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HomeMy WebLinkAbout0068 LONG POND ROAD - Health 68. LOug MarstOiWNIII.Is A%= 01W2a{ ' I --- - -- -- -- -- { - TOWN OF BARNSTABLE � I LOCATION y �°1 d SEWAGE # ✓� �`�1 VILLAGE �V�c'Sfia+�S �l/1�1� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N0.�, %/ , AW SEPTIC TANK CAPACITY /Coo SF�PJ1 LEACHING FACILITY: (type) 21 (size) l000 S� NO. OF BEDROOMS -n BUILDER OR 'S� PERIvIITDATE: GONNIMCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Gt No. � Fee_L— f THE COMMONWEALTH OF MASSACHUSETTS Entered in compute Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIpp tratton for ;Dtzpoor *pftem Con!Mrurtton ndividual Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System Components Location Address or Lot No. to L o n El Poll O o A o Owner's Name,Address and Tel.No. J�larston5 W15 MA Fail COC io (01'1-173- "54 Assessor's Map/Parcel01 -l- opt t y 4 1)+i c Q 5�, Q u 1 n c y, �4,k Installer's Name,Address,and Tel.No. IDS-4-17-b L-13 Designer's Name,Address and Tel.No. Bober+ G�lfoy_ 13t8 Ekonua-lon 14 Teaberry WVI bores+-dale, IAA Type of Building: Q Dwelling Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow -gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed D Date Application Approved by Date D Application Disapproved for the following reasons Permit No. W GO Date Issued No. �' ( � — i 1 4 Fee Ud THE COMMONWEALTH OF'MASSACHUSETTS Entered in compu ' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pprication for ;igpozar 6potem Construction Permit Application for a Permit to Construct( j Repair( )Upgrade( )Abandon( ) El Complete System Individual Components Location Address or Lot No. to 9 U n CZ (�0 t l O 60 0 Owner's Name,Address and Tel.No. Alar510n5 4115 MA Cni I -i«`oGlo 1 Assessor's Map/Parcel �)1 ) 0�� 44 "i c A rj}I U u I n t.�/, �A A Installer's Name,Address,and Tel.No. U H 17-b(0 53 Designer's Name,Address and Tel.No. 130 ExCejun t ion ►`i TeCiberr., 1_ru Tvr e!5ic r-de QA Type of Building: hp ,-- n�k Dwelling Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title ` Size of Septic Tank � Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable).. _ t� [��?{�Ck t. rt1 P__n Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with,the provisions of Title 5 of the.Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health, - Signed Date I H U . Application Approved by ` �i.,•, U I Date V Irlo AppLcation Disapproved forihe following real nos r Permit No. dLv %0 Date Issued 8 /1 u f' THE COMMONWEALTH OF MASSACHUSETTS; BARNSTABLE, MASSACHUSETTS GJ� ov, Certificate of Compliance THIS IS TO CERTIFY, that the On-site SewagDisposal System Constructed( ).Repaired (✓)Upgraded( ) Abandoned( )by 1 E 1 r l U �'r` i 1 at (o S L v f1{--R �C)n i I rk _ has been constructed in accordance ! with the provisions of Title 5 and the for Disposal System Construction Permit No. �Oqy - y(Iv dated 91- aJ Installer -Rt).he r` i 6_-7 t I �(� k i Designer I� The issuance of this permit shall not be construed as a guarantee that the sy§tem wi•11 function as designed. k Date ls ) Inspector ` {✓ No. 2(,U� yW 1 "*Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1igpo!5a1 *pgtem Construction permit Permission is hereby granted to Construct( )Repair(✓)Upgrade( )Abandon( ) System located at b'9 L o n ra Pn f 1 c) P oo rl M n r 51 U,7 S /A I I 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:Constru don must be completed within three years of the date of this permit. Date: /, o Approved by / fi /'lip! XS' UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS Permit No.G-10 ' Sender: Please print your name, address, and ZIP+4 in this box • PUBLIC HEALTH DIVISION ' TOWN OF BARNSTA2,LE 200 MATNr STREET HYANI NIS, MASSACH USETT'S 0260 i iI I I I I .� f1�!!!SF1l it 11llit F!!!!MI if!1311!!H!!?H 11111l2 1l!!!!7!!'!I . I • ' COMPLETE • 'COMPLETEF • I ■ Complete items 1,2,and 3.Also complete A. Signature. _ item 4 if Restricted Delivery is desired. ,���❑Agent I ■ Print your name and address on the reverse Addressee so that we can return the card to you. B. Recei by(Printed Name) C. Date of Delivery I ■ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: D. Is delivery address- fferent from item 1? Yes • -- ! If YES,enterr delivery•"address below: ❑No i wf , j Estate of Eleanor Martin 44 Utica Street • I Quinc y, MA 02169 3. Service Type I I ❑Certified Mail- ®Express Mail ❑ Registered ❑Return Receipt for Merchandise i ❑Insured Mail ❑C.O.D. j 4. Restricted Delivery?(Extra Fee) ❑Yes I 2. Article Number (transfer from service iabei) PS Form 3811,August 2001 Domestic Return Receipt 102595-02-M-1540 j • I 4 MPostage $ ® ` a2 Ln Certified Fee ��! CO " G �Jl Postmark Return Receipt Fee SE 1 2 2005 m (Endorsement Required) o P Restricted Delivery Fee 0 (Endorsement Required) \\\�Imo_ ff! O Total Postage&Fees . US< r ,--0 Sent To treet,.4pt. o S7 G� No.; -_e e#'------------------------------------------------- p CI'State,ZIP+4 :rya. _._rrr ' ) Certified Mail Provides: o A mailing receipt o A unique identifier f9r your mailpiece • A signature upon delivery o A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail or Priority Mail. o Certified Mail is not available for any class of international mail. n NO INSURANCE COVERAGE IS'PROVIDED with Certified Mail. For' valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,May 2000(Reverse) 102595-99-M-2087 t 1 t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a d DEPARTMENT OF ENVIRONMENTAL PROTECTION c ° .