu't" .�i Date Scheduled Time. Fee Pd._ ab Soil Suitability Assessment for Sew e Dispos l h Performed By: y1 �Ou��O(�✓✓ Witnessed By: r / IN. G"` �J LOCATION&.GENERAL INFORMATION Location Address 6 5 J c e5 (-A Owner's Name L y I h b S ¢ o ,n`^ J 1 il� 115 �� �6ne5 f� • V�'\a�S��S � Address v1• (21 Engineer's Name�l y r S_�a h S tN1 , l 5 Assessor's Map/Parcel: ' `'p NEW CONSTRUCTION REPAIR V Telephone# 50q 15 G,1 j`q Land Use• Sr �� 1 1 I Slopes(%) D Surface Stones 0 Distances from: Open Water Body '�v + ft Possible Wet Area JD—O—+ ft Drinking Water Well 0 f ft Draihage Way ,Dt ft Property Line ` 0 f ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands-in proximity to holes) • - g�A�k TK oc�N �� , eqf r1s' �2�5 GV-Z Parent material(geologic) ` C�( 60 Depth to Bedrock Depth to Groundwater. Standing Water in Hole:_ K0 Q Weeping from Pit Face ©� Q Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL-HIGH WATER TABLE Method Used: I&O e f Depth Observed standing in obs.hole: In. Depth to soil mottles: Kohe R. f In. Depth to weeping from side of obs,hole: ln, Groundwater Adjustment f[. Index Well-tr Rending Date: Index Well level�__ Adj,thetor— AcU.Groundwater Level m PERCOLATION TEST We fiW Timei►�M Observation Hole# i Time at 4" rr Depth of Pere b % Time at 6" Start Pre-soak Time® �7,�� Time(V-61 End Pre-soak - Rate MinJlnch Site Sul tability Assessment: Site Passed ✓ Site Failed: Additional Testing Needed(YIN) vim' Original: Pubic 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:ISEPTICWERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil• Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. opshtency.�"aravell 7- A �, GD 1�—31 t� �r1 q �. �P s- z 0 (e: 01 44—/f Icy �4 3 Q Loo DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ons' en Lac i� r� '51 rd "IJ D q e 3`¢ "one V�i�t 6 tfu cAwd d 4 �l16 ' e&e ��Z - Ih4 C2 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%O DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Co t Flood Insurance Rate Map: Above 500 year flood boundary No Yes Within 500 year boundary No v Yes Within 100 year flood boundary NO., Yes;_- occurring Depth of Naturally O e Pervious Material Does at least four feet of naturally occurring pervious mliterial exist in all areas observed throughout the area proposed for the soil absorption system? �Q s If not,what is the depth of naturally occurring pervious material? Certification I certify that on J (date)I have passed the soil evaluator examination approved by the Environmental Protection and that the above analysis was performed by me consiste �+ Department of En OF P �•(N Mq the required training,expertise and experience escribed in 10 CMR 15.017. Ssgc v o� 'DAVID yG� Signature Date �0 2� o D. m COUGHANOWR 'CENSEO 0 • EV UP :�SEP"I'IC�PERCFORM.DOC AL Q:\SEMOPERCFORM.DOC AsBuilt Page 1 of 1 � TOWN OF BB�ARNSTABLE LOCATION (U`l �/�Lrs �=�- ' SEWAGE VILLAGE _/1/' ��`�J A�SESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NC� LG SEPTIC TANK CAPACITY �- XVSJ� LEACHING FACILITY:(type) /� (size) ll NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No -) tom, tc1"rf'j: t. tore) i i http://issgl2/intranet/propdata/prebuilt.aspx?mappar=046029&seq=1 10/23/2012 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 69 J.ONES RD. MARTSONS MILLS &4D _ 0Zq t"'Ljq�,_k Name of Owner CHRISTINE FOURNIER Address of Owner: 18 EVERGREEN RD.PLAINVILLE MA.02762 Date of Inspection: 9/2/99 10 Name of Inspector:(Please Print)JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) 1 'd Company Name: n/a to Tod, Mailing Address: n/a y�oF �9y9 Telephone Number: n/a P, `v �y CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is r a e and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The Inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Ev uation By the Local Approving Authority performing at the time of the inspection.My Inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:9/3/99 The System Inspector sha submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 69 JONES RD.MARTSONS MILLS Owner: CHRISTINE FOURNIER Date of Inspection:9/2/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: n(a 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. n(a i he septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nla Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced n(a The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced _ obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 69 JONES RD.MARTSONS,'HILLS Owner: CHRISTINE FOURNIER Date of Inspection:9/2199 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank a-id 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance n[a_(approximation not valid). 3) OTHER nta revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 69 JONES RD.MARTSONS MILLS Owner: CHRISTINE FOURNIER Date of Inspection:9/2/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n/a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2198 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 69 JONES RD.MARTSONS MILLS Owner: CHRISTINE FOURNIER Date of Inspection:9/2/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste Flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 11 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 69 JONES RD.MARTSONS MILLS Owner: CHRISTINE FOURNIER Date of Inspection:912199 FLOW CONDITIONS RESIDENTIAL: Design flow:,Q g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):Z Total DESIGN flow: = Number of current residents:$ Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):JMQ Water meter readings,if available(last two year's usage(gpd): D& Sump Pump(yes or no): NO Last date of occupancy: nla COMMERCIAL/INDUSTRIAL Type of establishment: NA Design flow: Wa gpd(Based on 15.203) Basis of design flow: n(a Grease trap present:(yes or no):JM Industrial Waste Holding Tank present:(yes or no): r1Q Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:n& Last date of occupancy: n(a OTHER: (Describe) Wa Last date of occupancy: Wit GENERAL INFORMATION PUMPING RECORDS and source of information: 1224 System pumped as part of inspection:(yes or no):flLQ If yes,volume pumped nla. gallons Reason for pumping: nla TYPE OF SYSTEM XSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: WA APPROXIMATE AGE of all components,date installed(if known)and source of information: 1979 Sewage odors detected when arriving at the site:(yes or no) NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 69 JONES RD.MARTSONS MILLS Owner: CHRISTINE FOURNIER Date of Inspection:912199 BUILDING SEWER: (Locate on site plan) Depth below grade: V Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: n& Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: 4" Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ nta Dimensions: L S'6"H 5'7"W 4'10" Sludge depth: Z Distance from top of sludge to bottom of outlet tee or baffle: W Scum thickness:I Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 17" How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND,RECOMMEND PUMPING EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: nLa Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:17La Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: .nLa Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) nLa revised 9/2/98 Page 7 of 11 O � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 69 JONES RD.MARTSONS MILLS Owner: CHRISTINE FOURNIER Date of Inspection:9l2/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n& Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) n& Dimensions: n& Capacity: nta gallons Design flow: nLa gallons/day Alarm present: NO Alarm level:ji&- Alarm in working order:Yes—No—: NO Date of previous pumping: nLa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:n& Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) nLa PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 69 JONES RD.MARTSONS MILLS Owner: CHRISTINE FOURNIER Date of Inspection:9/2/99 SOIL ABSORPTION SYSTEM(SAS):.X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nA Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: _nLa leaching galleries,.number: _nLa leaching trenches,number,length: n& leaching fields,number,dimensions: n& overflow cesspool,number: n& Alternative system: n& Name of Technology: ji& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLSOUND AND F NTIONIN PROPERLY-THE PIT HAS NOT HAD MORE THAN 2'OF WATER IN IT CESSPOOLS: _ (locate on site plan) Number and configuration: Wa Depth-top of liquid to inlet invert: nta Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: nLa Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n(a PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:n& Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) D& revised 9/2198 Page 9 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 69 JONES RD.MARTSONS MILLS Owner: CHRISTINE FOURNIER Date of Inspection:9/2/99 SKETCH OF SE'NAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a N4 0 AQ a3` A� A, ire 9� revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 69 JONES RD.MARTSONS MILLS Owner: CHRISTINE FOURNIER Date of Inspection:9/2/99 NRCS Report name: n& Soil Type: nLa Typical depth to groundwater: nLa USGS Date website visited: n& Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement'sump etc.) _ Determined from local conditions Checked with local,Board of health _ Checked FEMA Maps _ Checked pumping!records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 � 1 TOWN OF BARNSTABLE � f LOCATION (l/`7 �/�' S SEWAGE # VILLAGE /%/` ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO L9/b SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 0 (size) 4h k4D NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: '' DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No a I U Af.14,0 (?y 07q ' No..q .-,M FRi3 0 APPROVED � $�0@�BRmehtTHE COMMONWEALTH OF MASSACHUSETTS 9= ,4OAR® OF HEALTH OWN OF BARNSTABLE Allp iration for Diripooal Wi orko Tonotrurtion Fautit Application is hereby made for a Permit to Construct ( ) or Repair (� ) an Individual Sewage Disposal S at: 1 .. stem:..`..... .s.._. -- ----- -••---------..•••_--_.•_•.•................ --.-----........_..........._........_....- a cst'ny-:�cj�rk�s.r) ��� or lot No. i �1�U+71r ••- -- -•------------------------ ----•-------------•-- ............ ..__. W ir-nQer d r •. . ........... . ---....................................... a �' i --------------------------------- Installer � LX� Address d Type of Building Size Lot............................Sq. fea V D13 welling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons----------------------------- Showers ( ) — Cafeteria ( ) a Other fi es ............... .......... .. .. d --------------------------------------------------------------- ----........ W Design Flow............ . ........................galloiis� per person per day. Total daily flow....... ............._........gallons. WSeptic Tank—Liquid capacity............gallons Length-,.............. Width---------------- Diameter---............. Depth................ x Disposal Trench— No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter......_............. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................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........................ a ---------------------------------------- --•------••---•••--••-•--• ....... .............. ......... ..:..........._.._.. ..._.. 0 Description of Soil........................................................................................................................................................................ x U ....