HomeMy WebLinkAbout0085 MISTIC DRIVE - Health 85 Mistic Drive
Marstons Mills
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL:AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
s -
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
_ PART A
CERTIFICATION
Property Address: S 44/.,S t+� �ri�✓�'
- ) ak.s-V-4 5 ,i S W
Owner's Name: /-iSj* r lyj- er
Owner's Address: $5- � riv o
Date of Inspect 7/O—®;
Name of Inspector• Please print) J akn )9' /'7 a lie,
Company Name: Ah r4.�I To We A" -Ceo-v,'c �—
Mailing Address: g2 Wj y,41 S , � 0
/Li�rsYoas /VI',/1� /L1lJ` 026�i8 cs �'
Telephone Number: -P$- IVJ 8-'7779 �-
E5
CERTIFICATION STATEMENT o m
I certify that I have personally inspected the sewage disposal system at this address and that the info ation reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed ed 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
Needs Further Evaluation by the Local Approving Authority
Fails
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.
Notes and Comments
****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
f.,
Page 2 of l l
y OFFICIAL INSPECTION FORM—N4'I' 'OR VOLiJNTARY:ASSESSMgNTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
/ ors i s 0)7
Owner: bsq wo.- Th-en
Date of Inspection: 7—/0--07
Inspection Summary: Check A,B,C,D or E/ALWAYS complete sN 4Saltinz.D
A., System Passes:
V 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 coinpletion of the replacement oryepair,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. k.
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 More 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: ~
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)am rqph.=d
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:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART x
CERTIFICATION-(continued)
Property Address:
Owner: f S* d 8»
Date of Inspection: .
C Further Evaluation is Required by the Board of Health:
Conditions exist which require fiuther 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(lxb)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 f
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 aseptic 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 I 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.
P
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front 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:
3
Page 4 of 11
r OFFICIAL INSPECTION FORM—NOTLFOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL `SYSTEM WSPEMON:.FOW
PART A
CERTIFICATION(continued) 4 .:
Property Address
,�
Owner: ;t./ski oy- j-k
Date of Inspection: "T/O--c9-7
D. System Failure Criteria applicable to all systems:.
�,
You must indicate"yes or"no to each of the following for all ins ch s.
_ g _ Pe
Yes No
V Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
gg esspo
V Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
v 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%2 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.
_lZ 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 30 feet from zprivate water
supply well with no acceptable water quality analysis. [This system passes if thevmll 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 failm criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to cmvect the failure.
i
L 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• - `
You must indicate either"yes"or"no"to each of tic.following:
(The following criteria apply to large systems in addition to the criteria above)
. I
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
i
the system is located in a nitrogen sensitive area((nterim Wellhead Protection Area—I WPA)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.
4
� 1
i
Page 5 of 11
• OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL_SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Ars vas s �' ,s
Owner: A Ise, for Bti
Date of Inspection: 7—.AO—O 7
Check if the following have been done.You most 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?
r✓_ Was the site inspected*for signs of break out?
Were all system components,excluding the SAS,located on site?
_✓_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The she and location of the Soil Absorption System iSAS)on the site has been determined based on:
Yes no
✓/_ 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(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM NOT FOR?
OL'UNTA1tY ASSESSMENT-S.
SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM
PART C
SYSTEM:INFORMATION .�
Property Address: Pr 441"5P11 �fiv
Owner:...�t'J a B r h
Date of Inspection: '/—/a--o 7
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 11 Number of bedrooms(actual): ,-
DESIGN flow based on 310 CMR 15203(for example: 110 gpd x It of bedrooms): LI e1�
Number of current residents:
Does residence have a garbage grinder(yes or no):Y
Is laundry on a separate sewage system(yes or no):#v [if yes separate inspection required]
Laundry system inspected(yes or no): _
Seasonal use:(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): q�z cl
Sump pump(yes or no): Ales
Last date of occupancy:
COMMERCIALIINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15203): gad
Basis of design flow(seats/persons/sgftetc.):
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
Source of information: Qwo'e '?"Ws -4'sf 'elao feo{ 6 (MB),r
Was system pumped as part of the inspection(yes or no):.&O�—
If yes,volume pumped:_,gallons—How was quantity pumped determined?