� 2 TITLE 5 0 M OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSME TS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 68 Long Pond Road Marstons Mills MA 02648 Owner's Name: Estate of Eleanor Martin Owner's Address: 44 Utica Street S Z !Fv Quincy MA 02169 Date of Inspection: July 18,2005 Job tt 05-208 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my 9011111N// training and experience in the proper function and maintenance of on site sewage disposal systems. I am a OF M i approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes m _X_ Conditionally Passes Needs Further Evaluatio by the Loc Approving Authority 0— �IN�LL. Fail ��ii��� Inspector's Signature: Date: July 18, 2005 �i����ll1��ltll�����`` The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Distribution box is deteriorated and leaking,needs to be replaced. High stains in leaching pit indicate pit has 8" effective leaching. ****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. Title 5 Inspection Form 6/15/2000 page 1 'Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 68 Long Pond Road Marstons Mills MA 02648 Owner: Estate of Eleanor Martin Date of Inspection: July 18,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: _XX_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. _No_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 exfTltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: _Yes_ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed XX distribution box is leveled or replaced ND explain: *****Distribution box needs to be replaced,has excessive root infiltration and is leaking.**** _No_ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Titles C Tncnantinn Fnrm�/1 S/7MlT 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Long Pond Road Marstons Mills MA 02648 Owner: Estate of Eleanor Martin Date of Inspection: July 18,2005 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 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Tifla; incnantinn 17-4/1;/'MM 3 gage 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Long Pond Road Marstons Mills MA 02648 Owner: Estate of Eleanor Martin Date of Inspection: July 18,2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/�day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—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. T tlo G inennrtinn Fnrm �ii:i�nnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 68 Long Pond Road Marstons Mills MA 02648 Owner: Estate of Eleanor Martin Date of Inspection: July 18,2005 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 X Were any of the system components pumped out in the previous two weeks'? X Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS, located on site? 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: Yes no X Existing information. For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] I Title G inenartinn 17-4/1;/"n 1 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 68 Long Pond Road Marstons Mills MA 02648 Owner: Estate of Eleanor Martin Date of Inspection: July 18,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms):330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): - Sump pump(yes or no): No Last date of occupancy: End of May 2005 COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Pumped every two or three years. Source of information: Homeowner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Unknown Were sewage odors detected when arriving at the site(yes or no): No T;+10 G incno f;i 17—4i1'nnnn 6 'Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Long Pond Road Marstons Mills MA 02648 Owner: Estate of Eleanor Martin Date of Inspection: July 18,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: - Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: V Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8.5 long x 5.2 wide- 1000 Gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:28" Scum thickness: Trace Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Baffles in septic tank are clear and are intact Liquid level is at the bottom of outlet invert.Septic tank has no visible signs of cracks or leaks that were found at time of inspection. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): T41. C 1ncno tinn Pn 4/1 snnnn 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Long Pond Road Marstons Mills MA 02648 Owner: Estate of Eleanor Martin Date of Inspection: July 18,2005 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX if resent must be opened) (locate on site plan) DISTRI ( P Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Distribution box needs to be replaced to pass Title V inspection. Observed excessive root infiltration and box is leakinz PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): I T41.G Tncn-nf;n Pn 9i1 S»nnn 8 I Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Long Pond Road Marstons Mills MA 02648 Owner: Estate of Eleanor Martin Date of Inspection: July 18,2005 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: One 6 x 6 Leaching Pit leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Liguid level 18" 20" below invert High stains indicate 8"of effective leaching in pit. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials,of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Titla C Incnartinn P— 411 c171)n0 9 'Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Long Pond Road Marstons Mills MA 02648 Owner: Estate of Eleanor Martin Date of Inspection: July 18,2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Long Pond Road Driveway Water service Garage #68 30 14 53 50 67 68 Titles C Incnortinn Fnrm ail cnnnn to : 'P2ge 11 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Long Pond Road Marstons Mills MA 02648 Owner: Estate of Eleanor Martin Date of Inspection: July 18,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 30 feet Pease indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) X Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.55 and topo map shows property above el. 100. Titlo f Tncnartinn Gnrm 4/1 VI()1(1 I 1 LOCATION SEWAGE PE VNT�mv. VILLAGE I N S T A LER'S NAME i ADDRESS QUILDER OR OWNER SoAn► DATE PERMIT ISSUED DATE COMPLIANCE 1SS-UED �5 ,t It s� as T c No...g0...... ys '' FzS....3. .... .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... ...................OF........fi! ........................................................... ApplirFa#iou for Uti#wia1 Workii Tomitrurfilaaa Prrutit Application is hereby made for a Permit to Construct (/) or Repair ( ) an Individual Sewage Disposal System at: AY,57ows /.O n/6a �� ✓ZDI M14 v S 40� ---....-- ••--•----••............... .•--- �---•---• --- ------------•--------- -------- ......................................... Location-Address or Lot No. ...AFAQ. .. 1!. ?................................................... /, /'' �1�! -------1 ��0 ARIZ. _...t��/3 L Owner Address ------- zk t-f-&A...........................•--•----..... G . a�.� s�._!.. .���w�. .......... ...... 1.4 Installer AddressPq �t�0 may® Q Type of Building Size Lot____________________________Sq. feet Dwelling—No. of Bedrooms.............J�.._.._.......___..__.___.__..Expansion Attic ( ) Garbage Grinder 4-1( Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ................................. . W Design Flow..................55..................gallons per person per day. Total daily flow----------3��.................. llons. WSeptic Tank—Liquid capacity?�W _gallons Length.a..(a._... Width_'1A0_". Diametel#-/6 Depth&...V.. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. • Seepage Pit No---------- Diameter....... ----- Depth below inlet_.. _..... Total leaching area.. ..Q....sq. ft. z Other Distribution box ( � Dosing tank ( ) `" Percolation Test Results Performed by--------------------------------------------------------------------------n�-------_--.-•----------------- Date__... -r.g®...--.... aTest Pit No. 1_.G..Z..minutes per inch Depth of Test Pit------- ..... Depth to ground water.?Seq?'` .._. L?i Test Pit No. 2.-�--'Z-._minutes per inch Depth of Test Pit------- -- Depth to ground waterEh!C / b -----------•---•---------------------•--•--------•---------............-----.........--......-----..........----------------•............................... Description of Soil...... . ; . . _� ......_._.... . � � -------------------------------------------------------------U ..................................... ----..... a� i 1.2_.-.._ it M----�'� �'-` ---------------------------------------------------------------------------------------------- e U Nature of Repairs or Alterations—Answer when applicable.__.___......................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 1 i:' p 5 of the State Sanitary Code— The unde,- igned further agrees not to place the system in operation until a Certificate of Compliance has been is e by the o rd of health. / Sign -------• -• ---------------------• -•--�(� ate Application Approved By... C:..........t. '•--•-•------•-•------- --------1� �6y�gd Date Application Disapproved for the following reasons:................................................................................................................ -------------------•-----.....----•----•--•---••------•------------------••------•-••--••---•-------••--------- .......---......................................................................... Date PermitNo........................................................ Issued....................................................... Date No. .............