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HomeMy WebLinkAbout0048 LAKESIDE DRIVE - Health 7148,Lakeside Drive i Marstons Mills / A = 102 - 011 l 1 i � /,0a-o// Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 48 Lakeside Drive Property Address Paul Gonsalves Owner Owner's Name / information is required for every Marstons Mills ✓ Ma 02648 7-30-18 page, 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 A. General Information s/�#. 13aog filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation � Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code 508-477-0653 S 113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑■ Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority «.- Brett Hicky ,�; y m�- -w 7-30-18 _ Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 G�Y�J� 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 48 Lakeside Drive Property Address Paul Gonsalves Owner Owner's Name information is Marstons Mills Ma 02648 7-30-18 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑■ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.W6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 48 Lakeside Drive Property Address Paul Gonsalves Owner Owner's Name information is Marstons Mills Ma 02648 7-30-18 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): The system required pumping more than 4 times a year due to broken or obstructedpipe(s).The ❑ Y q P P 9 Y system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: s ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc-rev.6116 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 48 Lakeside Drive Property Address Paul Gonsalves Owner Owner's Name information is Marstons Mills Ma 02648 7-30-18 required for every 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 system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El El clogged of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ El Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ° 48 Lakeside Drive Property Address Paul Gonsalves Owner Owner's Name information is Marstons Mills Ma 02648 7-30-18 required for every 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. ❑ [D Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ El The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Lakeside Drive Property Address Paul Gonsalves Owner Owner's Name information is Marstons Mills Ma 02648 7-30-18 required for every page. CitylTown 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 i❑ ❑ Pumping information was provided by the owner,.occupant, or Board of Health ❑ E] 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? ❑ 0 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) ❑ 0 Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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: E ❑ Existing information. For example, a plan at the Board of Health. ❑ El 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: 3 3 Number of bedrooms(design): Number of bedrooms(actual): 330/GPD DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Lakeside Drive Property Address Paul Gonsalves Owner Owner's Name information is Marstons Mills Ma 02648 7-30-18 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes © No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes © No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: 2016-50,000gallons 2017-51,000galoons Sump pum ? ❑ Yes ❑■ No p current Last date of occupancy: Date CommerciaUlndustrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 48 Lakeside Drive Property Address Paul Gonsalves Owner Owner's Name information is Marstons Mills Ma 02648 7-30-18 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Owner- last pumped 3 months ago Source of information: 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: El Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 48 Lakeside Drive Property Address Paul Gonsalves Owner Owner's Name information is Marstons Mills Ma 02648 7-30-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: New SAS added to existing tank in 2010 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No Building Sewer(locate on site plan): 4' Depth below grade: feet Material of construction: ❑cast iron ■❑40 PVC ❑other(explain): Town Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): r Septic Tank(locate on site plan): 3' Depth below grader feet Material of construction: K 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 1 Dimensions: 500gallons 611 Sludge depth: t5ins.doc-rev.6/16 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 48 Lakeside Drive Property Address Paul Gonsalves Owner Owner's Name information is Marstons Mills Ma 02648 7-30-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 30" Distance from top of sludge to bottom of outlet tee or baffle 311 Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 1311 Distance from bottom of scum to bottom of outlet tee or baffle Measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection with the liquid level equal with the outlet invert. The tank is not in need of at this time but should be pumped every two years for maintenance Grease Trap (locate on site plan): NA Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 48 Lakeside Drive Property Address Paul Gonsalves Owner Owner's Name information is Marstons Mills Ma 02648 7-30-18 required for every 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): NA Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Lakeside Drive Property Address Paul Gonsalves Owner Owner's Name information is Marstons Mills Ma 02648 7-30-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0'r Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection with the liquid level equal to the outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc rev.6116 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 M 48 Lakeside Drive Property Address Paul Gonsalves Owner Owner's Name information is Marstons Mills Ma 02648 7-30-18 required for every page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: 16 hi cap infiltrators(12.7'x25') El 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.): The leaching was in working order at the time of inspection. Leaching was dry when viewed with no high staining. