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0094 LONG POND ROAD - Health
94 Long Pond Road Marstons M ills ti , A- 014' I J 1 I III YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates [cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which ' you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, I'FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) ri7 .,, _ DATE: uvte y 2ooY Fill in please: ` APPLICANT'S YOUR NAME/S: (cam O' r� ; �� # BUSINESS YOUR HOME ADDRESS: l TELEPHONE # Home Telephone Number S?)8- cool- �23� NAME OF CORPORATION: NAME OF.NEW BUSINESS !?lam S TYPE OF BUSINESS �c w[r�SC4,t7 IS THIS A HOME OCCUPATION? V, ES NO ADDRESS OF BUSINESS lo�2r 6 ;- ` s �l MAP/PARCEL NUMBER ! D (Assessing]:' When starting a new business there are several things you must do in order to be in compliance with the rules and-regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - [corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COM ER'S OFFI E This individu I h s n i d f n ermit requirements that pertain to this type of busines 1�v1UST COMPLY WITH HOME OCCUPATION Au ho ' d Si ** RULES AND REGULATIONS. FAILURE TO COMMEN I COMPLY MAY FIESULT IN FINES. 2. BOARD OF HEALTH This.individual ha iinnf-or the nzit ' ements that pertain to.this type of business. Authorized Si ature** COMMENTS: "AZ4T0WK"DI M RIF, ILAM INS 3. .CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: for azar�ous Materials Inventory Sheet Checklist Date e Physical Street Address-Check database to ensure it exists Working Phone Number ,_Aetgal Amounts—(i.e.gas being used to fuel machines,thinner to clean brushes all count as hazardous materials) Storage Information—location of storage,how long is storage for? If none,note that. Disposal Information—where and who? If none,note that. pplicant Signature—understand what is listed and noted. ;C Staff Initial—any questions,know who to ask. Vehicle Washing/Rinsing?—provide a vehicle washing policy and explain it—note that it was given. Attach the Business Certificate with your sign-off and comments. "The Inventory form should explain what the business consists of and the procedures they are doine. Notes need to be left to explain what You discussed with them Date: &/ q / TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: BUSINESS LOCATION: 4 4Dz)Atcz0 rcA Mam4eulallISINVENTORY MAILING ADDRESS: 15"41-44--tg — TOTAL AMOUNT: TELEPHONE NUMBER: S15F' i87-723`= D CONTACT PERSON:_ e 4 1�r �4 EMERGENCY CONTACT TELEPHONE NUMBER: ?7 7(19 MSDS ON SITE? TYPE OF BUSINESS: l ek gee sc44 t° INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name, of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum i Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers Z!:�)/ Gclill� _c l2 0 (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS F" Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form l 03 f E Inspection results must be submitted on this form. Inspection forms may not be altered in any way. 3D A. General Information Important: When f1ling out 1. Property Information: forms on the computer,use 94 LONG POND RD. MARSTONS MILLS only the tab key Property Address to move your PAUL SULLIVAN cursor-do not use the return Owner's Name key. 94 LONG POND RD. Owner's Address MARSTONS MILLS MA 02648 Cityrrown State Zip Code I Im Date of Inspection: 3-16-07 Date { 2. Inspector: MICHAEL A. BURNIE # Name of Inspector DAVID J. BURNIE& SONS SEPTIC SERVICES blue water holding Corp. = ' Company Name =- - 105 FERNDOC ST UNIT A _ Company Address I , HYANNIS MA 02601' City/Town State Zip Code f- 508-775-0139 Telephone 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 3-16-07 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. PAUL SULLIVAN.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ 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. ND Explain: title5_2006_blank.doc•03/2006 Title fficial Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface.Sewage Disposal System Form B. Certification (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection B System Conditional) Passes (cont.): Y Y 1 ) ❑ 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 ❑ distribution box is leveled or replaced ND Explain: ❑ 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: 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 title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 i Commonwealth of Massachusetts Title 5 Official Inspection Form } Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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 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: title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System �/ Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form ' M B. Certification (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 Cityrrown State ZipCode PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection D) System Failure Criteria Applicable to All Systems: You imust indicate "Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ ® 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. El ® 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 6 ppm, provided that no other failure criteria are triggered. A copy of the analysis of 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. 