Reason for pumping: ,
TYPE OF SYSTEM
_Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attat;h'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 afe of all components,date installed(if known)and source of information:
- /H.s`taI 1�.� e1-�/-9y �lba •3�wp d.tvw.�/ }3' ��1—�f3
Were sewage odors detected when arriving at the site(yes or no): 1119
6
Page 7 of I I ;
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner. 415,,q UlojAek,
Date of Inspection: '7—/,P--07
BUILDING SEWER(locate on site plan)
Depth below grade: •3'
Materials of construction: cast iron 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:_(locate on site plan)
Depth below grade: /g
Material of construction: 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: jrco
Sludge depth: 0'` 1 2>' •, , �>
Distance from top of sludge to bottom of outlet tee or baffle: 33
Scum thickness: A" 6 g "
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: cgs c+r>H 'red obAr-0
Comments(on pumping recommendations,inlet add outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): / .�
,So�7/i tr 4- .k �I�Nc1 s1, /r •SSA /s 4,'ac>d/"7 -
GREASE TRAP: (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.):
7
Page 8 of 1 l J
OFFICIAL INSPECTION FORM—NOTMMVQLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM1 .
PART C. : }
SYSTEM INFORMATION(continued)
Property Address: ✓� �f
P
Owner: I Sa Lf/�rZ,Pi
Date of Inspection: y, /-0 7
TIGHT or HOLDING TANK: (tank must be pumped at time of impentate an site plan)
.Depth below grade: _
Material of construction: concrete metal fiberglass_polyethylene other(explam):
Dimensions:
Capacity. gallons
Design Flow: gallonstday
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: //(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: ®"
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.): y
P— 0y>1 i 4,..e Pcr n&t
PUMP CHAMBER: (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 ofpumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGKDISPOSAL SYSTEM INSPECTION FORM
PART C-
SYSTEM INFORMATION(continued)
Property Address:
Owner: 11s4 8 , �,
Date of Inspection: 7—JP_-�
SOIL ABSORPTION SYSTEM(SAS): P"' (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number'
leaching chambers,number.
V leaching galleries,number. 6`
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number
innovatlye/alternative system Typetname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
t,qu,�/ L,e,,e9 1714- -20 " ir9 9u��zr�s , r�s�r o� gel/e� �o S" efoav y�
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 or 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:
Dimension's:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
o
Page 10 of l l
omgALINSPEcnoN FORM-Rdivtoit V`OLvN'FAIiY•ASSESSMENTs
SUBSURFACE SEWAGE bISPOSAY:`SY471*INSPECTION FORM
PART:C .
• SYSTEM INMUTATION(continued)
Property Address: 'S s v Al• v
Owner._ ua 1d/or e;1
Date of Inspection:_ 7— /v�-o .4- • ��.• '". .
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. .
7uNk .
7r ccv�r i
i
10•
Page 11 of 11 '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: V-114�hl P"p-zo `
Owner. »--
Date of Inspection: ?10 ®7
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 17. l f feet
Please 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)
✓ Accessed USGS database-explain'
You must describe how you established the high ground water elevation:
a ws V '3 To 4�S; .72
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i'e s � -�i S��hG� �'� � /�3 �. �-t*aw•ta,. .�/�.� pva l•ev 4- /�v�ois. Ca'7� .S/�S II
11
TOWN OF BARNSTABLE
LOCATION al y' J e _SEWAGE
VILLAGE , ASSESSOR'S MAP & LOT , 4 �
INSTALLER'S NAME & PHONE NO. % v �G�►d�f•' �'�,
SEPTIC TANK CAPACITY 1,il�ry
LEACHING FACILITY:(type)� (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC W_ ATE
BUILDER OR OWNER ��1 yZ
DATE PERMIT ISSUED: I �✓ - '
DATE COMPLIANCE ISSUED: ,
VARIANCE GRANTED: Yes No
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F
YEE
THE COMMONWEALTH OF MASSACHUSE17S
BOARD OF HEALTH
:.........OF..... ----------_----_-------
Appliration for Uispoaal Works Tongtrudion runfit
Application is hereby made for a Permit to Construct (X or Repair an Individual Sewage Disposal
System at:
15. .......