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Lakeside Drive Property Address Paul Gonsalves Owner Owner's Name information is Marstons Mills Ma 02648 7-30-18 required for every page. Cityrrown 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: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 48 Lakeside Drive Property Address Paul Gonsalves Owner Owner's Name information is Marstons Mills Ma 02648 7-30-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑� hand-sketch in the area below ❑ drawing attached separately rent 94 3 Al-15.5" B1.3T A2-143 B2.31' B A3.46' B3.27 A4.62' B4.47 Back 1 t Front A t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Lakeside Drive Property Address Paul Gonsalves Owner Owner's Name information is Marstons Mills Ma 02648 7-30-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑■ Check Slope ❑o Surface water ❑E Check cellar ❑0 Shallow wells NoGW@144" Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: x 1 Obtained from system design plans on record Feb 19th 2010 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: A plan on file with the Board Of Health showed no ground water at 144". Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 48 Lakeside Drive Property Address Paul Gonsalves Owner Owner's Name information is Marstons Mills Ma 02648 7-30-18 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ■❑ Inspection Summary:A, B, C, D, or E checked ❑ Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ❑■ System Information—Estimated depth to high groundwater ❑� Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. 48 LAKESIDE DR Property Address r—b MCGEAN/GAGNON Owner Owner's Name e, information is required for MARSTONS MILLS MA 02648 12-4-14 every page. City/Town State Zip Code Date of Inspection ,... Z. u7 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 A. General Information forms the I tq computeto J r,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name � P.O. BOX 145 Company Address CENTERVILLE MA 02632 'eRDf City/Town State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 12-4-14 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. qqji t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 LAKESIDE DR Property Address MCGEAN/GAGNON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-4-14 every page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM IS ONLY 4 YRS OLD AND MET ALL PASSING REQUIREMENTS AT TIME OF INSPECTION.WATER READINGS WERE VERY LOW FOR THE PAST 2 YRS.APPEARS THAT THE SYSTEM HAS SEEN LITTLE USE B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3113 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 48 LAKESIDE DR Property Address MCGEAN/GAGNON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-4-14 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Insp ection 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 48 LAKESIDE DR Property Address MCGEAN/GAGNON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-4-14 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® I Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 LAKESIDE DR Property Address MCGEAN/GAGNON Owner Owners Name information is required for MARSTONS MILLS MA 02648 12-4-14 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins-3/13 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 48 LAKESIDE DR Property Address MCGEAN/GAGNON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-4-14 every page. Cityfrown 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 LAKESIDE DR l Property Address MCGEAN/GAGNON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-4-14 every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND A 12.7X25 LEACH SYSTEM CONSISTING OF 16 HI CAP INFILTRATORS Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2013--22 2014----58GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Tale 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 48 LAKESIDE DR Property Address MCGEAN/GAGNON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-4-14 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: 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•3113 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 48 LAKESIDE DR Property Address MCGEAN/GAGNON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-4-14 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: 2-23-10 PER AS-BUILT 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 Tank(locate on site plan): Depth below grade: 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: 1500 Sludge depth: LIGHT t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 LAKESIDE DR Property Address MCGEAN/GAGNON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-4-14 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness TRACE 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? WOODEN POLE 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 LOOKED FINE AT TIME OF INSPECTION RECOMMEND PUMPING EVERY 2-3 YRS 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 48 LAKESIDE DR Property Address MCGEAN/GAGNON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 124-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 LAKESIDE DR Property Address MCGEAN/GAGNON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-4-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): "If pumps or alarms are not in'working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: COULD NOT FIND OBSERVATION PORT t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 48 LAKESIDE DR Property Address MCGEAN/GAGNON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-4-14 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 16 INFILTRATORS ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system . Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO SIGNS OF FAILURE AT TIME OF INSPECTION Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments' 48 LAKESIDE DR Property Address MCGEAN/GAGNON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-4-14 every 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.): l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 LAKESIDE DR Property Address MCGEAN/GAGNON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-4-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately 15ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 LAKESIDE DR Property Address MCGEAN/GAGNON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-4-14 every page. Citylrown 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: GREATER THAN 5 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: 12-2014Date ❑ 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: DESIGN PLAN Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 LAKESIDE DR Property Address MCGEAN/GAGNON Owner Owner's Name information is required for MARSTONS MILLS MA 02648 12-4-14 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Y. e Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION 48 1-na-_:me DeyF- SEWAGE# 20►0 —.4(0 VU1 AGE M. M'.I I S ASSESSOR'S MAP&PARCEL 10 2- 10 it INSTALLER'S NAME&PHONE NO. M PAN q Z%W W,,1S CWX-9 310 SEPTIC TANK CAPACITY lcioo 0-XIM "Sr.) LEACHING FACILITY:(type) 1� ��%d5� 1eaS (Size) NO.OF BEDROOMS �' -0�0 Gera I(p X"_X .'tQAI'o2S OWNER ?"TWGf wtasaiaLTdJ PERMIT DATE: 2-(q- 10 COMPLIANCE DATE: Z-Z3-10 Separation Distance Between the: Maximum Adjusted fhmmdwater Table to the Bottom of Leaching Facility 5 Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) l�A Feet Edge of Wets and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ^ Feet FURNISHED BY M r��►N 6AZyo.0S JfNT ' .pf�P • B REq� -rt.