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. title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System ' �s� Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 94 LONG POND RD. Property Address , MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection 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. title5_2006_blank.doc•03/2006 Title 5 Off' ' I Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection 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,jMOMW 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)] title5_20067-blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System L� Page 7 of 16 c � Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection 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): 495 GPD Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 05-145.2 GPD g ( y g (gpd)): 06-145.2 GPD Sump pump? ❑ Yes ® No Last date of occupancy: CURRENTDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information cont. Y (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection General Information Pumping Records: Source of information: 4-16-03 10-21-99 PER BOH Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 GALLONS 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 24 YEARS PER ORIGINAL PLAN DATED 7-6-83 Were sewage odors detected when arriving at the site? ❑ Yes ® No title5_2006_blank.doc•03/2006 Title 5 0 I Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 22"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: 17"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: yearn Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 GALLON Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 1 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? title5_2006_blank.doc.•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 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):. title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design F!Iow: 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 5" 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 CORRODED AND FALLING APART AND HAD STANDING WATER ABOVE THE INLET LINE. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 I Commonwealth of Massachusetts e Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface-Sewage Disposal System Form GSM D. System Information (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 Cityrrown State Zip Code PAUL SULIVAN 3-16-07 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS no:located, explain why: Type: ® leaching pits number: 1-600 GALLON LP. ❑ 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.): THE LEACH PIT WAS COMPLETELY FULL AND IN A STATE OF FAILURE. title5_2006_blank.doc•03/2006 Title 5 Offi Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for,Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 -C-Iby-rrown State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date 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 Comments (note condition of soil, signs of hydraulic failure, level of ondin , condition of vegetation, P 9 9 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.): title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 I, Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M D. System Information (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection 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. I title5_20G6_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 t t i F a � oG 0 E a3`� r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 47M i D. System Information (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection Site Exam: Slope AV Surface water AIV Check cellar Ory Shallow wells Estimated depth to ground water: 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: 7-6-83 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: SDW 253 ZONE B 2-3' LEVEL 48.3 ADJUSTMENT=2.5' You must describe how you established the high ground water elevation: SEE ATTACHED title5_20067blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 a 1 i 1 C h f . �. � c J �w V Commonwealth of Massachusetts r W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information a Important: When filling out 1. Property Information: D� �j3 / forms on the computer. use 94 LONG POND RD. MARSTONS MILLS only the tab key Property Address to move your PAUL SULLIVAN cursor-do not use the return Owner's Name key. 94 LONG POND RD. Owner's Address MARSTONS MILLS MA 02648 Cityrrown State 'Zip Code t 3-16-07 Date of Inspection: Date 2. tor:ns ec p ,t j MICHAEL A. BURNIE Name of Inspector DAVID J. BIJRNIE &SONS SEPTIC SERVICES blue water holding corp. Company Name 105 FERNDOC ST UNIT A Company Address HYANNIS MA 02601 CityrTown State Zip Code 508-775-0139 Telephone 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 r 3-16-07 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. title5_2006_blank.doc•03/2006 a icial Inspection Form:Subsurface Sewage Disposal System /�� Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments 4M re e Subsurface Sewage Disposal System Form B. Certification (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health;will pass Answer yes, no or not determined (Y, N, ND) in the ❑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 exflltratlon 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: title5_2006_blank.doc•03/2006 Titl fricial Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments - Subsurface Sewage Disposal System Form M B. Certification (cont.) . 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection 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 ❑ obstruction is removed Elpreplaced distribution box is leveled or re la ND Explain: ❑ 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: 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 title5_2006_blank.doc•03l2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M B. Certification (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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: 't* This system passes if the well water analysis, performed at a DEP certified laboratory, for 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: title5_2006_blank.doc-,03/20016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System // Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for�Voluntary Assessments M e.: Subsurface Sewage Disposal System Form B. Certification (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State ZipCode PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection D)System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ElLiquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® 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 1.00 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 of 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. 