LIO . ..................... -T MI.$ -a..... .....
ocatiMA or Lot No.
....... V l. ............................ ..................................................................................................
Owner Address
Installer Address
Type of Building Size Lot.140i3......Sq. feet
U
Dwelling—No. of Bedrooms_....._...15.............................Expansion Attic Garbage Grinder ("0
4 .1
P4 Other—Type of Building ............................. No. of persons........_................... Showers Cafeteria
Otherfixtgles ..............................................................................................................
Design Flow............5.35............. -----gallons per person d Total).per k y. dal Ww------15-15.........................0109.11
9 Septic Tank—Li qapaci y. . ga. on!
tlX?..... Total lea
15... ... Width...jo."........ Total Length.__.___ / _
t ... A6._....sq.1.SbD I1 3 Length ... Wid --- Diameter---------Disposal Cz%"4 ching ar I f t.
Seepage Pit No--_---------------- Diameter....__._.__......... Depth below inlet...&.tM.... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank C )
Percolation Test Results Performed byt-P16M.-WU Date........................................
Test Pit No. I........?.---minutes per inch Depth of Test Pit....... t!. .... Depth to ground water....1,1()tj
Test Pit No. 2.......Z....minutes per inch Depth of Test Pit ..... Depth to ground water----14
-3.5 �11
0 Description of Soil.......s.A-k3 ..... J.10................
�4 T. 1. Y, - ----------------------------------
U ............. _:!n1l......0_.S I F_ ::!..G........
---------------------------------G.....-:.J,, .....SA+.J.,D.................................................................*-----------------*-----------
------------------------------------------
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 TL IL T1 LE --5.of the State Sanitary Code—The undersigned f
P?er agrees not to place the system in
operation until a Certificate of Compliance has been is ed y e boar ealth.
Signed.---- ..... .... ... ............................... -------------...........
Date
Application Approved By.............. - --
Ol 1 ---- ..................................... ....... ------
en-
Application Disapproved for the following reasons:.......................................................................................... Date......................
.......................................................................................................................................................................................................
Date
Permit No.........144-------�;L,,Q------------------------ Issued.......................................................
7 9' ' 6 V F�$.......�.°. .....
P t THE COMMONWEALTH OF MASSACHUSETTS
f BOARD OF HEALTH
ti.
r+3.�h,•5..............OF..._ °���:�.�"mot��.`'.'�V"J..S te .
f Applirutiun for Uiipuual Workii Tumitrnrtiun ranfit
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System..at:
Location-A d ess or Lot No.
s..---•- ........ .......NNA ............................ .........-••-----------......-•-......----.....---•••---•---•--..............-•--••-•---•---------
Owner Address
Installer Address
Q Type of Building Size LoA IJ.3......Sq. feet
U Dwelling—No.No. of Bedrooms......... .............................Ex Expansion Attic g—. p ( ) Garbage Grinder (t•4 0
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtu es .
W Design Flow............ . ..............,.__-,,gallons per person �errdy Tota ail flow___....1)........._....___...__..._._ to �l
WSeptic Tank—Liquid*6apacit 1.5.00gallons Length.j.1..... .. Width!.._ __. Diameter................ D��sp+
x
Disposal �-PIUk .-...... ....... Width...I`'�--...--........-Total Length..4' Total leaching area "l ----..sq. ft.
Seepage Pit No.......:..:.......... Diameter.._...:...._.__..... Depth below inlet..:_:_ - Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank )
Percolation Test Results . Performed bye 'it)� � '6�J_ �L _. Date.............., = -------------------------
Test
a Pit No. I........Z.-...minutes per inch Depth of Test Pit.._...._ ... Depth to ground water_._}_So�F_
G14 Test Pit No 2.........- minutes per inch Depth of ,Test Pit �Z' Depth to ground water_._�_r.�_t�
ion of Soil A ia�. y_. ' ' `, '.J 1 . �.n,`�1 �
-..-- ------
x -------------------------- -----� �.......... ^``�-�C......5. �4.t7..-----------.....-----------------------------------------------------------------------------
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 T provisions of T T Li
p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed......................................................................................
