HomeMy WebLinkAbout0256 MISTIC DRIVE - Health 256 MISTIC` %bMARSTONS MH LS
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTALROTP,(-Tjnv
RECEIVED
0 12004
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: cZ$6 r ��# �nY� =ViAP
5---^- .�
•
Owner's Name: S t p Geos +e�rla `'^RCEI.,
Owner's Address:
Bate of Inspection- 121aesbN4 INC IVA,MA
Name of Inspector=esse rint) %c6r .Company Name: krk arsrow A0.r0Ll i rs ca�S
Mailing Address: XD o
Telephone Number: ,Sa$-
CERTIFICATION STATEMENT
I certify that t 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-W of Title 5(310 CMR 15.000). The system:
x Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: ,s/a a
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 She 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 Itow the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Forth 6/15P-000 page l
Page 2 of I I
OFFICIAL INSPECTION FORM='NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
. PART A
CERTIFICATION(continued)
Property Address: /r(tr c -- P
Owner:- *XkAcla
.`t
Date of inspection: S!7joY'
Inspection Summary: Check A,B,C,D or E I ALWAYS complete all of Section D
A. System Passes: J
___X_ I have-mot 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 to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by oard of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the followmi ements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the tank(whether metal or not)is structurally
unsound,exhibits substantial irtfiliaation or exhltration or 'hue is imminent.System will pass inspection if the
existing tank is replaced with a complying septic.tank as" ved by the Board of Health.
*A metal septic tank will pass inspection if it is y sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is a 'a le-
ND explain:
Observation of sewage backup or Olt or high static water level in the distribution box due to broken or
obstructed pipes)or due to a broken, ed or uneven distattion box.System will pass inspection if(with
approval of Board of Health):
ken p4w(a)we replaced
obstiuctkat its remmoved
distrnlmtkm box is knied or replaced
ND explain:
The system pumping more than 4 times`a year due to broken or obstructed pipe(s).The system will,
pass inspection if th approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
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Page 3 of I I
t
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 0JX Rc 4 �i✓o
r �—
Owner: D
Date of Inspection: p
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determi 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 CM 15.303(i)(b)that the
system is not functioning in a manner which will protect public health,safety d 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 o salt marsh
2. System will fail unless the Board of health(and Public W ter Supplier,if any)determines that the
system is.functioning in a manner that protects the public alth,safety and environment:
_ The system has aseptic tank and soil absorption stem(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water pply.
The system has a septic tank and SAS and a SAS is within a Zone I of a public water supply.
_ The system has a septic tank and SA d the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and AS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Metho d to determine distance
"This system passes if the we ater analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic mpounds indicates that the well is free from pollution from that facility and
the presence of ammonia n' ogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are trigg d.A copy of the analysis must be attached to this form.
3. Other:
a
3
Page 4 of l l
OFFICIAL INSPECTION FORM NOT-FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE D O&4L SYSTEM INSPECTION FORM
PART A.
CERTIFICATION(continued)
Property Address: d s SST/c. Pi�
Owner: qw
Date of Inspection:
A System Failure Criteria applicable to aft 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
�C Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
4' Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow
__T Required pumping more than 4 times in the last year NOT due to clogged or obstructer pipe(s).Number
of times pumped
v Any portion of the SAS,cesspool or privy is below high ground water elevation_
rr 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 I 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 Nthe well water analysis,
performed at a DEP certified laboratory,for cafform bacteria and volatile organs compomads
indicates that the well Is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is egua to or less thm 5 ppm,provided that no other failurecriteria
are triggered.A copy of the analysis must be attached to this form.l
. (Yes/No)The system fails.i have determined that one or more of the above failure criteria exist as
described in 3 10 CMR 15.303,therefore the system fads.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a d of 10,000 gpd to 15,000
gpd-
r ..�
You must indicate either"yes"or"no"to each of the following
(The following criteria apply to large systems.in addition to th aria above)
yes no
the system is within 400 feet of a s drinking water supply
the system is within 200 feet a tributary to a surface drinking water supply
_ the system is I a nitrogen sensitive area(Interim Wellhead Protection Area—IMPA)or a mapped
Zone 11 of a pub' water supply well
If you have answ es"to any question in Section E the system is considered a significant threat,or answered
`'yes"in Secti above the large system has failed.The owner or operator of any large system considered a
significant under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. system owner should contact the appropriate regional office of the Department.