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... .itl,....'................OF........ ...... - Appliration for Rapaiial Works Tnnitrurtinn ramit Application is hereby made for a Permit to Construct (V/) or Repair ( ) an Individual Sewage Disposal System at: 017 A" -•-•...:�.�?ry •-.�'!���� /Z , !�JfL•L. � .-- •----•----••-------•--••--� -----�..... .......................................... �" .. Location-Address or Lot No. .......................................... --�kl_...... -...441 ,. l�di,3 C Owner Address ••------------------------•------ Installer Address Type of Building Size Lot_900_�s_O._._..Sq. feet Dwelling—No. of Bedrooms........... ...........................Expansion Attic ( ) Garbage Grinder/Vo) '4 Other—Type of Building ............... No. of persons............................ Showers a g ------------- ----------P .......................................... ( ) — Cafeteria ( ) dOther fixtures ......................................: --•---••--•------------ --- --------------•---••--------•-•---............................... W Design Flow.................5.5..................gallons per person�,,,per day. Total daily flow......... .?____...............gallons. WSeptic Tank—Liquid capacit/9420..gallons Length,8._.6_.._.. Width'__/b_... Diameter' _ _".___ DepthK._2? /.. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter...._. Depth below inlet._w5r....:�•._...... Total leaching area_/.9....sq. ft. ZOther Distribution box (✓) Dosing tank ( ) Percolation Test Results Performed by.-____-_--_'._1.,>-_' � ----•--------------•----------•--••••--••--•--• Date.--------.._..-----•---•-••---..._-•--- a Test Pit No. L .. "___minutes per inch Depth of Test Pit-------- .... Depth to ground water IV-P^1.--_ -.-_ fZ Test Pit No. 2..=--.. ..minutes per inch Depth of Test Pit...___!?:.°.... Depth to ground waterer !74_ t� a ---•--------------------•---------•-•---•--•--•-----•-•---••--•-•---•-••......-••-•----•----•-••_-•-......................................................... O Description of Soil..--- _"_ .._...............................................� ........ x -------------------------------------------------------------•---- V ....--••-•-•-••-......-•----......_ ........ ........................ .~� `..�-----`--- ��e�.v'��a----------------------------•---•-----....-------------------------- U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------------------- -----------------------------------•----------------------------------------------..............-------------•-----------------------------------------•---------------•--------------------._......_._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'i p of the State Sanitary Code— e undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss b oard of health. Sign ....... . - . --- --•-- -----•---•-•------------ Zb-/5-`E ..................ApplicationApproved ------ / y Date Application Disapproved for the following reasons:................................................................................................................ --------------------------------------------------•----------...••--•--••------_..._ Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... "�./st/..........O F......., .! '?e!V.. �` �',��f.......................... TUrdifirtttr of fwuntplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (V) or Repaired ( ) bY..........r �x -� -- ----------------------------------------------------------------------------------------------------------------------------------------- ,�� Installer at. _ , l --- ------------------••------------------ �_ : ..--•--------------- has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----eL _-.51-S............... dated------------------------------.................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR ED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........... Z- /Z.----� .............. Inspector----, �44 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ ..........OF........ ?!'1. -c 4. ...................... r ! -- FEE..._._. ............ Ditipuual Work.5 TTklyaamitrnr#uan �ernti r Permission is hereby granted-------! `' = ......... to Construct ( ��or Repair ( ) an Indio&al Sewage Dispo=sal System atNo............ -----•---- ?/.....------......... --..... .----.------ . Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... . / —O .................................. Board-&Health DATE ... ---------- --- ---•.----- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS kz IST//VG 4 ` 07 ' SST', - - ;'' .. `� ' •�Q�� �. Z3 2 .}Z 22+7'T 0 52 2 7�ST�OG�S I* � - 6`'-/Z'• niG-Z�J c,un.' -. 21 f S 2.48 10 5�t Z Q /vco v? sync pry 15' mw �7 O ) Q 0 TRN 4 22+ BOY, � 2t+`1 LOT /23 22+4 } SQ. +'� 2a 00 VEWA ESERVE ` - - - - - 2/+4 Zt+S 21+9 214.2 21 f srz , 24'} CJ 4 ` 2I+L'3 P E•� T 4 W N k'ECC�it�Z3S re ep Tow/v WFA.TE )e /.5 AJOT- A M /A//.r-IUi�p :DVIC. 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