+ (��5 - 3 �uT 1Il•s 3( a �B 4� zZ fr Nr R 0 �2 42 http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=102011&seq=3 12/5/2014 TOWN OF BARNSTABLE LOCATION 48 Lfl-CEst OE .D P-\\I E SEWAGE# 2-0%0 - 4(o t VILLAGE P'1. 0`1 11 S ASSESSOR'S MAP&PARCEL 10 2 /0 ( 1 INSTALLER'S NAME&PHONE NO. M PR4Nq `3 C?_eoup-s SEPTIC TANK CAPACITY 1500 e p wC., Liu sT•) LEACHING FACILITY:(type) I a,4'X ASS S pmNeSS (size) NO.OF BEDROOMS 3 - a0 57%e_N(X 1 to H-Xe t�% -CAP XWF►k..J a4A-T5 OWNER c\ PERMIT DATE: 2-1 q _ COMPLIANCE DATE: 2 -Z - 10 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) P Feet FURNISHED BY M f)?,hJ Y "6AZQQu3S d�aT 'Poet RED- /�. 13,5 31 Town of Barnstable P# 3� Department of Regulatory Services r , Public Health Division Date ( v Rim& �fD MAt A�� 200 Main Street,Hyannis MA 02601 Date Scheduled 411 D Time-!�=F—M Fee Pd. f Soil uitability Assessment for Sewage isposal Performed By: Witnessed By: VI't steaLo LOCATION& GENERAL INFORMATION Location Address Owner's Name Address J Assessor's Map/Parcel /Q0/0/j Engineer's Name NEW CONSTRUCTION REPAIR ✓ Telephone# / 9 S Land Use 1Z"d`P 0_C✓N Slopes(%) b 370 Surface Stones AJc <',�/ Distances from: Open Water Body Possible Wet Area _ -I--_ft Drinking Water Well ft Drainage Way, ft Property Line _ ! ft Other aft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 1 'sue lcoSr, 7,a.� Parent material(geologic) 'l .) V Depth to Bedrock A 1-1cl- Depth to Groundwater. Standing Water in Hole: ���a-b , Weeping from Pit FAce Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: - __— in., Depth to soil mottles: in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adl.factor— Adj.Groundwater lAvel PERCOLATION TEST Ditte CR,11 Time l o�op Pm Observation � - - --- a Hole# Time at 9" -)- s- Depth of Perc �� Time at 6" Start Pre-soak Time @ .® Time(9"•6") & rtl i n t End Pre-soak �.0 Rate MinJlnch L Site Suitability Assessment: Site Passed I Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the, Barnstable Conservation Division at least one (1) week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture" Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency, v LA;t'�� 0 d2y� C a DEEP OBSERVATION HOLE LOG Hole#_ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) ;?.Sy Lomc6*167a DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel w DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consist ra I Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No Yes Within 100 year flood boundary Nm_ Yes .� Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious 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?____4L Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environric o an at the above analysis was performed by me consistent with the required training, xpa er ce escribed in 310 CMR 15.017. Signature Date C Q:\.SEpTlC\PERCFORM.DOC Page 1 of 2 TOWN OF BA LOCATION 48 Lq+ce s►M -D Qw E VILLAGE. : 1 S ASSESS INSTALLER'S NAME&PHONE NO. A SEPTIC TANK CAPACITY I S O0c LEACHING FACILITY: (type) 11 AS` NO. OF BEDROOMS OWNER ?ATe-\Caf+ w�sW�•a� PERMIT DATE: Z T CI ' Zj COl Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom Private Water Supply Well and Leaching Facility(If ar site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetland 300 feet of leaching facility) FURNISHED BY �'I f ►J N 6 APP-C tr1 crLa https://itsgldb.town.bamstable.ma.us:8431/Home/ShowAsbuilt?mp=102011&sq=3 4/23/2020 Page 2 of 2 sf' V V https:Hitsgldb.town.bamstable.ma.us:8431/Home/ShowAsbuilt?mp=102011&sq=3 4/23/2020 Town of Barnstable OF1HE T � o Regulatory Services Thomas F. Geiler, Director + BARNSTABLE, 9�A MASS, ��� Public Health Division TF0 e"pg a Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 2- 013 — 1 p Designer: Shay Environmental Services, Inc. Installer: Address: P.O. Box 627 Address: WeaY F�Amosta rtwr East Falmouth, MA 02536 m� H�--(�� On ' ( �'�� Mczcla�v, ��CiS\O�S was issued a permit to install a (date) (i staller) septic system at 4B Lr�KG z>F_ !7b?�S€) NA ,�`�\\5 based on a design drawn by (address) Shay Environmental Services, Inc. dated (designer) zX 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. I 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. _. _;ate TN� MgSS a F CARMEN (Installer's Signatur E. U .: .SHAY No. 1181 'ip GIs S F� esigner's Signature) (Affix Desi p 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:Health/Septic/Designer Certification Form No. Q Fee ©� THE COMIAONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -'TOWN OF BARNSTABLE, MASSACHUSETTS es 01ppIicatiou for &,gpotal *pgtemc Cow6tructiott permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑ Complete SystemeXindividual Components Location Address or Lot No. 48 b;cEst OE -_N?W ' Owner's Nam ddress,and Tel.No. M,1�1 11 s ��c,C V,�Ztv\ Assessor's Map/Parcel Installer's Name,Address,and Tel.No. q 2 �to Designer's Name,Address and Tel.No. Mcnnc� c` 5 Ccfn 4k�9 Type of Building: ..ll Dwelling No. of Bedrooms Lot Size 1 DSO sq. ft. Garbage Grinder (N A Other Type of Building S No.of Persons Showers( Vj-Cafeteria( +� Other Fixtures Design Flow(min.required) TV �j� gpd Design flow provided gpd Plan Date OL- - \Q Number of sheets i Revision Date '-- Title Size of Septic Tank SMCn\ e?6S7 Type of S.A.S. Description of Soil �� �_Tl� Nature of Repairs or Alterations(Answer when applicable) C;Zle A-6 CA M 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 Heal Signed Date Application Approved by 21h p Date 2 — Application Disapproved by: Date for the following reasons Permit No. 2® t u -0 y& _ Date lssued No. V !O O�D i x.. Fee P 10 TH OF MASSACHUSETTS Entered in computer: / Jj THE COMONWAL p PUBLIC HEALTH DIVISION J TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Di!5pogal *?stem Construction Permit Application for a Permit to Construct( ) Repair Upgrade( )r Abandon(�) El Complete SystemXlndividual Components Location Address or Lot No. 4 g LgicES+OE Owner's Nam"dress,and Tel.No. i Assessor's Map/Parcel �oZ 1 SGMp Installer's Name,Address,and Tel.No. � I b Designer's Name,Address and Tel.No. CG n M Gnn� cr;�s Type of Building: ' ''77 Dwelling No.of Bedrooms Lot Size , U00 