-
Application Approved BY ..:t'` .,-,'------------------------------------- ....................... ......ate �/
� /------
Date
Application Disapproved for the following reasons:.............................................................
.........-••--•--•-----------•---------•----•---.......-•----.....---•--•-------------•-•••-•------...-------------------••--•-•----•---•------------•••......------••-•----..........................
A _....Date-----
ry---n--
Permit No. ._...-/.y.:._a Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........�L9ZLl t_...........OF.....................:.'.................:...........................................
Tnrtifiratr of f omplinnre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by...............................................................
.............. •--•--................. �! --........---•-•-----.......------------...................---•--------------------.
at �i �staller
--------•------------ •-----------------------
has been installed in accordance with the provisions of TIT 5 Thee Sfate_Sanitary Code as described in the
application for Disposal Works Construction Permit No...._.....l�..................v/............. dated-...-_.--_-_.--_--..-_.__-_---_--_---_-_-------.
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..... '`�._ 1 Inspect .
....: .. `�. -.-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H A TH
..............OF..............---....---------------••----------................. �d
No.... ................ FEE........................
Biupuunl Vorkv Tun#r ion rrmit
Permissionis hereby granted....................................------•--.......--------------------.....----•---••----------...------.......----•---•---...........-•---
to Construct (� r >r ( ) an Individual Se gage Disposal Syst
at No.-•--.....L4-....... <� = i
•. -•...................... ..
Street
as shown on the application for Disposal Works Construction Permit No.__._./______________ Dated..........................................
.........................•---•---------------•-------------•---•--------•-••-----••-----•--...-----.•--•-
Board of Health
DATE.
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
GENERAL NOTES.' �;RN SOIL TEST PIT DATA
I. THIS PLAN IS FOR THE DESIGN AND Y' `ore �� 2' L d T���s 'P- 91 52-
CONSTRUCTION OF THE SEMAGE DISPOSAL INVERT EL EYA TIONS_' �--f �•r.a rr r�-r t or� 19ND. _PEEN. 101, 30 GRND
0 T.P. . o I s b
. ELEV.
FACIL I TY ONLY. 9 q O O G. Y. EL EV. �- G. h'. E!_FV.
INVERT AT BIIT DING
2. ALL CONSTRUCTION METHODS AND MA TERIA!_S INVERT IN A T SEPTIC TANK 973,10 t
FOR THE SEPTIC SYSTEM SHALL CONFORM4 Fl LL
TO MASS. D.E. 0.E. TITLE 5 AND LOCAL INVERT OUT AT SEPTIC TANK 9 g• 14 loZ' `3 ACCESS COVERS MUST BE Y.TTHIN 12 OF FINISH GRADE. 2,