•-••••••---•••••-•-••--•--------•-•-•--•---••----•-•••-•---•-_-_-_-_•-•-•_••---•-•--------------•••-•--•---•-----•-----•----••--•------••-...--••-•••--•-_--••••-•-__-_-•-.......__-•-•.......------ w ............................................... ..... ----- U atgre o Rep or ,Alteratjons—A wer w en a lic ( �k �6® e 1 .... ---- ------ T. --•-- - . r-s---- --- : ---- -/.S-�n.�_...I.. ...T.--..-- --... 'Ll h. -....._..?-...---......... Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h been i s d b th oard healtl1,_ � he 2 Signed ......... . .......... -- ... ...... ....::...0........................................ .....................................� Dace ApplicationApproved By .. . .... ............. ....------------ - ........ .......... ... .. ... ...................................... ................Dace.................. Application Disapproved for the following reasons: .. . .............. .. ......................... ....... ............................................... ....................... ...._.. ...... ...,...... ........................ . ............................. ... . ................e...... ........---- '� Dare Permit No. -[....... Issued ........... ....' .. - .......---------------- ace ..... ........................... l t No................ ....... Fics.............................. THE COMMONWEALTH OF MASSACHUSETTS s BOARD OF HEALTH / TOWN OF BARNSTABLE . pphration for Diripuutal Wurbi Tomitrurtiun jimnit Application is hereby made for a Permit to Construct ( ) or Repair (Individual Sewage Disposal System at r! 1/1 . -..._....... .................-•--•1'�.......tc..I........ ------------------------.-----.•-----..----------•------------------------.....--.----....-------• Loc=ttiin::49dress• or Lot No. yner 1 t Installer Address Type of Building Size Lot............................Sq. feet ►.. Dwelling—No. of Bedrooms....... _____________________________Expansion Attic ( ) Garbage Grinder (/-//-P aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- ------------•-- •-•--••--•••......•-------•-••......-•-- W Design Flow............. .......................gallons per person per day. Total daily flow..__.. .-'�-�..._._.................gallons. WSeptic Tank—Liquid capacity............gallons Length-----_-------- Width---------------- Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No_____________________ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.-----------------------------------------------------••------------------ Date......................................1.4 .. Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x ...---•--•--=---------------•-•------•••••----••--•-•-•-•••-•------•.....---------•••--•------•--......................---•......-----•....."--•-•••....---- 0 Description of Soil........................................................................................................................................................................ x W ...-•------------------------------------------------------------------------------------------------------------------------------------ -------- ---------- ------------ U Nature of Repairs or Alterations—Answer when applicable.-)_1.1StF_--1-1_.____._.,r"kLt_•-____ti-t?a� L( ( ���L . :r _.i�._..�t,..-��-------�--= � -- --ram (---- ,,n ..•.. ... � -��----..=........�-...J `-:.�.'�X.......-----• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been .sss ed by the board of health. C� Signed -------`------..��- --.. �1..�----. � ./•�•...... ...........................................`_�!.. / Dace Application Approved Byr..,"..:fir... ..... / /'1 "°� I � l ate .f' ^Application Disapproved for the following reasons: .............._....._..-................................................. ...... ........... .....................................:..._.................---..._..----.---...-----...............................................--------................_...wNa_ ......