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. title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- �� ^ Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form • �M grey` B. Certification (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection 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 It 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. titles 2006 blank.doc•03/2006 Title 1 Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection 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,jgkgodft 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)] title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 c � Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form M N0y`' D. System Information 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection 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): 495 GPD Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No 05-284.93 GPD Water meter readings, if available(last 2 years usage(gpd)): 06-145.2 GPD Sump pump? ❑ Yes ® No Last date of occupancy: CURRENTDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form • 7M D. System Information (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection General Information Pumping Records: Source of information: 4-16-03 10-21-99 PER BOH Was system pumped as part of the inspection? ® Yes ❑ No If es vol pumped: 1000 GALLONS i yes, volume p p gallons How was quantity pumped determined? Reason for pumping: Ty pe 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 24 YEARS PER ORIGINAL PLAN DATED 7-6-83 Were sewage odors detected when arriving at the site? ❑ Yes ® No titles 2006 blank.doc•03/2006 Title 5 O I Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ^M Subsurface Sewage Disposal System Form . Sven. D. System Information (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection Building Sewer(locate on site plan): 22" 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): 17" 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 ❑ Yes ❑ No certificate) - - ------------------------ ---------------------------------------------------------------- - Dimensions: 1000 GALLON 3" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 1 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 How were dimensions determined? titles 2006_blank.doc.•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System C� Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form • 4 N See D. System Information (cost.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 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): 9 9 ( P P P ) ( Depth below grade:_ Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):. title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4^M D. System Information (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 Citylrown State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 5" 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 CORRODED AND FALLING APART AND HAD STANDING WATER ABOVE THE INLET LINE. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No title5_2006_blank.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 C� Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL.SULLIVAN 3-16-07 Owner's Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-600 GALLON LP. ❑ 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.): THE LEACH PIT WAS COMPLETELY FULL AND IN A STATE OF FAILURE. titles 2006_blank.doc•03/2006, Title 5 Offi ' Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 l , Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form ' .y SV•y`e. D. System Information (cont.) 94 LONG POND RD. Property Address MARSTO;NS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 _ Owners Name Date 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 o`construction Indication of groundwater inflow ❑ Yes ❑ No 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.): title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System- Page 14 of 16 I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Narne Date of Inspection 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. title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 15 of 16 J A � O � Q o E A� I9�6`�,04 ' a 3 3°'O; � 3 �' , • Commonwealth of Massachusetts • Title 5 Offi ial Inspection Form Not for Voluntary As iessments Subsurface Sewage D sposal System Form �M yVay`' D. System Information (cont.) 94 LONG POND RD. Property Address MARSTONS MILLS MA 02648 City/Town State Zip Code PAUL SULLIVAN 3-16-07 Owner's Name Date of Inspection Site Exam: Slope /lam Surface water Al2) Check cellar Of y Shallow wells �axr- Estimated depth to grot nd water: /b Please indicate all mett ods used to determine the high ground water elevation: ® Obtained from system design plans on record 7-6-83 If checked, date of design plan reviewed: Date 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 lJSGS database-explain: SDW 253 ZONE B 24 LEVEL 48.3 ADJUSTMENT=2.5' You must describe how you established the high ground water elevation: SEE ATTACHED title5_2006_blank.doc•63/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 rdf j83 �/�4.rs�vvc �i'LlS ;TOWN OF BARNSTABLE �� 0 LOCATION , 99 /a SEWAGE #6 6 7`/�' VILLAGE M4 rS fin 714 1 Il c ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. . w/d., Z i he I.Le vat 52 Lk SEPTIC TANK CAPACITY voo /f/U LEACHING FACILITY: (type) C� /f ao ,5 d�� (size) /3, o? X a NO.OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: /��� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Na 13 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by C 53 3� cly To 0-0 It -71 No. _ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for �Bi gat *p5tem �tCon5truction Permit Application for a Permit to Construct O Repair Upgrade Xbandon( ) ❑Complete System LJ Individual Components Location Address or Lot No. q (,01�G food r frift Owner's Name,Address,and Tel.No. p?: ,,t Assessor's Map/parcel d ( k4 3( "01)491ffLi, / ✓7-0 Installer's Name,Address,and Tel.No. i�4 'rj°S Designer's Name,Address and Tel.No. ��_ ►3ox ?C,31° �Z w�-Jr Gross F"��d CC4srW1, q Ll77 -531.3 Type of Building: Dwelling No.of Bedrooms 3 Lot Size z(9 0 30 sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons -2— Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 C> gpd Design flow provided �3 3 1 , gpd Plan Date -3 -30—" Number of sheets Revision Date Title Cf Size of Septic Tank n ��pc� '1�I��r Type of S.A.S. Z Poo 5ol #-ZQ Description of Soil } (J 1 414 Nature of Repairs or Alterations(Answer when applicable) /L&L.1 l- t30 k 'Z SOa !;#1 lAZ© L.(- Date last inspected: `3 /��2,0Q_7 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. 2 Signed Date 7 3c)-- Zio- Application Approved by c Date 3_ 3 v dlJ� Application Disapproved by: Date for the following reasons Permit No. CV? "� Date Issued 6._ 07 -7 I ' �.��_3�a� (off No. Fee _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Mi5 oY *p! tem Construction Permit r0 3 3 Application for a Permit to Construct( ) Repair( Upgrade bandon( ) ❑ Complete System "Individual Components Location Address or Lot No. C/ q L v n c, Fund jy, J,e Owner's Name,Address,and Tel.No. /1 ArtST-".S /h�'I is S�/ i v•�1 P�- � !t� Assessor'sMap/Parcel' d 31 df,i/ ✓ii M Installer's Name,Address,and Tel.No. C../+V--ew,,04 CZ Designer's Name,Address and Tel.No. C HS1AAd-re.l� G</v24i V�J• (30x -73 1-2 Croy F,-Q f Ph Type of Building: + Dwelling No.of Bedrooms 3 Lot Size 2P.030 - sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Z.i Showers( ) Cafeteria( ) Other Fixtures , Design Flow(min.required) -3 3 gpd Design flow provided 3 3 1 . gpd Plan Date - '3o-4" Number of sheets Z Revision Date Title Size of Septic Tank l 000 6X 1)1 bl, _Type of S.A.S.�z� ro o 5 AI N'Z.O Description of Soil :5,� Q i Nature of Repairs or Alterations(Answer when applicable) �Qt�l� �- 30 x 2 Soo 15/11 th-C) CC_ Date last inspected: 3 /j- Zoa 7 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 jCompliance has been issued by this Board of Health. Signed Date .-30 Z ,x� } Application Approved by r Date �✓ 3,0 o�7 Application Disapproved by: . !7, A Date � = for the following reasons ° Permit No. a °a / — ' I Date Issued .! - 3 0- 07 - --------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS .h BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Se age Disposal System Constructed ( ) Repaired ( ) Upgraded (�). Abandoned( )by 114¢t,W J rt 0 1!V B11*S t.3 (IL at 1 `� �Kt nJ� N �v � 114' s�'S /�'1 /J has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ���- �a ( dated Installer � 4u3 L�'L TG+ �'r S t� Designer 4co p r 4/vttL I #bedrooms 3 Approved design flow gpd The issuance of this permit shall not e constr ed as a guarantee that the system ill functi n designed. Date s Inspector ——————--————-——————————————————————————————— No. J t Fee I 7 o THE COMMONWEALTH OF MASSACHUSETTS i PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 1=i5po5al ,*p!6teM Construction ermtt Permission is hereby granted to Construct ( ) Repair ( ) . Upgrade ), Abandon ( ) System located at e!�/ t Lr,yu &1 17041.1 ON4/S�r>411s !411 1/1 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: Construction must be completed within three years of the date of this permit. Date -3- 0 © Approved by I'< q� g5 22d• �teoaranon o�t'lans.era�itreclncanons �f'o m %���e ��. �t•tP e��e �R��� 1 y�•'� The plans and specifications for every on-site system shall be prepared.as follows: (1) Every system shall be designed by a Massachusetts Registered Professional Engineer or a Massackusetts Registered Sanitarian provided that such Sanitarian shall not desics gn a. sy stem designed to discharge more than 2,M gallons per day pursuant to 310 CMR 15.103. Any outer agent of the otvner,.may prepare plans for the repair of a system.designed to discharge not more.than than 2,000 gallons per day pursuant to 310 CMR 15.203 provided , Registered Sanitarian and.appro they are reviewed by: Massachusetts, by the approving authority; (1). Every;plan submitted for approval must be dated and bear the stamp and signature of the designer, (3) Every plan for a new system or plan for the upgrade or expansion of an existing.