sq.ft. Garbage Grinder (NIf1 r Other Type of Building `` syy t No.of Persons 3 Showers( K� Cafeteria( ✓j Other Fixtures t.L:l1 a'�Z k -�(^ v. to k ( •,�X�C��4 Design Flow min.required)_ J d Desi n flow provided ���. oZ P, gpd g ( �� gpd g Plan Date a`1 �'' 1 Cj Number of sheets c^ Revision Date Title Size of Septic Tank (,Q C,c,\ p�(�S� Type of S.A.S. Description of Soilr , p\� Nature of Repairs or Alterations(Answer when applicable) f At cs\CX\ r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in t, accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed r { Date Application Approved by ,R F Date i2 Application Disapproved by: Date for the following reasons ' Permit No. ri (U - 0�/% Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (x) Upgraded ( ) Abandoned( )b S y at 4BLA E 5 M• �t has been constructerd in accordance 0 0 — t with the provisions of Title 5 and the for Disposal System � rt S em Construction p p y o PermrtNo. � �/A dated 2-/�1-/D. Installer Designer #bedrooms Approved design flow O gpd The issuance of this permij shall not be construed as a guarantee that the system w`,l fun lion as designed. Date �J?3 1!L Inspector y No. `�3 fU " v."?� Fee 1L•�. - : . _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS x1h6po.5al *paem Construction Permit Permission is hereby granted to Construct ( ) Repair Upgrade ( ) Abandon ( ) System located at qt� L,-)<.+S+DE -3D2\VE i`\f1CZS�bt�S Mi ��S .-dn—das described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions./Provided: Construction m st be completed within three years of the date of Hits perms . / Date ��� /,�� • Approved by � I kjyP TRANS. NO.: Z CITY/TOWN: ��,�5 �;� APPLICANT: C, ADDRESS: �t�`� �:� '`'�!CRE2• . DESIGN FLOW: L gpd REVIEWED BY: DATE: N/A OK NO GENERAL K Y Legal boundaries denoted [310 CMR 15.220(4)(a)] Street, Lot, tax parcel number and lot number noted on plan [310 CMR 15.220(4)(u)] Locus Provided [310 CMR 15.2204(t)] Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for components) [310 CMR 15.220(4)] Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for upgrades]- i not, a variance is required [310 CMR 15.412(4)] Location of impervious surfaces (driveways, parking areas etc.) [310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR 15.220(4)(c)] Location and dimensions of system components and reserve areas. [310 CMR 15.220(4)(e)] E, System Calculations [310 CMR 15.220(4)(0] daily flow septic tank capacity (required and provided) soil absorption system (required and provided) v whether system designed for garbage grinder North arrow [310 CMR 15.220(4)(g)] Existing and proposed contours [310 CMR 15.220(4)(g)] Location and log of deep observation holes (existing grade el. on each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h) and (0] Location and date of percolation tests (performed at proper j elevation?) [310 CMR 15.220(4)(1)] Percolation test results match loading rate? [310 CMR 15.242] Certification statement by Soil Evaluator [310 CMR 15.220(4)0)] Observed and Adjusted groundwater (method for adjustment / given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)] Address -/4+_)' Sheet 1 of 7 N/A OK NO Location of every water supply, public and private, [31.0 CMR 15.220(4)(k)] within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply within 250 feet of the proposed system location in the case L within 150 feet of the proposed system location in the case of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins located within 50 ft. [310 CMR 15.220(4)(1)] Water lines and other subsurface utilities located [310 CMR 15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[1]) Profile of system showing invert elevations of all system components and the bottom of the SAS [310 CMR 15.220(4)(o)] Stamp of designer [310 CMR 15.220(1) and 310 CMR 15.220(2)] ✓ Stamp of Registered Land Surveyor (required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] Test Holes adequate (two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2) or as approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] Test hole adequate to demonstrate four feet of suitable material? / [310 CMR 15.103(4)] �✓ Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.103(3)] Benclunark within 50-75' of system [310 CMR 15.220(4)(q)] Materials specifications noted? [various sections of 310 CMR / 15.000] System components not > 36" deep (unles .Local Upgrad f Approval LUA requested) [310 CMR 15.405(1 Address A6 Lr�``'�L \�� 1 ��� �� 1�� Sheet 2 of 7 N/A. OK NO Size OK? [310 CMR 15.223(1)] 1/ Inlet tee located ten inches below flow line [310 CMR 15.227(6)] r. Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR 15.227(6)] Outlet tee with gas baffle or approved filter [310 CMR. 15.227(4)] Note regarding installation on stable compacted base [310 CMR 15.228(1)] Separation between inlet and outlet tees (no less than liquid depth) [310 CMR 15.227(2)] Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5)) or pennitted for upgrades under LUA [310 CMR 15.405(1)(k)] Minimum cover 9" (Tanks buried more than 9" must have risers ✓ on all openings and on the d-box) [310 CMR 15.2228(1) and 310 CMR. 15.232(3)(f)] Three access covers (inlet and outlet must be 20" or greater) - middle access at least 8" (by 7/07) [310 CMR 15.228(2)] Access to within 6 " of grade - one port for systems<I 000gpd, two for systems >1000 gpd [310 CMR 15.228(2)] v All at-grade covers secured to unauthorized access? [310 CMR 15.228(2)] > 10 ft from-building-foundation [310 CMR 15.211(1)] F Buoyancy calculation Required/Done [310 CMR 15.221(8)] H-20 Where appropriate? [310 CMR 15.226(3)] tZ Setbacks from resources [310 CMR 15.211] Multi Comp-11 artrnenxt Tank `s W Required when other than single-family dwelling or flow>1000 gpd [310 CMR 15.223(1)(b)] First compartment 200% daily flow; Second compartment 100% LIZ daily flow [310 CMR 15.224(2) and (3)] "U" pipe through or over baffle, outlet of each compartment with gas baffle or approved filter [310 CMR 15.224(4)] Address Sheet 3 of 7 N/A OK NO BiJTLDIN`G SEWERY" D OTH'�R PIPING x Located at least ten feet from any water line? [310 CMR 15.222(2)] V Disposal piping at least 18" below water line (when water and sewer cross, see 310 CMR 15.211(1)[1]) V Cleanouts required/provided ? [310 CMR 15.222(8)] Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable [310 CMR 15.222(6)] Proper pitch on all runs? (.005 within gravity-distributed trenches and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] Siphon problem/ (leachfield below pump chamber) Endcaps or vent manifold specified? Size and orientation of discharge holes specified? (not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe j types allowed) DTSTIIlg?UTTONBOXb; Stable compacted base [31.0 CMR 15.221(2) and 31.0 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a)] Riser if deeper than 9" [310 CMR 15.232(3)(0] Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum sump 6" [310 CMR15.232(3)(e)] Watertight cover if<2000gpd); waterproof manhole if>2000gpd [310 CMR 15.232(3)(d)] y PUMP Capacity(emergency storage above working=design flow)? [310 CMR 231(2)] Proper setbacks [310 CMR 15.211 (same as septic tanks)] Watertight 20-in minium access manhole at least 20" MUST BE TO GRADE [310 CMR 15.231(5)] Service components accessible (not too deep with piping, disconnects accessible) Alarm floats - alarm on circuit separate from pumps specified? 