-� Dare ^ Permit No. ."'r Issued .............. :..... --,� —v-----e—s.-.,—_—...—.—,—. -- --,.---„_—.-- ..,-----.—.—.—.--.--/--..—.--.—__a L---- _--o—>-. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cer#ifirate of Gmptia nre THIS IS TO CERTIFY,,That the Individual Sewage Disposal System constructed ( ) or Repaired (� by ............................................................ .................. I ................................................._........................ at - .... - c% . ....__ t'�1..:- ......_ � c�.........,....� '1.1 � . .C... .......... ......................................... has been installed in accordance with the provisions of TITLE 5 f The State Environmental Code as described in the application for Disposal Works Construction Permit No. ... � _� _ ... .... dated .-------................................ .... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEA 1AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... ^" 1------: �.A` Inspector _ � �^.,�- ,o'.`---�% G... �� it '....... -----------------------.-------------------------•----------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH oq N ... ....I......... ... TOWN OF BARNSTABLE12.0... �--- 1 Uiupu,ial Morb T,anutrudiun Prrutit Permission is hereby granted .__._.. k. ..�._E .............L-I'��--- to Construct ( ) or Repair (� an Individual Sewage Dispo al System ''f atNo.--------•••-......•--••---•--••. •. .. ..........A--••--------------• . ......... Street as shown on the applicati n for Disposal Works Construe,on Permit No.!._!.__�____. _ Dated___,_...__.._..........................::. -- ... -- ------------ Board of Health FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS r , L© AT 0 SEWA G E PERMIT NO. VILLAGE INSTALLER'S NAME & ADDRESS 1?bi324./ coo A/ B UtLDE R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED r y(, C-7 No..- d.... Fu�......l...cl THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH ................OF................. ....... Applira#iun -fur Biiipuiittl Works Tomitrnrtiun Vautit Application is hereby'made for a Permit to Construct (�` or Repair ( ) an Individual Sewage Disposal System at: Xt �i...!1...... 1.�.'S,_.__/?1�: ._.n'l�{,1 i �14 --•--•--•---------•-------------------------- Location-Address or Lot No. -----�'h .n �10.--------<.IZ.r P.t-------- --------t�_o_x.... h` A tt9 ....................................... _ Owner Address WH ' ............. -------------------------5. ........ Installer Address dType of Building Ckrr7 Size Lot_�14°`.�_'�______Sq. feet V Dwelling—No. of Bedrooms........... --__---__-Expansion Attic ( ) Garbage Grinder QY44) Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a Other fixtures -------------------------------- - g ..0..................gallons per pet-son per day. Total daily flow_---------,3.0- .........._._.......___g< W Design Flow..................5.� gallons. WSeptic Tank j--Liquid capacityl.Q.o-Ct_gallons Length--------/.'.... Width-----P....... Diameter_---5 ...... Depth.___'.------- x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.-------------------sq. ft. Seepage Pit No------j------------- Diameter.........6--------- Depth below inlet_.. .L_.` ...... Total leaching area...AQA©-__-_sq. ft. Z Other Distribution box ( ) Dosing tank ( ) e9,e1J- �G�' S-13-7;7 ~' Percolation Test Results Performed bY--------------------------------------------------------•---------------- Date---------------------------------------- 1_4 Test 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--.--..--__--_-.____._- -- --------•- - ------- ---------••--------------. Description of t x W ----------------------------------------------------------------------------------------------------------------------------------------------------- - --------------- ............-.............. txj Nature of Repairs or Alterations—Answer when applicable.