4
Page 5 of I 1
OFFICIIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
/� CHECKLIST
!'1
Property Address: ;c
_
Owner:
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,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?
e , Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
— 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)P 10 CMR 15.302(3)(b)]
5
Page 6 of I 1
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
nn'' SYSTEM INFORMATION
Property Address: �X5% Jar f e J)Pi�
r�
Owner: !moo
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15203(for example: 110 gpd x#of bedrooms):
Number of current residents: .2
Does residence have a garbage grinder(yes or no): / -b
Is laundry on a separate sewage system(yes or no):� [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):LZ
Water meter readings,if available(last 2 years usage Ggpd)): 03 10am 0 l r, l�
Sump pump(yes or no):
Last date of occupancy: C urr tl
COMM ERCIAIANDUSTRIA L
Type of establishment:
Design flow(based on 310 CMR 15.203): apd
Basis of design flow(seats/persons/sgketc.):
Grease trap present(yes-or no):
Industrial waste holding tank presen es or no):_
Non-sanitary waste discharged a Title 5 system(yes or no):_
Water meter readings,if av " le:
Last date of occupanc e:
OTHER(des ):
GENERAL INFORMATION
Pumping Records nn
Source of information:.. Na. iz C c yuWyQ� �V.O
Was system pumped as part of the inspection(yes or no):_��
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all com o ents,date ingoled �owp)and source of information:
Were sewage odors detected when arriving at the site(yes or no): F--
6
a '
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR YOLUINTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: c7 ti C
a
Owner: Akoc(CJ�
Date of Inspection: O
BUILDING SEWER(locate on site plan) .
Depth below grade: 3y
Materials of construction:_cast iron K 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:A (locate on site plan)
Depth below grade: d 7 d
Material of construction:?C concrete metal_fibemass__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: 41 Yt�
Sludge depth: 3 r
Distance from top of sludge to bottom of outlet tee or baffle: e7 S
Scum thickness: *7" N
Distance from top of scum to top of outlet tee or baffle: 7
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: Me*,SNtea
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert evidence of leakageA etc.) � �� � f� CLa
4-00tc 5 SO&A a
d
GREASE TRAP:_(locate on site plan)
Depth below grade:i
Material of construction:_concrete_metal_fiberglass olyethylene other
(explain):
Dimensions:
Scum thickness.-
Distance from top of scum to top of outlet tee baffle:
Distance from bottom of scum to bottom outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommen ions, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,eviden of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: r lam'
Owner:
Date of Inspection: ? �/
TIGHT or HOLDING TANK: (tank must be pumped at ' inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal berglass,polyethylene other(explain):
Dimensions:
Capacity: Kfloat
Design Flow:Alarm present(yes or no):
Alarm level: Alarmes or no):
Date of last pumping:
Comments(condition of ,etc.):
DISTRIBUTION BOX: ( (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:" Or/CA
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage in�t_op�rr out of box,etc.): �f
7LV /a ox vtf cc � �>� t✓c7 K rt0 S t4 k C�f/�j �61GA
i
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):.
Alarms in working order(yes or no):
Comments(note condition of pum ber,condition of pumps and appurtenances,etc):
8
Paee 9 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMEjNTTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: A36b �e
Owner: a�
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
7 leaching pits,number: .?
leaching chambers,n•,unber.
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.): C*j f [ t `L a ck ra K,�✓®
t3 .$
o D�
CESSPOOLS: (cesspool must be pumped as part of' ction)(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 in (,ves or no):
Comments(note condition oil,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 conditio f soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SMS URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: TsG /`f
Owner: aJa
Date of Inspection
i
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.
6 IUD
131
tYa t
• Page l 1 of 11
OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: sc /'s./�
Owner: rs
Date of Inspection: p
SITE EXAM
Slope Y 5
Surface water IJ�
Check cellar Y45
Shallow wells µ+o
Estimated depth to ground water 3b 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: Z
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:
it
11
d 0
No. - -- ------- Fee----- ----- --------
BOARD OF HEALTH / •
TOWN OF BARNSTABLE
p K Application-*rVet[ Congtructionpermit
Application is hereby made for a permit to Construct (Pr, Alter ( ), or Repair ( )an individual Well at:
--b r----lets N-�,s _ I jL-- —— — ----------------------------------
Location — Address Assessors Map and Parcel
?S� M t s1''dZ 0/, -4&Js t_M,/f s ------ -
Owner Address
-SCciw,-„e ll ------------------------------ - o. � e/�a - �" -- - 01)G y - -
Installer — Driller Address
Type of Building
Dwelling-----------------------------------------------------------
Other - Type of Building------------------------------ No. of Persons-----------------------------------------
Type of Well Y r, p_v_e —_--- - ----- Capacity------------------- - -- - - —--—
Purpose of Well-_11__/_�
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until a Certiffiicatee.of Compliance has been issued by the Board of Health.