BOARD OF HEAL TH REGULA TIONS. ) INDIC TFS
INVERT IN AT DIST. BOX °1-7•1� - - / 3•ra T6PSo1L d
q [ 'O �-�,� — y PETIC. Tf-ST
3. ALL SEPTIC SYSTEM COMPONENTS SUBJECT TO INVERT OUT AT DIST. BOX 9-7, 5 6 - - - -�- —
VEHICLE L OADING (I.E. UNDER DRI YEW YS, ETC.) -`I'I�- 5 V So t t I s
SHALL BE DESIGNED TO MI THSTAND H-20 LOADING. INVERT IN AT G ALL E� q 6,5 — MIN. 2+ OF .r 5 V�i o)L I 8
3 d q . I C7 l 4' MIN. ' --1 � 1/8 -1/2 DIA. �--�-
BOTTOM OF 6ALL F,r5 g 3, — I YASHF_D STONE INDICt1 TES
4. ALL SEMER PIPE SHALL BE SCH_FOUL E 40 OR L IOUID j OBS.`h'Vf-D s LYE 5,g
APPROVED EQUAL. OBSERVED GROUNDMA TER �0 DEPTH �—�' Z �•5 ►� - C
GROU�Dh A TFR
AD✓LISTED GROUNDMA TER i.�o�,�- 10 N_ DIST. N �� 3/4'-1 1/2' DIA. t� M - C
5. BEFORE STARTING CONSTRUCTION CALL DIG SAFE mJr, _--�} IS O GAL. BOX W� WASHED STONE
1-800-322-4844 FOR LOCATION OF ^' S *-' I
UNDERGROUND UTILITIES.TIES. SEPTIC TANK C H_ O I I
�3 �O NJ.TCt1 TFS
I C 1-1-1 ---i-- TEST PIT
6. DATUM IS S S UM>Ez7 3� 4
i
7. THE CLIENT SHALL REMAIN RESPONSIBLE FOR - -
OBTAINING ALL PERMITS, SPFCIAI. PERMITS, I � 1-4� W'f�a ►-�O y✓A�Y��L
VARIANCES, ETC. FOR THIS PROJECT. m ,
DATF_.- 11 I CD q 3
B. IT SHALL REMAIN THE CLIENT'S RESPONSIBILITY
TO HAVE THE PROPOSED DA&LING FOUNDATION �� - 2-0 TEST BY- PLC 5V9NS11tZG euG6�1taG-
DESIGNED TO ACCOUNT FOR THE EXISTING GRADE WITNESSED SSED B Y. S,
AND SOIL CONDITIONS AT THE LOCATION OF THE - --
PROPOSED DMELLING. of M PERC. RATE MIN./ IN. I M-C SA p.l-D
5—VK t-r C,U T AA T3 t `
F L_I M 11Ja -f�T7 1 A ROGER
tiN i `YLi_ li.
1
v MICHNIEWICZ 32;',
o F C o t.l �"r R u Cr101�! No.30420 P D.FSIG/�.r CFI TF_/?l�'.'
tzb Y05 sv G A L1,cTs .o,9�, C IVIL �p
Fr_ow.
�1-1 4 �'� 0 P- S L) 1 �/� $ L� rU � � L 8 �is��'N _�_ H_DROn�! Dl✓F-l_L.ING P 110 GAL/DA Y PF-P 13FDR00Af
h t-'TJ 1�S D G �?.OUNUVU�k'T�R A-r L ,bas' `'f 7Z'6'Q� /2,G 434
DA TE PR SSIONAL ENGINEER CI VIL DA TE P OF IO L ANDS V Y R FGUQL 5 o GAS S. ,DER DAY.
.SEPTIC TAA NK RFO!/IRFD:
GPO X 150,f
PROP `SEPTIC TANK 150 0 GAL.
9BX20 /s /'1 /� S GA�LL�Y�
CATCH Bd_SI�' I nT T r/ TTl T,7rn
---------------------- - RIM - 96. 16 �'�`/ 3 �6'T01.�� ilATE^- 2. MIN!/TF_S�INc.��
-Qfl, ---
1' `O.`` GALLONS PFI% PAY
'�ts�
q .�C Rr moVE ALL - ,3 S ul'i��3 L� >O ) L SI?F OF /_FACHING Fi?Cl/ITY PROVTO&9'
�- GY. vl1b� Z�»� Q PO Uu� r,
Q .9p0 5 YTTH _a TONE
CATCH IN "ram� "p Fz,O POS ':-..� 3�P T�G 1.�-C 1�r�+••�G - Z
Z Q` FAkG t Lt �"( SIDEWAII 3 6 S.l . X 2 , 5 = 501 0 GPD
J T.P. #1 � � RIM � 98. ��oTTa�y 'L 6 C) S.F. ,Y I, O = J.
2 60 GPD
101. 3 ,,� - �+►--ro L G R,�'.r .. I ►.� GCVO RbG
V41114 T) r L c 5'. C cl TOTAL s 4°I�o 3 So GPn
BrrF_AKOUT CAL COLA TIONS.
Q 1. 5 - /�9'�s •, LvA R SL cPF _—I x 1so '
m II o � aD 1 L EGEND .,.