----------------------------------------------------------------------------------------------. ------------•----•----------•----------------------------------------------•------------------------------------------------------------------------•---------------------------- --------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. � Sign •--- -- - - - -------------•---------•-------••-----•-•-•---.....---••-- -......--_•- -•--•-•-•----••- Date Application Approved B --- --- ;t ..... 7 Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- •-•--------------------------------------------------------•------------------•-•-•---------------...........------------------------------------------------......---......--•----------------•---•-- Date PermitNo......................................................... Issued...................... ................................. Date l__._........................... ___, ----------------------------------- e,v No..-•----.__�`.......�....... FEx......I✓..^'.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH v. OF................. .I. c?�L .. r Apli iration -fur Ui�ipviittl Works Tomitrurtiou Vrru it Application is hereb 'made for a Permit to Construct or Repair an Individual Sewage Dis osal PP Y �"`S P ( ) a P Sy texn at: 1 ......--••-- Location-Address or Lot No. r•�a: ,'e Owner Address W ,,-a •--•----•-------...__��___.#1�+sly#--�--•-�'�z----._...-•------ I, ------------------------•-----•--•-•--- •-•--- Installer Address Type of Building C141 C Size Lot_ r.° ...._ _______Sq.":feet Dwelling—No.,of Bedroom s;___.__.3-------------------------------Expansion Attic ( ) Garbage Grinder (40) Other—Type of Building -_._f..................... No. of persons..._____-________________-__ Showers ( ) — Cafeteria ( ) QOther fixtures ---------`---------------------------------------- ----------------------------- W Design Flow..................'S..l?________________--gallons per person per day. Total daily flow........... vq_________-.--..........gallons. Septic Tank JLiquid capacitvl-or,-C.gallons Length___-_5j__'_____ Width----- ....... Diameter__._ ~.'_._.,_ Depth-- ___--._--. xDisposal Trench—No_____________________ Width____ --_____----_-- Total Length------------------.- Total leaching area.--_-._...__._.--_-_sq. ft. 3 Seepage Pit No......1_____________ Diameter________.(__'.____ Depth below inlet_-. _:6__� ______ Total leaching area !�'� sq. ft. � P g.� �--- -----------•-• 1. Z Other Distribution box ( ) Dosing tank ( ) Q� /�C "` J`I5-7;7 Test Pit No. 1________________minutes per inch Depth of Test Pit..-:w`-- .------ --- --- Date-----:-----ter----------.--_--=-_':.''.- a Percolation Test Results Performed b ----------------------.................................................... P -------.. Depth to ground water.-----------•-_-_,_----- r (� Test Pit No. 2......_,._..minutes per inch Depth of Test Pit___________________'_ Depth to ground water__._._______________._. i Description of �1--- n t1i `' -- .tom . -, `r", +`;.- t k " x ______ 1 yt / f UNature of Repairs or Alterations—Answer when applicable-------------.._.................... r . _ . 1____________.__.__-_____.. _, ---- _____.______._.____---- k _-__-_____-__-__ ._ ._---.-_ -.._-.-_-----__-_-_. Agreement------------------------------- The .. undersigned agrees to install the aforedescribed Individual'Sewage Disposal System in accordance with the provisions f Article soX of h — I the State Sanitary Code The undersi ned further agrees no 1 h t to ace the system in PY g g P Y operation until a Certificate of Compliance has been issued by the board of health. K L �'--• --- J : Date Application Approved BY - Z�S/ign •-----. " : '7.'...d Date Application Disapproved f or'Me following'reasons:-----•----- ---.------------------ -----------------------•------------.....------- .....--------. _______________________________A__.___._..._....