-system... - Which requires a variance to a property line setback distance;'must Also reference a plan which bears the stamp and signature of a Massachasetts- Licensed Land Surveyor in accordance with M:d.L. c; 112, (4) Every plan for a system shall be of suitable scale(one inch=40 feet or fewer for plot ./ derails of system components), (Lid.shall include. plans and one inch=20 feet or fewer for V 'dezRclian of: to be served: (a) the legal boundaries of the facility (b) the holder and location of any easements appurtenant to or which could impact the IV A-'.system; ... (c) the Iocanon of the all dwelling(s)or buildin (s)existing and proposed on the facility d identifie em addri of those to be served by the syst ; '(d) the'Iacation of existing or proposed impertous areas; including:-driveways and parking areas: - .._ ._.. . - - (e) location and dimensions of the system (including reserve area); :. (f). sysirm design calculations,including design daily sewage flow, septic tank capacity (regnired and provided); soil absorption system capacity (required and provided); and V whether system is designed for garbage grinder; (g) North arrow and existing and proposed contours; (h) , location and'Iog of deep° test. and andl thests including names of thee date of repres ntativ,eeof the isting grade elevations marked on each approving authority and soil evaluator, i) location and results of percolation tests including the aate of test and the names of /iha representative of the approving authority and soil evaluator, . } name and certification number of the Sod Evaluator of record; (k) location.af.every water supply.public and private, 1. within f feet at the grogosed system location in the case of surface water supplies'and gravel packed public water supply wells, on in the case;of tubular public 2. within 250 feet of the proposed system locati water supply Wells, and 3, within 150 feet of the.proposed system•1°catioa in the., case of private water supply wells; etated 1) location of--any surface waters of the Commonwealth;-rivers, bordering ve g wetlands, salt marshes, inland or coastal banks. regulatory floodway, velocity zone, tributaries to surface water supplies,certifie surface water supplies, d vernal pools,private water supplies or supplies, alines, gravel packed-or tubular public water supply wells, subsurface drains, leaching catch basins, or dry wells; and the location of any nitrogen sensitive area identified'in 310 CMS 15.215 within which portions of the proposed _VStem are located. m) location of water lines and other subsurface utilities on the facility; observed and adjusted ground-warer elevation in the vicinity of the system; o) a.complete profile of the system; ' n (p) •a note on the plan listing all variances to the provisions of 310 CMR 15.000 sought in conjunction with the Plan; the location and,elevation of one benchmark-within $O to th feet it the facility , N/ which is not subject to dislocation or loss.during constructiois'oit the faciliy; (r) when dosing is-proposed, 'complete design an3 specificatiorr of the,dosing system proposed including.but hot:limited to dosing,chambe capacity anel depthrere ckprovided),' pump curves and,specifications, number of dosin, Yp Y cued or (s) when a Racirculatistg Sand Filter or equivalent alternative technology is rep 1V� —proposed, a complete plan and specification for the Sincludin tem ctheinear nearest wdsting street, } a locus plan,to show the location o e fa of die facility; and (u the sweet nurriber and lot number, any, v) the materials of construcuon.and the specifications of the system. 04/;03/2007 11:50 5084775313 ENGINEERING WORKS PAGE 01 Town of Barnstable Regulatory Services Thomas F.Geller,Director SAMhublie Health Division Thomas McKean,Director "o Main StrCV4 HysnWx,MA 02b9I I. i(Iilce: 5W862.4644 Faye: 508-79b-6304 Anataller& Des er Ce ' ica on /,�- 9 . Seer a Permit# Assessor's MapTarcel d 1 Date: _ ag Designer: 76 Address: Iw Address: liq on �n1 !Ni 6a�r(°C`SS. was issued a pernut tv install a ( ) Onstaller) septic system at 4LP✓► ;, based on a design drawn by (address) 4 E n �_ P� • dated-_!e jam' ° (designer) I certify that the septic system referenced above was installed substantiallyy to which ima w lode minor roved changes such as lateral relocate the the design, w Y � � distribution box and/or septic tank: _ I certify that the septic system refemced above was installed with major changes (i.e. greater than 10 lateral relocation of the SAS or any vertical relocation of amy component of the septic system)but>� accordance with State St Local Regulations. Plan rdvisian or certified as-built by designer to follow. OF —ices Si ) CIVIL No.35109were p esigner's Signature) ) (A fFix Deg ) (D E Air, HEALTH RMSION, T B IS AS• E LL OT YOU. AB P IC AL T DI . 'II NNI Q Hagdd tiWDesigWr C&Oficafico Form 3.26-04.doe ' ( � E W A E PERMIT NO. L 0:CA T 1� a. RAJ G VI'1LAGE I N S T A LLER'S NAME R ADDRESS s U I l D E R OR OWNER i c�c9/l1 ol AaZ r/uC, "'- DATE E PERMIT IS� � �� S V E D ' ,DATE COMPLIANCE ISSUED 4Z� 3a 3` Lo PN - � iw- d� No...n.I.J.- FEs.._......yd.. THE COMMONWEALTH OF MASSACHUSETTS T BOARD OF HEALTH l e 03l p�L� OF......................................... ............................................-- d I Appliratio t for UiiipDiitti Workii Tomitrurtion Prrutit Application is hereby made for Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst at: c�!..r........ !!Y..Y.I..K.9. -•-.Y..c!!! . -_--• ......................................... `//////�f�.'..I/� L c'eti• -Address AJJ • r La •-o. Or ........�_-•_ CL.OIW 1:�..-. ... •.. ...___•----..__•.................................. ... rG-�.. _. _^. ............. ..�.YJL?LL..•• ..•••...... ""O Owner /`_Address W �. w _ ...................f _ ':be.............___._._................................. a .......... Installer Address Type of Building Size Lot..Z0,-4-3a........Sq. feet UV Dwelling—No. of Bedroom Expansion Attic ( ) Garbage Grinder ego ............-•-•••-•-- — p`4 Other—Type of Building x -1,__._.. No. of persons........�................ Showers ( ) Cafeteria ( ) 04 Other fixtures _....--•----•-------•-----••---• . W Design Flow.........S ..........................gallons per person per day. Total daily flow--------- ........_................gallons. WSeptic Tank—Liquid capacity./°."_.°.gallons Length__V4...... Width.0V.`1A.__.. Diameter................ Depth..'Y`,"'.__. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------/-__------- Diameter.................... Depth below inlet.................... Total leaching area....;.............sq. ft. Z Other.Distribution box ( ) Dos'�nkt, ) Wj~' Percolation Test Results Performed by..,.;:jo. _ _ . .v__.. .:................... Date........................................ aTest Pit No. 1________________minutes per inch Depth of Test it....e ....... Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ....................................................................................................•--......-----••............_......---•••......•---._••-- 0 Description of Soil........................................................................................................................................................................ x U •-•--•--------•-•-....-•••------••-•-•••-•------•....•••••-•••••-••-•-••-•-••••--•••-•---------•--•-•-•-•••••••••-•-••-•----••-••-•-•-•-------•••...--•------•--•-•--•...•--•------•---••-•......-•--••- UNature of Repairs or Alterations—Answer when applicable.............................................................................:................. ,,. Agreement: t The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITHE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in o ration until a Certificate of Compliance has be n issued a board of Health. Signe . ......:.......::............ Date plication Approved By.......... ................. . -_-�`�-P-3. •--•-•-•-•••-•--....--•-----•-------- Date Application Disapproved for the following reasons---------------------------------------------•---..........----•-------------.....---------...-----•---....---- ...............•-••....•.....--....•••-•............--•-••-••---•-••------••---•••-•--•----••---•--...---•..........--••••-•-•------•--•---•-----•-•--•--•-••--•-•-•-••..--••••......••-•-••....-•----. Date Permit No.----- Gl•-------•--------------- Issued....................................................... Date dd EsNo.............:........... F ........ ''� I ' 4r, 71 y' ..r A... THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH -•....................----- ---------..OF............................................ Appliration for Dhipniitti Workii Tomitrnrtinn rrnt t r . Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal p , Sys em at: Lo ti n•Address ,/� /� or No. ... .. ..0 < }.... ....... ................•---.....--•--•----•-....----- --.LdG -vk�` G�,._'x... .-_`. a----.-------.--..--..--_----- Owner Addres a �........+ r :__........ � ........................................................... Installer Address U Type of Building Size Lot_.2d,,o-�.-©......Sq. feet Dwelling—No. of Bedrooms ,3................................Expansion Attic kZ Garbage Grinder WI) aOther—Type of Building ..... No. of persons........4�................. Showers ( ) — Cafeteria ( ) dOther fixtures ---------------•-----------------------------•--....--•----._...------------------•......------.._........_.......-----...........------........_..... W Design Flow.........J7.-r .........................gallons per person per day. Total daily flow-------.... .0_____...............gallons. WSeptic Tank—Liquid capacity./Oz�rgallons Lengthl!: ...... Width.:! .tC�.. Diameter________________ Depth..2��G..__. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing ) 'A/ aPercolation Test Results Performed by._.1�cs ..I. . .........t....................... Date................. Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P+ -•••----•----•------•---•-----•------•-----•..........................................•--•---••••---......................................................... 0 Description of Soil........................................................................................................................................................................ x U --•--•-•-•--------•--------------•-----•----•-----...---------------------.......-----•------•-------------------•--------------------••...--•-------•-•--------------------••------•------------------- w UNature 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 TITLE: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in o eration until a Certificate of Compliance has be issued by the oar of health. Signed.= ..........................b cation A roved B .qj�a�F.� PPP y---•-------- ---......................•--- ------------------.............--•-- ----•--_----------- •------------•--- Date Application Disapproved for the following reasons--------------------------------•-------•--------------....----•------------...-•------..._....--•------•••------ -------------••---------•-----------------•---------•-••----•--------------...----•-...........-----......•--...--•-----.....----....---------------------------•--•----- ••---••-------------------.... Date Permit No.......A--* .. j. ------•----•--• Issued....................................................... Date 'fHE COMMONWEALTH OF MASSACHUSETTS { BOARD OF HEALTH ..................:.....O F..................................................................................... .k::,��� :• ;-:�= �rrtif irtttr of f�Ant�littnrr THIS IS TD CERTIFY, That the Individual S wage D> posit System c ns rutted ( ) or Repaired ( ) by......... - -- ----------------------------------- . ..----- ....................................................... at 6j � ` Inst ter --...--•--•---..... ._....•-----. . --•-----------------------------------•---••----.............................._•' has been installed in accordance with the provislonsjof TITLE 5 of Jhe State Sanitary Code as dc�ibed in the application for Disposal Works Construction Permit 1NTo..=..'. .._. .�� -- --...