4/ Exceeds two units must have two pumps operating in lead-lag �- mode. [310 CMR 15.231(6) and (8)] Stable Compacted Base [310 CMR 15.221(2)] Buoyancy calculations needed ? Provided? [310 CMR 15.221(8)] Address AT �����` �C��' �"� �� 1V5 Sheet 4 of 7 w N/A OK NO SOIL AB'SORPT30N SYSTEM 81- .(SA ),GENEWon Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240(1)] Required separation to groundwater? [310 CMR 15.212)] Aggregate specified as double washed [310 CMR 15.247(2)] System Venting required/provided? (system under driveway or V >36" deep) [310 CMR 15.241] Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] Breakout requirements met? (No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] CALLERIE`S,PfITS,CHAMB�ERS;3J 0 CMR 75'253' � �° `"'� z Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR 15.253(6)] Each structure with one inspection manhole (if>2000 gpd must be to grade) [310 CMR 15.253(2)] Aggregate I' minimum- 4' maximum. [310 CMR 15.253(1)(b)] 2' sidewall credit maximum [310 CMR 15.253(1)(a)] s! In bed configuration, inlet every 40 sq. ft. [310 CMR 1.5.253(6)] TRENCHES�310``CMR 15 251 � fl r Width 2' minimum 3'maximum [310 CMR 15.251(1)(b)] t/ 100 feet - maximum length [310 CMR 15.251(1)(a)] Minimum separation 2x effective depth or width whichever greater (3x if reserve between trenches) [310 CMR 251(1)(d)] Situated along contours [310 CMR 15.251(2)] t/ Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document] BED SAS (Maxiri=um5size of bed orfield 5000gpd) `' #Ya minimum 2 distribution lines [310 CMR 15.252(2)(a)] p Maximum separation between lines 6' [310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6" minimum, 12" maximum. [310 CMR 15.252(2)(g)] Separation between beds 10'minimum. [310 CMR 15.252(2)(f)] - Bottom area used in calculations only [310 CMR 15.252(2)(1)] Address 1 Sheet 5 of 7 DLDTH PLhhAN{TNVO)LV1✓ h �b A N Pressure Dosed System ? Provided pump and piping calculations as required [310 CMR 15.220(4)(r)] Pressure dosing required on all systems >2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and I/A ,Remedial Use Approvals] If used in gravelless system - make sure jet is directed as not to scour soil interface [Guidance Document] Inspections once per year (systems< 2000 gpd) or quarterly (>2000gpd) good to note on plan [310 CMR 15.254(2)(d)] Construction in fill - Did the plan specify that the fill shall meet the specification of 310 CMR 15.255(3)? Impervious barrier and/or retaining wall ? [Guidance Document] Irnpervious barrier installation must be supervised by designer [310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer [310 CP✓IR 15.255(2)(a)] Side slope not exceed 3:1 ? [310 CMR 15.255(2)] of Breakout requirements met? [310 CMR 15.252(2) and Guidance Document] At least 5 ft. from impervious barrier to edge of SAS (10 ft. v' recommended) [310 CMR 15.255 (2)(e)] Grau�lless S stern /rI/A x i�/) YOYaI�etterS "' } ¢ .l'�. LVJ= b. n'Z' s.v.r 'ts t', g YCheck DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scour soil interface 1/ Altrn"afiv Septic System [�T/Ai Approval Letter]„ Mv " . Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for V/ perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant submitted a copy of a maintenance Are the variances listed on the plan ? [310 CMR 15�.220 (4)(q)] V RLS Stamp necessary on plan if a component is within five feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed - [Refer to 310 CMR 15.414] Address Sheet 6 of 7 N/A OK NO Nitrogen,S�erisrtzue Ar eas �r `� �� Is the system in a Designated Nitrogen Sensitive Are .(Zone Mfor a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well ? [310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR 15.216(l)] Pumping to septic tank ? [ 310 CMR 15.229] Shared System [310 CMR 15.290] V Address Sheet 7 of 7 FRIEDLINE& CARTER ADJUSTMENT, INC. 436 Main Street, P. O. Box 338 Hyannis, Massachusetts 02601 Tel. (508) 771-3232 SEP 3 200 FAX (508) 790-2344 Tow 2 N 0r &ALTf TO: ( ) Building Commissioner or Inspector of Buildings ` ' ( ) Board of Health or Board of Selectmen O Fire Department TOWN OF Marstons Mills TOWN HALL MA RE: Insured: WASHINGTON, Cheryl A. Property Address: 48 Lakeside Drive Marstons Mills, MA Policy Number: HP307182 Type of Loss: Water Date of Loss: 9/7/2002 File#: 94440 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. General Laws, Chapter 143, Section 6 to be applicable. If any notice under MGL, Ch. 139, Sec. 3B is appropriate, please direct it to the attention of this writer and include a reference to the captioned insured, location, policy number, date of loss and file number. On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by First Class Mail. N. LAGUE Adjuster 9/10/2002 TOWN OF P"ARNSTABLE LOCATION SEWAGE # VILLAGE . A�k/5,124L6 �'Lll//S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 11�J! J C�� ` 7��l�✓�P� SEPTIC TANK CAPACITY /S;Jy &L LEACHING FACILITY: (type).X;Xt/n ,13 `�',r�(size) /d'X 30'/vZ NO.OF BEDROOMS BUILDER 0R0� PERMTTDATE: 8Z /�� COMPLIANCE DATE: 53 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �� Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Rto4 t GJo �b 3 o" A a,/a ev poNfi � - No. .S Yo '�°', ., Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYication for Mi-opogal *pgtem Construction i3ermit Application for a Permit to Construct( )Repair(/Upgrade( )Abandon( ) ❑Complete System �dividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel /5 S Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 7/-9�3ff Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(/to Other Type of BuildingGe- No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 33e gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /ODG 9a l ak'b&42 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 7/,t-le 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 b thi Bo d f Health. / Signed Date Application Approved by Date Jq1Z Application Disapproved for the following reasons Permit No. �!