� Rai 5 < `. 4
% .
—50— = EXISTING CONTOUR PFv-/i;TONS.'
>'o Nsp��a N t P Ro F- `moo.` _ NO. i/A TF RF_ VI5I011/
n z o� Sa a C,A�L . �, -z - PROPOSED CONTOUR
e� l�°y, s E PT I G
m \ /1°4��'a4i T�'` ` 50 = PROPOSED SPOT GRADE -
c P DIRECTION OF STORMWA i L
RUNOFF
4-" CA 7:H ASIN
LOT 53 �" �_ '�RIM = 9. 7 4
JOG 46973f S.F.
)
289. 14 �� o PLAN SHOWNING THE DESIGN OF A PROPOSED
ItNa - SUBSURFACE SEPTIC DISPOSAL SYSTEM
LOT 53, MISTIC DRIVE, BARNSTABLE, MA
SCALE 1 " = 40 ' NOVEMBER 29, 1993
i tJ S L0`r L S 1-0Cobv`rV b EAG,!E SURVEYING cC ENGINEERING, INC.
-Q G R,0 U V-.3'V WA1''9,R 441 ROUTE 130, SANDWICH, MA
PROJECT NUMBER 93-150
GENERAL NOTES.'
�:-►-� rti�'. GALLi -'C S �'1_ ;'�=cl i-�IT D,�1 Tt
1. THIS PLAN IS FOR THE DESIGN AND T G P O F
CONSTRUCTION OF THE SEWAGE DISPOSAL P-1, �f�T I_:' V TT f9/S_' ; 1�nA,T j o,,, T.P. -1 T.P. ��
FACILITY ONL Y.
INVFRT A T MY!'DIN', 9 q, O O t G`{ n b'. j/. ,l EV.
2. ALL CONSTRUCTION METHODS AND MATERIALS INVFRT IN A T SL-PTIC TANK g®.-7 0 _
FOR THE SEPTIC SYSTEM SHALL CONFORM t o�,�_n --�TO MASS. D.E. 0.E. TITLE 5 AND LOCAL INVFRT OUT AT SEPTIC TANK 9 a• U 5 ACCESS COVERS MUST BE WI,7HIN 12' OF FINISH Gr;aO_.
BOARD OF HEAL TH REGULATIONS. I
INVERT -IN AT DIST. BOX 37•-75 I/rDI '"C.;' 3 i. 'r0PSD1L
3. ALL SEPTIC SYSTEM COMPONENTS SUBJECT TO INVFRT OUT A r ,DIST. BOX 9-7• g 9 9 ' _31
— _ `1,� _ PEfrc. 'T '.J
Tb � ol� •r
VEHICLE LOADING (I.E. UNDER DRIVEWA YS, ETC.l `-f 1 f fc-_
SHALL BE DESIGNED TO WITHSTAND H-20 L OADI/UG. INVERT IN A I C,A"E�'S q 6 5 - �>IN. 2' OF a
BOTTOM OF GALL � J 3. 3 d .714 ' MIN. ' --- , 2 - 1/H'-112' DIA. 11�5�1 L'
4. ALL SEWER PIPE SHALL BE SCHF_DULE 40 OR L 10010. NCI SHED STONE INDIC�a TES g i L=r '
APPROVED EOUAL. OBSERVED SPOUT'✓,�),VA/ER ►-'0 tis F DEPTH 5 ,`;';D 7 .�'►„D t� - C
ADJUSTED GROUNDr✓A TFq + o+� +� !0 DIST. k l 3/�t'-1 1/2' DI GHOU\U/hA 1 i_=R I '
5. BEFORE STARTING CONSTRUCTION CALL DIG SAFE min: _ v O GAL. BOX �, ? irASHEO STON ►`n
1-800-322-4844 FOR LOCATION LlF m - I S; ;�-j
UNDERGROUND UTIL I TIES. SEPTIC TANK IND.,,;
� -P
6. DATUM IS �SSUM D 3 q 7. THE CLIENT SHALL REMAIN RESPONSIBLE FOR
OBTAINING ALL PERMITS, SPECIAL PF_RVITS, ;a ' Ira'
- -..