--•---•--•--- dated------------------------------------------------ THE ISSUA CE O THIS CERTIFICATE SHALL NOT BE CONSTRUED AS UARANTEE THAT THE::. SYSTEM WIL FU I N SATISFACTORY /4. . I °^+ nspector DATE. ...................... ... nd THE COMMONWEALTH, OF MASSACHUSETTS BOARD OF HEALTH u lx OF . 9t�lT�h/S�F..................•-•................. No.......�..3......7.`� FEE........................ tt1`` nrkii T�rn�# Winn rrmit Permission is hereby granted.............fir"'.��.....'%m.,k- --.-•---.....-•---•---•--•---•----------------------••---•---......---............_.-----......--- to Construct ( -� or Repair ( ) an Individual Sewage Disposal System at No.----•-......---- .` p A/f,.C.tl ---•--•----•... --- -- ---- . •--------•••• .................. r.x- Sk eet �'j ? tr �' /r/, 9 as shown on the application for'Disposal Works Construction: eimit No...................... Dated.......................................... a, C f!-------•---------------------•---------- - �O /7- eir3 � B• of_Health DATE----• I t . FORM 1255 A. MLSULKIN, INC., BOSTON 5►►.iGLC- FRS►�Y - :3 BE�2ooM I 1.1a .GaRBL�.6E �jwNDE2 C)AlLl{. FLOW :. 110 x 3 = 33oG.Po 5EP.T►G 'rAQK = 33Ox15o% ' '49yG•P. 0 y5E- %000 GAL.. 01,5po5AL. PIT v5E boo GAS• I Sin e vNA ,�.eeA = 13 Z s.F. 9B ,CaT- A? 13Z SF X ?.5 = 33oG.P �, So-T'toM AeEA _ 1,13 5•F 1 3 5:F X I,D 113 G.P ID 'TarA L. DE-4 1 bN = /+/43 6.P.V. 97 1 Tra. -To,TAL_ DA 1 330 G.Po p9• 8 , s 97 PE2C.ot-ATION RATE ; 1"IN ZtAIM oP-1.a55 \' Q b Pe f'`��� ;�a'' f�U ��`tH Of M� tN O o , - 98•z 1-27 r� 141CHARD d AIAN GN roc o0 BAXTER '' u JONES 3 No.24048 �• 25 a \v) 1 i C � 4k,ST v�y Q• C.. / T6`�T �p 2 /Zb � CG• z 99G TOPFND=1oo.0 98 a 1Nv. 427. D �D�/� loov INV. Sv,�Sp�G guT q�IN�• SEPTIC. l,�' Y �/it/✓. r �"' G TANK GL:1� � 9G.o �• � ' .IN INV. Goo 6A4-- 9G.�4 L EAGy G'GEAM �E�• Tu/asNED • .5AM G.2A✓,5 • �� � GER.TIFIGD P�-oT PLAN 451 W.4T. No. .SC.A.L L- P ti•-A N R E P S�E N GE 1 CERTIFY THAT TH IF-PP-oPosai> NS�,SNoVYN N�26o N CoMPL% !S WtTN-T HE S 1 oEL1N OT /2 j Auer SE75AGK R.6R�►Q>ccMEN`f> of Tµ� '(v W N A NT> 1 S WO-r7 GiIC Z(�3-/, PC7 9 LOGp.T D WITN1�! 41E FL-oQD P AIN BA-AT E sz e N Y E INC. $LEG I sz r--'Zr D'►.Au o 5 u P.v EY�es 'Tw!S`PL.AN 15 NOT 4tn5Frn o►d AN osTEQ.v1LL.lr - MASS. I W 5•T?-U to a K-r e.v e Y �--T N E o I:F5 ET 5 6 W 0 U L'T> NoT t3 - ugEDTo DETE.Rl^1►-1� 1-o"T -INE.�j APPL_IGA►�T J�r5 q YLc y A tt cam►see c iH`cr a G a C_4. �, 1- Town of Barnstable P# l l Department of Regulatory Services > BMWOTA" : Public Health Division Date �3✓� "„ �200 Main Street,Hyannis MA 02601 3 ArED f,AA't� � Date Scheduled Time Fee Pd. t y i Soil Suitability Assessment for Sewage Disposal Performed By: �� r e. Witnessed By: _ LOCATION& GENERAL INFORMATION Location Address • Pad IU Owner's Name1,j2`✓4 t�w MC4 rS4n-n s M 115 _• Address f?cs rs,�_,,s M:I IS, /t4A- O Z(o Assessor's Map/Parcel: o I N — ®3 ' Engineer's Name pe_t/--r NEW CONSTRUCTION REPAIR Telephone# C509) 4-7'2-57 S F Land Use J dtKi+�ta rl 1 Slopes(%) �u Surface Stones ` `^ Distances from: Open Water Body t S� ft Possible Wet Area 1 LTJ ft 'Drinking Water Well !t r3 A Drainage Way t ^V ft Property Line ZA� ft Other ft r <' SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc testsi locate wetlands'n proximity to holes) N) U eA3- P611i~ i ,i It� rTt Parent material(geologic) Vow Depth to Bedrock J Depth to Groundwater. Standing Water in Hole: N� Weeping from Pit FACe ,5 Estimated Seasonal High Groundwater sa ` S 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.m �r Adj,faetor_ Adj.aroundwater Level, PERCOLATION TEST bete " .' `q Thne l Observation 'Z Hole# Time at 4" - -.-. Depth of Perc 2 i r Time at 6" Stan Pre-soak Time @ Time(9"-V) -- -- n . End Pre-soak. S (n"AJ4-(j 40 �l n Rate Min./Inch < Z-'M`^ i h Z Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) original: Public Health Division Observation Hole Data To Be Completed on Back----------- *a*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# 'I Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Con istenc ravel Z. � 5 Z. 1 U�►2`��� it S.�- 3 DEEP OBSERVATION HOLE LOG Hole# -Z-- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consis en avel 3/3 5� MIV 317 G v c s; 1t- -i U C z M- - S a,,.A z.s-Y s DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color. Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Con i to c O el DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. onsi ten I y Flood Insurance Rate Man: xx Above 500 year flood boundary No_ Yes Within 500 year boundary No ?� Yes Within 100 year flood boundary No Yes Depth of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? �rQ S If not,what is the depth of naturally occulting pervious material? Certification I certify that on 1� l RG (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,expertise and experience described in 310 CMR 15.017. Signature Date( Q:\SEPTICVERCFORM.DOC I MOMNOWN LEGEND 524°58'40°E - f 18.07 r 78 PROPOSED CONTOUR RIDGE � S' o B jz $ 79 PROPOSED SPOT GRAD Rek\ect`o0 CLU Asa Meigs Rd Schoo► St �, .......... ...........�}r EXISTING CONTOUR n 102.76 x EXISTING SPOT GRADE a '° °d°rB'` 3 az � a Z WO ad y. £ TEST PIT P� o< 6 a �D,. m �a'0. l—�EQ I uC �/ EXISTING WATER SERVIC °�0`'r° °' o wo°a 0 P°. UGW UNDERGROUND WIRES /°��c ass LOCUS o� i BENCHMARK 1 / Mockingbird to LOCUS MAP N.T.S. APN 14-3 1 r \ GENERAL NOTES: 20,030± SF r DECK 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE x 9 9.11 LOCAL RULES AND REGULATIONS EXCEPT AS REQUESTED BELOW: VENT 1) 310 CMR 15.405(1)(b) CONTENTS OF LOCAL UPGRADE APPROVAL: ,.• A 2' variance to maximum cover requirement of 3', for 5' 9 -13 2� maximum cover. S.A.S. shall have H-20 units and be vented. Z x 99.11 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR No. 94 29' TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE I 112 STY. W.F. .;.' L'.. h DESIGN ENGINEER. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING T D.F. I Of�.J 1 `... d` �jp;l 4. FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN Fi Pq N ENGINEER BEFORE CONSTRUCTION CONTINUES. ` NI¢cV j 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 0 0 0 0 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF BENCHMARK: 99.55 Tx 99.11 I '. L CIO THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF RT.COR. BOTT. STEP �_2 L= °' HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. ELEY. = 100.00' TP-1 ��Or 7. WATER SUPPLY PROVIDED BY TOWN WATER. 84 S. THERE ARE NO ABUTTING WELLS LOCATED WITHIN 150' OF THE S.A.S. (ASSUMED DATUM) , I 9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED ;x f100.00 w x 99.70 TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. EXISTING SEPTIC TANK 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY TOP OF TANK EL.=98.78 THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING INV.(OUT)=97.45± g963 _ Jk,/ x 98 CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS f f } w,�.�.., ,m„• d� IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S. EXISTING S.A.S. .> AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). TO BE PUMPED & ,K /ytA 1- l 00.27 12. CONTRACTOR SHALL EVALUATE STUCTURAL INTEGRITY OF EXISTING FILLED WITH SAND i NE (t SEPTIC TANK PRIOR TO CONSTRUCTION. { C3RJVEI+s k j f i 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY err {' AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. 125 o PETER T. �s PROPOSED SEPTIC SYSTEM UPGRADE I `` �N28°0633"W �.. McENTEE ^h� Hy ^h huts 99.34 o CIVIL 94 LONG POND ROAD, MARSTONS MILLS, MA � 3d _._-. No. 35109..:_.�. v Prepared for: Paul Sullivan, 94 Long Pond Rd., Marstons Mills, MA 0264$ Engineeringb . Surveying b : ALE DRAWN JOB. NO. +o SS/ Al��G� y. P.T.M. 134-07 FLOOD PLAIN DESIGNATION DGF OF?A,VffMF I`4T I�� 9 U -01„PAVI•~°+dlENT Engineering Works HOOD SURVEY GROUP 1"=20' Community—Panel No. 250001 0015 C (INSET A) 1'p �u, SS 12 West Crossfield Road 18 Route 6A Map Revised: August 19, 1985 aDATE CHECKED SHEET N0. Zone "C" LONG POND (so' WIDE) `RC)AD �3v ,01-) (508)t477-531302644 Sandwich,08) 888M 090563 3/30/07 P.T.M. 1 of 2 NOTE: TO PREVENT BREAKOUT, THE PROPOSED F.G. EL: 99.8(MAX.) FINISH GRADE SHALL NOT BE < EL:94.5 T.O.F FOR A DISTANCE OF 15' AROUND THE (EXISTING) vENT PERIMETER OF THE S.A.S. EXISTING F.G. EL: 100.0%P(EXISTING) F.G. EL: 99.8tt MAINTAIN 2% MIN SLOPE OVER S.A.S. T 4" SCH 40 PVC PERFORATED PIPE WITH SCREW CAP SET TO WITHIN 3" OF FINISH INSTALL RISERS OVER INLET & OUTLET INSTALL RISER OVER D-BOX TO 2-500 GALLON LEACHING CHAMBERS GRADE TO SERVE AS INSPECTION PORT. TO WITHIN 6" OF FINISH GRADE WITHIN 6" OF FINISH GRADE IN SERIES WITH STONE ALL 11 SIDES INSTALL RISER OVER CHAMBER e L =37" L=4, SHOWN ON PLAN AND SET COVER WITHIN 6" OF FINISH GRADE B" 4" SCH 40 PVC 4" SCH 40 PVC 2" LAYER OF 1/8" TO 1/2" e (MIN.) S= 1% (MIN.) Em "- M:�: STONE EXISTING n 10^ �a^ ® S= 1% MIN. 6 ®® (OR APPROVEDDFILTER FABRIC) n 48" LIQUID INV.=96.17 INV.=96.00 2' EFF. DEPTHT ® v. A LEVEL 3/4"-1 t/2" EXISTING ADD GAS D-BOX 4' S.2' 4' DOUBLE WASHED BAFFLE ]V STONE INV.=97.45t I EFFECTIVE WIDTH = 13.2' EXISTING 1000 GALLON SEPTIC TANK i INV.=94.30 TOP CONC. ELEV.=95.3 —BREAKOUT ELEV.=94.8 NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING INV. ELEV.=94.30 ®a®® PIPE INVERTS PRIOR TO CONSTRUCTION. ®B®®®6®®®®® ®®®®®®®®a®® 2) D-BOX SHALL BE SET LEVEL AND TRUE TO BOTTOM ELEV.=92.30 2 x 8.5' = 17.0' 3' GRADE ON A MECHANICALLY COMPACTED SIX 3' INCH CRUSHED STONE BASE, AS SPECIFIED IN 5' MIN. ABOVE BOTTOM OF EFFECTIVE LENGTH = 23.'0' 310 CMR 15.221(2). T.P. EXCAVATION OR G.W. 3) INSTALL INLET & OUTLET TEES AS REQUIRED. LEACHING SYSTEM SECTION 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE. NO G.W. ENCOUNTERED = BOTTOM OF TP EL: 88.3 (TP-2) SEPTIC SYSTEM PROFILE ESTIMATED DEPTH TO G.W.=50'f BELOW EXISTING GRADE (BARNSTABLE G.I.S. DATA) N.T.S. (3) 5" DIA.OUTLETS 15.5" -� I- -+72" DESIGN CRITERIA i O t2° NUMBER OF BEDROOMS: 3 BEDROOMS i � SOIL TYPE: CLASS II LS1'a DESIGN PERCOLATION RATE: 5 MIN./IN. �� rn SOIL LOG DAILY FLOW: 330 G.P.D. H-10 LOADING 2 C7 �' DESIGN FLOW: 330 G.P.D •,� ... 7c D-BOX 4' .�..._... -� DATE: MARCH 29, 2007 (P-11,718) GARBAGE GRINDER: NO Ln N.*a �-- SOIL EVALUATOR: PETER T. MCENTEE P.E. )LEACHING AREA REQUIRED: (330 = 445.9 S.F. WITNESS: DONALD DESMARAIS - HEALTH AGENT .74 EXISTING SEPTIC TANK: 1000 GALLON CAPACITY (ESTIMATED) ®®®® ® ®®®® Elev. TP-1 Depth Elev. TP-2 De th ®®®IM®®®®®®® 37" _� —�- USE 2-500 GALLON LEACHING CHAMBERS IN SERIES N j ®®®®®®® I Ca O� 99'6 A SANDY LOAM 0 99'8 '4 SANDY LOAM O" ®�®®®®®®®®® `r 'S 99.1 8" 99.1 8^ 10YR 3/3 10YR 3/3 SIDEWALL AREA: 2(13.2' + 23.0') X 2 = 144.8 S.F. N �� N B SANDY LOAM B SANDY LOAM BOTTOM AREA: 13.2' X 23.0' = 303.6 S.F. 102" � 10YR,5/8 10YR 5/8 c li �'" 97.8 C1 24" 97,1 C1 32" TOTAL AREA: 448.4 S.F. ' SILT LOAM SILT LOAM 4" KNOCKOUT 5Y 5/3 5Y 5/3 DESIGN FLOW PROVIDED: 0.74(448.4) = 331.8 G.P.D. 95.2 C2 55' 94.8 C2 60'" 20• OIA. COVER 62" KNOCKOUT O�4• KNOCKOUT 62• I 1 w �o .PROPOSED SEPTIC SYSTEM UPGRADE PROP. S.A.S. i IN `` 74„ 4" KNOCKOUT I_------- -1 MED.-COARSE MED.-COARSE 94 LONG POND ROAD, MARSTO N S MILLS, MA SAND SAND 2 S--{ 2.5Y 5 4 2.5Y 5 4 / 1Sullivan, 4 Lon Pond R 'I MA 026 Prepared for: Paul Sulllva g d., Marstons Mills, 48 Engineering by: Surveying by: SCALE DRAWN JOB. NO. 500 GALLON CAPACITY, H-20 LOADING 88.3 138" 88.3 138" Engineering Works HOOD SURVEY GROUP N.T.S. P.T.M. 134-07 /� NO GROUNDWATER OBSERVED 12 West Crossfield Road 18 Route 6A CHECKED SHEET N0. CHAMBERS S.A.S. LAYOUT PERC RATE <2 MIN/IN ("C2" HORIZON - TP 2) Forestdole, MA 02644 Sandwich, MA 02563 DATE N.A (508) 477-5313 (508) 888-1090 3/30/07 P.T.M. 2 Of 2