�':� Date Issued Y_ Z 7 No. ,d.' � 1( � Fee �. THE COMMONWEALTH OF MASSACHUSETTS' Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS ,.Yes 0[ppricatiou for Migpool *pgtem CotYgtructiou Permit Application for a Permit to Construct( )Repair(1/)Upgrade( )Abandon( ) El Complete System elndividual Components Location Address or Lot No. [J¢ 1eslp Owner's Name,jddress and Tel.No. Assessor's Map/Parcel Installer' Name,Address,and Tel.No. (Designer's Name,Address and Tel'.No. Type of Building: Dweelling-"�` No.of Bedrooms Lot Size sq.ft. Garbage Grinder r Other Type of Building No.of Persons Showers( Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow .33a gallons. Plan Date Number of sheets Revision Date Title_. * Size of Septic Tank �Type of S.A.S. X BLS X Z d a Description~of--Soil _ Nature of Repairs or Alterations(Answer when applicable) - R 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 Compliatl nce has Si Signed issued th' B f Healt 8/1 /�g g Date Application Approved by Date 9 Z Application Disapproved for the following reasons Permit No. =S� Date Issued g Z 7Z9,F THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that�he On;tsite Se e Disposal System Constructed( )Repaired(Upgraded( ) Abandoned )by at y �O S� 1, �1S70�1s /LJi'/S has been constructe in a cordance with the provisions of Title 5 and the for Disposal System Construction Permit No. '7 --TV dated 7 Z 7 , Installer Designer The issuance of this 4t sh �nl bekonstrued as a guarantee that thus .11 unnc 'on s dgsit ned. Afa/wl/ Date p ' ! g Inspecg �— S_.S 0 —/QZ4 ^ D`I ——Fee 5V, ------------------ — No. �C7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migpogaf *p5tem Conelruction Permit Permission is hereby anted o Construct( )R�`air(; )Upgrade( )Abandon( ) System located 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:Constructio must�e completed within three years of the date of this 't. � , Date: Obi z 7 J' Approved by ,_� r h 7 � > 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) 1, Aj,e/`1" i j AfAl 1�hereby certify that the application for disposal works construction permit signed by me dated g�2Sl�� , concerning the property located at �G�i/ �'�' /� meets all of the following criteria: /There are no wetlands located within 100 feet of the proposed leaching facility Y ere are no private wells within I-40 feet of the proposed septic system ?There is no increase in flow and/or change in use proposed There are no variances requested or needed. ° If the proposed leaching facility will be located within =50 feet of anv wetlands. the bottom of the proposed leaching facility will w be located less than tourteen I lal feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) d / B)Observed Groundwater Table Elevation (according to Health Division well map) co e�.SIGNED DATE: Y-7/Zv�l LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder.art l M/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT ENGINEERED PLANS) 1 hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at mess all of the . following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility i . There are no private wells within 150 feet of the proposed septic system . There is no increase jn flow and/or:hange jn use proposed . There are no variances requested or needed. • If the proposed leaching faciiicv wjil a located within:50 feet of any wetlands.the bonom of the proposed leaching facility will I14t�e located less than fourteen(.I-')feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division weil map) SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folds:eat r AA i .M t t-"z � I I� II 1 O O - - - Gi Z t LIO LF d J6 30' p �oOr t TOWN OF BARNSTABLE f LOCATION _7 L4��c�5���—° �� SEWAGE # O VILLAGE_A41151e//.f .��/�/ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /Sba &L LEACHING FACILITY: (type)y�clft Lis CZA (size) i_v X 3o' X NO.OF BEDROOMS 3 L BUILDER 0 0 G�lf,5 1111Z 7?/I PERMTTDATE: �/Z 1747GX COMPLIANCE DATE: J $ Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �f 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 9 DATE:11.2A195 PROPERTY 'ADDRESS:_48 Lakeside' Drive . Marstons Mills Mass . On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . Two 1000 gallon leaching pits, 6 ' x7 ' _ Based on my Intention, I certify the following conditions: R�c�ivEO 1 . This is not a title five septic system. JUL 2 8 1995 2 . The sewage .system is in proper working order mo at the present time . Oman w c e � 9 SIGNATURr-: Name:—J LR.Macomber_Jr__ Company: J_P_Macpmber &—Son!rInc Address: Box 66 Ceilte,r,vLll.e ,M�sl'sJ,_ �02,i3�211.1 ;:...� ..( C' .�. Phone: 508_775_3338__�_---- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY � s JOSEPH P. MACOMBER & SON, INC. Ton ics-Cesspools-Leechfields Pumped & Installed I-11wn Sewer Connections P.O. BOX 66 Centerville, MA 02632-0066 775-3338 775-6412 _ yr; J CT'^SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION Address :,f r-c,perty 48 Lakeside Drive Marstons Mills ,Mass . , Owner's name Leo Nuwnari Date of Lion 7/24/95 PART A CHECKLIST Check if the following have been done: ,Pumping information was requested of the owner, occupant, and Board of Health. V/ 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. As built plans have been obtained and examined. Note if they are not available with N/A. : The facility or dwelling was inspected for signs of .sewage back-up. The site was inspected for signs of breakout. All system .components, excluding the SAS, have been located on the site. The manholes were uncovered, opened, and the interior of the 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 SAS on the site has been determined based on existing information or approximated by non-intrusive methods. ZThe facility owner (and occupants, if di.fferent from owner) were provided with information on the proper maintenance ,.of SSDS. Recommendations 1 . If any exterior changes are made; The sewage system will have to be brought up to, a title five septic system. 2 . D'o not use a garbage disposal . i g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ` SYSTEM INFORMATION /) FLOW CONDITIONS If residential number of bedrooms number of current residents garbage grinder, yes or no' e.s laundry connected to system, yes or no VQ seasonal use, 'yes or no If nonresidential, calculated flow: Water meter readings, if available: 1993=101 , 000 gallons =GPD=276. 71 1994=121 , 000 gallons=GPD=331 . 