VARIANCES, ETC. FOR THIS PROJECT.
B. IT SHALL REMAIN THE CLIENT'S RESPONSIBILITY S ��
TO HA XE THE PROPOSED DWELL ING FOUNDATION CH .- �_v �
DESIGNED TO ACCOUNT FOR THE EXISTING GRADE �'I TN�SScD B y'• �^,
AND SOIL CONDITIONS AT THE LOCATION OF THE b L)N
PROPOSED DWELLING. -
�, PEW.LRC. rE -_ Z_ ,�IIN./ IN.
H auot yN 6't Li '
r 1�Gft3'rbR)�1✓D AT 'S)a i�, 11 OF 1Z L)C l�1 0)J MICHNIEWICZ � •;;�
No.3G420
TNc rv-ovoSE-p GALz�', (s `; -3� CIVIL
C A 1-� �L S��' 11-i 1' M -G `/A DESI[ilV Ff_G'i;''
4 F F S IJ 1 `�� 8 L �O 0 L B �-, 7'�3 9,j `
L1IiVG tl 1!0
L`rS `T /2,G 93 c-
l2.6
DATE PR SSIONAL ENGINEER CI!/IL DATE P OF IO LAND S I Y R EOUA`.'.' -� G,a._ PER G'.1Y.
SEPTIC TAi✓K
55 o (,PrJ X '56-4 G iL.
`'K S.�=PTIC T,11#( `�0 0 CAL.
9BX20 5 L� >rL��
CA TCH 3AS- / ' _
--------- •-- ------------ _ RIM = 98. 16 ��1 �TD1.� T'� Ur ti CI!_ITY
_sip _ 6ALL 'AIS PEf;' DAY
0
.9 T•�C ti' .Mavl� ALL L �.-i 5 UI `S A*8 Lf, Sb ) L �I�E OF f_F_4L LNG FW,l'.ITY PROVIDES'
q, .i'�O. �-� A 1 ��- c`r 11 b'� Z C�11u A CO L)u TJ rj'- GALL L_ -'`; ✓I Th' - - TONE
-rN�. 'P RO PCB S G `.3 P T1 G L PA G1•-1 1 t-i CG
Z� �;� CATCH IN ;-.�G�L� �"� ��IGIr;;aLL ?3 6 �,
J T.P. #1 - = RIM = 98. t .Pc-AGE. �w �� C� --
Z 101. 3 Jv �> >J� i, G R��' .L ►• s ,�G.GO R.t�A 1-aG IOTTU,N z iz O S.F. X _ 1, 0
Q ¢� = ? �. Vu 1 'ti"'�-1 I) T L' e C F F� o-T� C. 4(1 Co ti
l nR O`� YRF_Ah'OUT (,AL CLI A TIO,tiS.'
�N 1
ti p x
o ` ,, •°'' 4PR 7 �, �ti LEGEND
—50— - EXISTING CONTOUR p,L=VI 0/J,
;,i, 0�„�\ P_ o i�50� = PROPOSED CONTOUR NO. ;)II Tt= ; r VISION
/;. cSaaG�L . N�
V �EPTtG (5
As,' ,: �-/�.0 Y m5o = PROPOSED SPOT GRADE --- -- --
n DIRECTION OF STORAWA TER ---- -—
n.
RUNOFF -- -- ---- --- -- - -- -- - -- --
C ' V
� CA)CH ASIN
LOT 53o
46973f S.F.
28-9. 14 o PLAN SHO`✓NING THE DESIGN OF A PROPOSED
It\ C3 SUBSURFACE SEPTIC DISPOSAL_ SYSTEM
L 17T 53, MYSTIC DRIVE, BARNStABLE; MA
SCALE 1 " = 40 ' NOVEMBER 29, 1993
EAGLE SURXEYING S ENGINEERING, INC.
441 ROUTE 130, SANDWICH, MA
g0 �C31
t b)J �'�R GT PROJECT NUMBER 93-150