___._________._.__-_..______.__________-_._______.__..:_________________..._..___._.._____r:_____.____._.____._______...__._.__.__.____._.___________ Date PermitNo......................................................... Issued......................................................... Date i THE COMMONWEALTH OF MASSACHUSETTS BOARD OR HEALTH 'tl�'L .. OF.......... ....: Tnt-ifiratr of Tlamphaurr THIS IS T0:CERTIFY,_That the Individual Sewage Disposal System constriTctedF or Repaired ( ) by r = f`= ---------•-•-•---------- . ^7 s t Installer --------------------•--•----------------•--------•-•----- has been installed in accordance with the provisions of A XI of, The State Sanitary Code as described in the application for Disposal Works Construction Permit No.._ _:____.�2',�C?._.__..__. dated'--"__f.;------ '__.___.._. THE ISSUANCE OF THIS CERTIFICATE SHALL, NOT BE CO STRUED AS 7UARANTEE^ THAT THE SYSTEM WILL FUNCT ON SATISFACTORY. rrL............. DATE.. �.._.l. ...._ Inspector_._.. •-- --•-- THE COMMONWEALTH OF MASSACHUSETTS BOARD F `HEALTH Gy r /L OF ,KG a FEE Permission is hereby granted----------R,.... 0. ---- ---------•---------•----------------------• », ....• to Construct (1.-j or Repair"( ) an Individual''Se age Disposal 'System at No...... ----------Tlg 1 r�.......A A .................d''f--=....M 1- -,` ....---------------------...--- Street as shown on the application for Disposal Works Construction Pgait N if Dated-__-s~ /_ 77 r s 'y ................................... Board of DATE...................--------•-------------------•-----------._._._._...-----•--- a a FORM 1255 HOBBS 7&.WARREN. INC.. PUBLISHERS �a°j- ✓ .� a + 1R • ,t�•— _ .? • .• ,.. rem .77 ,pq i to�J1:6 Crr�Dc r ' . HEREBY CERTIFY THAT THE pl__Aw CIF 9_.ANU Ek STRUCTURE STRUCTURE SHOWN HEREON WAS �.00Ai Eu ON r BY AN ACTUAL FIELD SURVEY ON a 197-7 AND CONFORMS TO THE ' ZONING BY-LAW OF THE TOW,! OF k - A MASSACHUSETTS.. IN #' r• . ?//f M ASS. to , -REGISTERED LAND SURVEYOR` SCALE . I"_ r,a /l�� 1977 7 DAT E ',NOFMgssq CAPE COD SURVEY CONSULTANTS or JAMES C'yGN A DIVISION OF BOSTON SURVEY CONSULTANTS,INC. ` H. "OU T E 132 r , WISWELL N H YAPJh11 S, MASS. No. 11029 O - /flo STFIF-v Q� t Np SUR��� ! r LEGEND rISTRN 2 /� RACE LANE LD 11 V D BLACKTyORN Q eel UT§n §T#ES OMPONENTS IL- LOCUS W O� PEBBLE p WATER LINE —� W Q PATH Dv GAS LINE K 0 0 a TEL/Ccr ABLE TV EMERALD LANE Ou EXISTING LEACH PITI I NOT CELE'SSPOOL SIlk TO GARB NOT 0 G R ON BOX © SCN00� SCALE 1 OT . MARSTONS MILLS. MA OWED LOCUS MAP (cl � � a no 00 , cFp 11 / GF / 99 q, O THIS IS A MINIMAL (� GRADING / COLOR10�111 E PROPOSED 104 T PLAN Co USE COLOR PLAN ONLY \TOUR FOR INSTALLATION FULL DETAIL IS BEST j VIEWED IN \ FULL COLOR O t:. AREA = 22067 sf+— 105 LAND COURT PLAN 30751-1 _ ASSR MAP 46 Pa 29 / I !- G G G / Y ZN V [o A) � PROPOSED SOIL �� Q ABSORPTION SYSTEM ' -SEE DETAIL w( " ON BACK v :T- 4 GIS �n O 'epCNStA ® �T�" ELEVATION Il O 104. 05 a to op OF CONCRETE GLEVAT§OoNNS ELEVATIONS SPECIFIED ARE INVERT ELEVATIONS PLAN (BOTTOM OF PIPE) EXPRESSED IN DECIMAL FEET SEWER LINE OUT EXISTING SCALE: 1 in = 20 f t SEPTIC TANK IN 103.25 0 20 40 SEPTIC TANK OUT 103.00 6==== 105 D-BOX IN 107.45 O 10 20 D-BOX OUT 100.28 LEACHING SYSTEM IN 100.15 PRINT ON 11 x 77 in BOTTOM OF LEACHING 98.15 PAPER FOR PROPER SCALE OFA1gS OFM4S ;Jo.� SEWAGE DISPOSAL '� DAVID S9�yG ���P DAVID s9�ya ` SYSTEM PLAN NOTES D F, D J� -TO SERVE EXISTING DWELLING COUGHANOWR H COUGHANOWR LYNN No. 1093 No. 461 ROSADO INSTALLER MAY MOVE SOIL ABSORPTION `"1.� •• _�� OWNER(S1 OF RECORD SYSTEM UP TO FIVE (5) FEET LATERALLY �FGI �PPRop o IN ANY DIRECTION. ELEVATIONS SPECIFIED Sq s0�1 E A FS�� 69 JONES ROAD ON FLOW PROFILE MUST BE MAINTAINED. C 155 Geo Ryder Rd S MARSTONS MILLS, MA I PROPERTY ADDRESS TREE REMOVAL AT INSTALLERS DISCRETION. Chatham, MA 02633 DavidcouOHotmail.com DATE: NOVEMBER 3. 