50 Vacant UNK Last date of occupancy GENERAL INFORMATION Pumping records and source of information: } L NO System pumped as part of inspection, yes or noBoth pits dry if yes, volume pumped Reason for pumping: Both leaching pits dry. Type of system N6 Septic tank/distribution box/soil absorption system NO Single cesspool -NO Overflow cesspool No Privy NO Shared system (yes or no) (if yes, attach previous inspection records, if any) ' Other (explain) 2-Precast 1000 gallon leaching pits. Approximate age of all components. Date installed, if known. S.ource of information: 20 years -------------- NO Sewage odors detected when arriving at the site, yes or no • E ' s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: NO (locate on site plan) depth below grade: NO material of construction: concrete metal FRP other(explain dimensions: NONE XXIX sludge depth XXXX distance from top of sludge to bottom of outlet tee or baffle XXXX scum thickness XXXX distance from top of scum to top of outlet tee or baffle XXXX distance from bottom of scum to bottom of outlet tee or baffle 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, recommendations for repairs, etc. ) NONE DISTRIBUTION BOX: _ (locate on site plan) NONE depth of liquid level above outlet invert Comments: .(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) NONE PUMP CHAMBER: No (locate on site plan) MON$ pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc. ) NONF 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INI'ORHATION continued SOIL ABSORPTION SYSTEM (SAS) : XXXX ( locate on site plan, if possible ; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number 7_6 ' Y7 ' precgRt leaching leaching chambers and number Titg Both pits are dry. leaching galleries and number House is vacant . leaching trenches , number, length leaching fields, number, dimensions overflow cesspool , number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) Sand & Gravel ;no signs of hydraulic failure or ponding . All the vegetation normal ; system is structurally sound . No repaitrs nee Pump main leach pit -once every two years. CESSPOOLS (locate on site plan) : number and configuration NONE 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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) N-G1-N E PRIVY : (locate on site plan) materials of construction NO-NE dimensions depth of solids Comments: (note condition of soil , signs of hydraulic failure, level of 'ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) . NONE 4 � 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L.SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' Town Water a\ e s 17 e oT DEPTH TO GROUNDWATER 201+ depth to groundwater ' method 'of determination or approximation: Test hole 14 ' ne... water . _. ••�-rrzrs�irrs-c—�vex r..-crss::arsasa.•as-�.a-ss-3s -�c:�rsrs»_ _ _ —va�arz-t�:r.�-a��rcr--.1 TOWN OF Barnstable BOARD OF HEALTH i SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION �RT'RIIL'CJP}i�LirT R1IlRTleRL'a • 'iGSI�ZTOIImiSiTi;Tii�IIi311'1. SiIC itR'eCSfRTT.:Ie't4SlJL�JJaRritiT.!Y.�Ztil" :� —TAPE OR PRINT CI.EARLY— PROPERTY INSPECTED STREET ADDRUS __"r+8 Lakeside- Drive Marstons Mills ,Mass . ASSESSORS MAP, BLOCK AND PARCEL # 1Oo 'Ofl OWNER' s NAMELeo_ Nuwnari PART D - CERTIFICATION NAME OF INSPECTOR J.P.Macomber Jr. COMPANY NAME J.P.Macomber & Son Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632-0066 Street Town or City State ZIP COMPANY TELEPHONE (508 ) 175 - 3338 FAX ( 508 ) 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate, and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : XXXX System PASSED The inspection which I have conducted has not found any information which indicates that� the system fails, to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . t Inspector Signature ' Date 7 (9& g5 One copy of this c tification must pr�.­' :.ded to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the in�,:}ection FAILED, the owner or operat ,: .;hall u1-= rade the system within one of date f he inspection, e-ss al I,J toed c,; iequi. ok.t; .,rwise :rovi ;i 310 �' 15 . 305 . doc Water ...�� Coris'ervation ^�` SAVE Tips ME! , . CHECK FOR LEAKS Water Loss in Gallons Due to Leaks Leak this Loss Per Day . Loss Per Month Size 120 3,600 • 360 10,800 • 693 , 20,790 1,200 36,000 • 1,920 57,600 3,096• 92,880 0 4,296 .128,980 ® 6,640 199,200 6,9.84 200,520 8,424 252,720 9,888 296,640 ® 11,324 339,720 12,720 381.600 14,952 448,560 `.0 i iiri iC weaea-'r. lei MaCicC ExecLive Office cf Envrcnmemc, Department of Environmentai Protection ' I Water Pollution Conmrol Tecnrncer Asswcnce anti Training Sections YAW&m F.Wsid 6o.wnw Trudy Co:s Seawry,EOEA Thomas&Powws Aanq Oorm m"w 06/12/95 ATTN: Joseph P. Macomber, Jr. Joseph Macomber and Son PO Box 66 Centerville, MA 02632- Dear Joseph P. Macomber, Jr. , I am pleased to inform you that you have attended training, met the experience qualifications, and have passed the Title 5 System Inspector exam, pursuant to 310 CMR 15 . 340 . The passing grade for the exam was 39/52 or 75% . This , is an official notification that you are a Certified Department of Environmental Protection System Inspector pursuant to 310 CMR 15 . 340 . You will receive a System Inspector certificate at a later .date. If you have any futher questions, please write to me at the following address: Kimball Simpson D.E.P. Training Center 50 Route 20 Millbury, MA 01527 Thank you very much for your time and consideration in this matter. Sincerely, Kimball T. Simpson, DEP Training Center Director [2405) Roo,; • KQ►bury, MA 01527 0 FAX 508.755-9= • `—Pnons 508-756-7281 3-24" DIAM, ACCESS MANHOLES VENT PIPE (® Least 24 inches tall) � � �.,,�4 rrX��"a..•^ .`^�� � � �� � *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. Schedule 4d PVC w/Charcoal Odor Filter `' -,� t 10' min. from '. ESTABLISHED VEGETATIVE COVER ` acJ' ra Existing Foundation house to septic tank \ TOP OF FOUNDATION = ELEV, 100.00 P within 6 in. of finished grade INLET Septic tank covers must be D-BOX cover must be i within 6 in. of finished grade INLET r r r Grade over Septic Tank 99.50 Grade over D-Box-99.50 rode over SAS - 99.50 a . i' .iACCESSe&€sslete irYaaaepR B1J sTtst 1 E R �.THCOVE S FOR THE SEPTIC '_:--SP C E 1,`ti• BACKFILL WITH CLEAN SANDs r � . Y. W 1, M1 N ISTR BUTION BOX A D I 0 AND LEACHING COMPONENT � r PONENT NATIVE OR PERC SAND .�rp�""'•-,.„: � ,� , r H ALL BE RAISED T WITHIN e T.' S0 I 6" OF ^r r. E$ 0. HOLE H 10 6 � 4.50 02 T N 9 '-'�.F LEVA 10 •, �r:P 0 UNIT E FINISHED GRADE. a= r I D l � Cover G X Maximum ova DIST. 0 3' M m i•: ,r,. 0 01 or Greater N PORT TO BE ;•. ,,, '. ^.,` ." ,., '.eater 4 PVC (CAPPED) INSPECTION •' ° • '°" _ EXIST. :^ '•• " "� •' STEEL R CONCRETE INSTALL TUF TITE GAS BAFFLES OR EQUALS INSTALLED AND TO BE WITHIN 6 OF GRADE REINFORCED ,PRECAST i PIPE +n 1500 GAL . S= o.o INV. ELEVATION - 94.00 .1; `'+'•• ON ALL OUTLET TEE ENDS EXIST. O N O 50^ 1" per foot w.' r PLAN VIEW FROM EXIST, FOUNDATION co SEPTIC TANK o co M v a' SAS TO BE COVERED . _ 0, p � 15' WITH FILTER FABRIC /-3-24'REMOVABLE COVERS t ,` S�•,, s CONCRETE FULL II H 10 II rn BOTTOM ELEVATION - 93.00 / ` y II j a) OJL t4.a �t,ar'14°t$ar•..y. �%" � °•'.`ems; ' tira;"'`.w y 6 in.of 3/4"-1 1/2" w compacted stone j y y rn 4 ROWS OF 4 UNITS AT 6.25'/UNIT+ 2 END CAPS 25.00' S' MIN ABOVE BOTTOM OF n min, clearance I 3' INLET' % c 34 6 34 INLET 8 min �2_-min. inlet to outlet g•min. TEST PIT OR GROUND WATER - ? SYSTEM PROFILE _ ,', EFF. TPIATH 12.70 EXISTING SUITABLE MATERIAL 14 OUTLET IIJJ GENERAL NOTES Y INLE Liquid Isval- 10•mM. 11 Bottom of Test Hole 1 Elev.= 87.50 GROUNDWATER NOT OBSERVED 5 -7• . --- L__ "•5' _7• 1. Contractor is responsible for Digsafe notification, VERIFICATION Not to Scale 6 in.of 3/4"-1 1/2" GROUNDWATER NOT OBSERVED 0 144' E :'•, 4'-0" min, and protection of all underground utilities and pipes. compacted atone c b� 6e.s"ele '`.' Liquid depth 2. The septic tank and distribution box shall be set NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE BOTTOM OF TP-1.: = 87.50 S❑IL ABS❑RPTI❑N SYSTEM (SECTI❑N) level on 6" of 3/4'-1 1/2" stone. ESHWT = NO GROUNDWATER OBSERVED 0144" HIGH CAPACITY INFILTATR❑R (H-20 L❑ADING)/ GE❑RGE ❑'BRIEN 3. Backfill should be clean sand or gravel with no stones over 3 m size. (OR EQUIVALENT) 10'-0 5' -6' 4. This system Is subject to inspection during installation NOTE: EFFECTIVE DEPTH OF INFILTRATOR IS 12" CROSS SECTION END-SECTION by Carmen E. Shay - Environmental Services, Inc. NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" 5. The contractor shall install this system in accordance with Title V of the Massachusetts state code, the approved plan TYPICAL 1500 GALLON SEPTIC TANK and Local Regulations. NOT TO SCALE 6. If, during installation the contractor encounters any soil conditions or site conditions that are different (H--10 LOADING) from those shown on the soil log or in our design installation must halt & immediate notification be made to Carmen E. Shay - Environmental Services, Inc. 7. No vehicle or heavy machinery shall drive over the PERCOLATION TEST septic system unless noted as H-20 septic components. 8. Install Tuf-rite gas baffles or equals on all outlet tee ends. Date of Percolation Test: February 16, 2010 9. All Distribution Lines shall be 4" diameter Sch. 40 NSF PVC pipes. Test Performed By: CARMEN E. SHAY, R,S., C.S.E. 10. All solid piping, tees & fittings shall be 4" diameter Results Witnessed By:DAVID STANTON - BARNSTABLE BOH EXCAVATOR: Shay Env. Svcs. Schedule 40 NSF PVC pipes with water tight joints. Percolation Rate: <2 MPI ® 42" Assumed 11. MUNICIPAL WATER IS AVAILABLE TO THE SITE and Surrounding Test Hole Test Hole Properties. No. 1 No. 2 DEPTH SOILS ELEV. DEPTH SOILS ELEV, 0 99.50 0 99.50 NOTE: THE PROPERTY LINES ARE APPROXIMATE AND Sandy Loam Sandy Loam COMPILED FROM THE PLAN BY GERALD A. MERCER, SURVEYOR 10 YR 3/2 10 YR 3/2 ENTITLED "PLAN OF LAND OF SAND SHORES IN M, MILLS,MA A, 99.00 0"-6" 99.00 DATED OCT. 1957 - BOOK 138 PAGE 25 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN Loamy Sand Loamy Sand IT SHOULD BE USED FOR NO PURPOSE OTHER THAN 10 YR 5/6 10 YR 5/6 THE SEPTIC SYSTEM INSTALLATION. 6"- 42" Be 96.00 6"- 42" Be 96.00 Med-Coarse Mod-Coarse Sand Sand NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE 2.5 Y 7/4 2.5 Y 7/4 FROM THE EXISTING LEACH TRENCH TO BE DISPOSED 42"- 144 CI 87.50 42"- 144 c, 87,50 OF AS PER BOARD OF HEALTH SPECIFICATIONS. EXISTING LEACH TRENCH TO BE PUMPED DRY & FILLED IN PLACE N/F CALVIN FULLER ASSESSORS MAP 102 PARCEL 011 ZONING - RESIDENTIAL Pere #1 Depth to Pere: 42" to 60" S 88D 18' 30" E TEST HOLE #2 Pere Rate= <2 MPI Assumed _ _ � NO Groundwater Observed 0144"A Ad 99_ ______-__---------_----- '---------ELEV=22- 12-yam --- �--99 NoUObserEved ESHWONE No WETLANDS ARE LOCATED WITHIN A 200' RADIUS I rrQ:a�- Pipe 1 OF:THE PRL�t} RTY TE D-Box ALL OUTLET PIPES FROM THE O 12.T DISTRIBUTION BOX SHALL BE ' SHED LOT #14 SET LEVEL FOR AT LEAST 2 FT. 12" CONCRETE COVER 11,000 Square Feet 6 - 5" OUTLET !.,Y„ 2'+ LEGEND KNOCKOUTS -15.5" OUTLET 12"I 12" INLET 88XO DENOTES PROPOSED o TEST HOLE #1 DECK ELEV'= 99.50 ® A+ ,,� ` 6° SPOT GRADE LOT ##15 00 _- , ., 2- DENOTES 104.46 DENOTES EXISTING LOT ##13 15.5" 4` - scH: 4o Te SPOT GRADE 1.75 Z PLAN--SECTION CROSS SECTION PL PROPERTY LINE PROJECT BENCH MARK TOP OF FOUNDATION EXISTING ELEV. = 100.00 (Assumed) 3 BEDROOM y a z o 6 HOLE DISTRIBUTION BOX -�- PROPOSED CONTOUR HOUSE -J o M NOT To SCALE 97- ,_ -.:._, - -97 EXISTING CONTOUR A 005 m O "A Design Calculations o O d' DEEP TEST HOLE & r______, �___-_- A PERCOLATION TEST LOCATION � I I 3 EXIST. 1 A 1500 GALLON Number of Bedrooms: 3 Equivalent to 330 Gal./Day ' SEPTIC TANK Garbage Grinder: No r* �� Leaching Capacity Proposed: 330 Gal./Day Minimum (Min, Per Title V) �----� FENCE I ---� --' I Septic Tank - 2 x 330 Gal./Day = 660 USE EXIST. 1,500 GAL. Septic Tank. o I solL ABSORPTION AREA: using percolation rate of <2 min./inch PRIVATE DRINKING WATER WELL I EXIST, I Bottom Area: 0.74 gal/sq. ft. x 472 sq. ft. = 349.28 gallons DRIVEWAY m m I Sidewall Area: NOT USED Providing: = 34928 gallons REVISIONS ,---------- ----- --- ----a---------- 99 ------T7a.-6tf I I S 88D 18' 30" E I I I Use: 4 ROWS OF 4-HIGH CAPACITY H-20 CHAMBER UNITS WITH NO NO. DATE: DEFINITION I % ; STONE FOR AN SAS HAVING TH DIM SIONS: 12 7 x 25 0 #1 2/22/10 Elevations/Typo I � _----____ ----------------_-_--_--_-- Bottom Area: (General Use Approval for 4.72 SF/LF of INFITRATOR --- - - - 4 UNITS + 2 'END CAPS per ROW = 25.0 FT 4 ROWS x 25.0 x 4.72 SF/LF = 472 T-4 E T-O� -D -FV-� DESIGN FLOW PROVIDED: 0.74(472 S.F.) 349.28 GPD L (40 FOOT RIGHT OF WAY) PREPARED FOR : PROPOSED SUBSURFACE SEWAGE DISPOSAL SYSTEM Bedroom o Bedroom OF m PATRICIA WASHINGTON #48 LAKESIDE DRIVE DEN utility MARSTONS MILLS, MA Roam #48 LAKESIDE DRIVE Lower Level MAR STO N S MILLS , MA PREPARED BY: �. C.�.�117�'N E. SHAY Living �� OF A. � 02360 Bedroom Room I 0 2 0 40 5 0 `, r �'NVIRONMENTAL SERVICES, INC. 111 THORNBERRY CIRCLE Dining Kitchen MASHPEE, MA 02649 {1 Room `\ i�P111r> ta 1d' w VARIANCE REQUESTED: SCALE: 1"=20' ' ` ` TEL/FAX : 508-539-7966 Upper Level 3 BR HOUSE FLOOR SCHEMATIC 1. REQUEST A VARIANCE TO INSTALL THE SYSTEM MORE THAN 3 FEET BELOW GRADE SCALE: 1 "=2O' DRAWN BY: C S DATE: FEB. 19 2010 A VENT PIPE HAS BEEN PROVIDED & H-20 SAS n:11 r ' (Description Provided By Owner) PROJECT#SD-1169 FILENAME: 1.16 i P. WG SHEET 1 OF 1