2015 508 364-0894 PG.1/2 JOB- ETE-3989 S O�� TEST L�O G PERC* 4876MBER 2, 2015 DESIGN CAME UIATWNS SOIL EVALUATOR: DAVID D. COUGHANOWR, ASE *461 WITNESSED BY: DAVID STANTON. HEALTH DEPT. DESIGN. FLOW: 3 BEDROOMS X 110 GPD = 330 GIRD TEST PIT NO GROUNDWATER ENCOUNTERED SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS PERC AT 65 in - 2 MIN/INCH IN C SOILS USE EXISTING 1000 GALLON SEPTIC TANK IF IN ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER INCHES HORIZON TEXTURE (MUNSELL) MOTTLES SOUND STRUCTURAL CONDITION. IF NOT, INSTALL 103.90 0-2 O LOAM 10 YR 3/2 NONE FRIABLE NEW 1500 GALLON SEPTIC TANK. 2-5 A SANDY LOAM 10 YR 3/3 NONE FRIABLE DISTRIBUTION BOX: INSTALL UNIT DEPICTED BELOW. 5-24 B LOAMY SAND 10 YR 5/4 NONE FRIABLE SOIL ABSORBTION SYSTEM: 100.23 24-44 Cl LOAMY SAND 10 YR 5/4 NONE FRIABLE THE LONG TERM ACCEPTANCE RATE FOR A CLASS ONE 44-144 C2 MEDIUM SAND 10 YR 6/3 NONE LOOSE SOIL WITH A PERCOLATION RATE BELOW 5 MINUTES 91.90 PER INCH = 0.74 GALLONS PER DAY PER SQUARE FOOT. NO GROUNDWATER ENCOUNTERED TEST P I T 1 PERC AT 65 in - 2 MIN/INCH IN C SOILS THE 24 ft x 12.5 ft x 2 ft LEACHING GALLERY ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DEPICTED BELOW CAN LEACH: INCHES HORIZON TEXTURE (MUNSELL) MOTTLES 103.95 0-4 O LOAM 10 YR 3/2 NONE FRIABLE BOTTOM AREA = (24 x 12.5) = 300 sq. ft. 4-8 A SANDY LOAM 10 YR 3/4 NONE FRIABLE SIDEWALL AREA = (24+24+12.5+12.5)x2 = 146 sq. ft. 8-26 B LOAMY SAND 10 YR 5/6 NONE FRIABLE TOTAL AREA = 446 sq. ft. 100.20 26-45 Cl LOAMY SAND 10 YR 5/4 NONE FRIABLE FLOW CAPACITY = 0.74 x 446 = 330.04 gal/day 45-144 C2 MEDIUM SAND 10 YR 6/3 NONE LOOSE INSTALL A 24. ft x 12.5 ft x 2 ft GALLERY AS CONFIGURED 91.95 BELOW. FLOW CAPACITY = 330.04 gal/dog WHICH EXCEEDS j Y ' 9 y THE 330 gal/day REQUIRED FOR A THREE BEDROOM DESIGN. W0 GALLON MWM TANK USE' SO BEY Scr-9500-#'-9 I in NOT r9 Sam ommw no am9m 92810mm ►' TAPER TO DRYWELL 24.0 ft -�r- SCALE UNIT CO � o ® co 0 5 ft- 4.1 14- co ° 8 in LO E) IFTI -1 41 CO In v N (N m . •�� ' STONE m � 3.5 ft 8.5 ft 8.5 ft 3.5 ft �� ft— - — --__ 6 i n i 500 GALLON DRYWELL DIMENSIONS & DETAIL INSTALL ONE INSPECTION INLET OUTLET 0 RISER TO WITHIN THREE COVER COVER USE INCHES OF FINAL GRADE & INDICATE LOCATION _. H-10 .., :. ON AS-BUILT 3 IN DROP j UNIT t —► I� FLOW LINE f 'Y r p 33 _ p�. BU�DING ,a lam. 14 r O »� o �;0� in D . BOX oat otn LE 48 in � 00000i LIQUID GAS j LEVEL BAFFLE 102 �w CROSS SECTION VIEW b in STONE BASE INSTALL AN APPROVED GEOTEXTILE j SEPARATION BETWEEN INLET & OUTLET FABRIC OVER STONE TEES NO LESS THAN LIQUID DEPTH CROSS SECTION VIEW24 in 0 o - --- 28 3/4 in TO ; EFFE�TI VEo 3/4 in TO 1-1/2 in GRAVEL 1-1/2 in GRAVEL D iammur o 0o xX In DEPTH o ©, 46 in 58 in 46 in -- 750 in 12 in -INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE C MIN STARTING WORK. —► -ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM Lr) FROM c c —� O REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CN TANK TO CODE (310 CMR 15). L0 -INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND O ^ SAS QT UTILITIES BEFORE EXCAVATING FOR SYSTEM. ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES & APPLIANCES. AND PERIODIC b in STONE BASE PUMPING OF THE SEPTIC TANK. 2I /„ 21 CROSS SECTION VIEW S -SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. p 0 L C TOP OF FOUNDATION RAISE COVERS TO WITHIN ALL PIPE TO BE SCH. 40 PVC EL = XX +- 6 in OF FINAL GRADE AND TO PITCH AT 1/8 in/ft MIN 103.9 -BO { 3' USE H-20 M A X EMST �� 100. 9 EXISTING 1000 GALLON o00o a°.�000� n ��pp °o,,6 n PRECAST ogo a o0000 SLS22���� T��VIfO 103.00 a°oQo°d000°0000 DRYWELL a°�oa°oaa°oo 100.28 °o p oo=ooflo °°000 000 EXISTING REFER TO DETAIL BOX STOIt I NE SOL QBSORpT�ON + 100.45 BASE 100.15 -REFER EXISTING a in STONE. BASE IF NEW 33 ft 5-12 ft ������ DETAIL BOX O 98.15 NO GROUNDWATER Ln BELOW MOTTLING OBSERVED _ 97.90 SEWAGE DISPOSAL SYSTEM PLAN 69 JONES ROAD MARSTONS MILLS. MA 11NOVEMBER 3, 2015 ETE-3989 PG 2/2 -