Signed ---
e date
Application Approved By — - — —
date
Application Disapproved for the following reasons: ---------=------------------------------- ---
_-_---- -- - - --- —---- --- -- - --_--------
date
Permit No. -------- Issued-- -- -� - -------
date— -- -- ---
BOARD OF HEALTH
TOWN OF BARNSTABLE
C ertif irate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed (s-), Altered ( ), or Repaired( )
Installer
at— -=�S� /H i S ��C N�,Lt 1C��c�S /-.As ---— --
has been installed in accordance with the provisions of the Town of Barnstable Boa d of Health-Private rivate Well Protection
Regulation as described in the application for Well Construction Permit NIP� ��� Dated----THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------ —- Inspector--------- - --- —--
�V__ ---No. -- ------- Fee----- ---=-- --- -
-
BOARD OF HEALTH
V
•- � - TOWN OF :BARNSTABLE �
Zip'Cicat ortArVerr CongtructianPermit
"Application is hereby made for a permit to Construct (V5 Alter ( ), or Repair ( )an individual Well at:
AA
r" Location''- Address,,, Assessors Map and Parcel „ -----
6eo�GC_ Js� MtS-ic
Owner Address—— — ---- -
- I
S�unity c l l - - ----- - -- °-- Q� -- G
-
Installer — Driller Address
Type of Building I
Dwelling -----='--------
d---
Other 7.Type of Building =- --- -------------- No. of Persons------------:
T �. e of Well �°j -
YP -- ------ -___--- Capacity--- ----------------------------
Purpose of Well---1!
1 Agreement: I
The undersigned agrees to install the aforedescribed individual well it accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation The undersigned further agrees not to
place the well.in operation until a Certificate,of Compliance has been issued by the Board of Health.
Signed
— Q date
Application'Approved By — �- - -- -
date
Application Disapproved for the following reasons:
date
Permit No. � Issued - - - -
date - ---— ——
.WiY4Tieili9iTiA'. ,E+!il.!69 ai9ea!f+1+4371i1NbiliPi�i,Ei i4e;!Lii'filil�liVild9Yti'f69i1i9i�ilP�iVi9iei N!Ai'�i9iew�is'iai9i9iTi2s?iti�.wliO3litSlG?PliliS9MilifYiEi9i►i4iti^!i i.G^il
BOARD OF HEALTH
OF BARNSTABLE
Certificate Of Compliance
THIS IS TO.CERTIFY., That the Individual Well Constructed (A-), Altered ( ), or Repaired ( j
by---------- ------------------------------
—Installer -----. ---- —
J co r!11 S / �C l.J I�Iq G/S'/fiµ S /1�t �l
at' _
has been installed'in accordance with the provisions of the Town of Barnstable B'oa d of Hea h Private Well Protection
Regulation_as:described in the application for Well Construction Permit No ��� -Dated---- _______
THE ISSUANCE.OF THIS,CERTIFICATE:SHALL NOT-BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY. �d
DATE--- . - - -- Inspector=--=------=- -- —— -
a?�FS h�S4i>e,.+.Y!Yo iPi?Ys'Ss+aFi4Sfi,i .ea-bb0 4iei4i�dC.ifita'%i!r!MT_e1PiLGl36+l0iTi4i4�TGTiCi@i.Ei3 9i:.a3i�AC0@i�YOCOi9i4i�V,�,.+iebfi!iw+i�i.�b!i1i.!if��ili9iSi!69i�iii++�i?iRi+M
BOARD OF HEALTH 3
TOWN OF BARNSTABLE I
Vert Contruct ion Hermit
r No. - q..100
Fee----------- --
Permission is hereby granted 0;4 :S&4kvA,e//1
to Construct ( '�, Alter (. ); or Repair ( ) an Individual Well at:
No.—
SSG /1-+rSritl Mo•ST® < M%�s
street ——-r—
as-shown on Eh pl'cation"f•r Well Construction Permit
�.
Dated =
Board of/Health7/
I
DATE
T
f t
No. % '� Fix...✓
THE COMMONWEALTH OF MASSACHUSETTS.
BOARD OF HEALTH ,
.... TOA.p... ...........0 P......... ................ ...:...
Appl ratiun for 3tapusal - urlw TunsI rmton rmit
Application is hereby made,for a Permit to Construct (1'61--ar Repair ( ) an Individual Sewage Disposq..1
Systema-w� ,
I.ociti=•Ad cu of �,ol No.
.«.....«..« «_ « .�.�,�.���«.«.�Pik .._ ««..«�'�, B p�«. G��. •�. �.v�
P GZ 3.
Owna............. .fw :��:..• a `�. .«.« ...� .:4�
Iaatalla A �rcu
Type of Building Size Lot.... feet
Dwelling—No. ........�+ g—No. of Bedrooms.. .... . ..........................Fxpaasioa Attic ( �n Garbage Grinder
124 Other—Type of Building �. . No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ............. .....•..................................................................................��.,T ...«. .......«....
Design Flow..............��..... ....... �y ,,gallons per person peer dhy.•Total daily gow............. 0..............ggljonf,
Septic Tank—Liquid'capaci ..��G.. lons Length...1L1».�..Width..I�P.. .. Diameter.b:?�.f:.. . Depth...... ..
W Disposal Trench—No. b? .A Width. Total Lea Total leaching area................ s ft.
x M.
...... �......�.......... gth........... g q.. I.......,
Seepage Pit No....... ....:...... iameter.... ::s?.... Depth below Inlet....Z:?.::.Z:.. Total leaching area.....r:: `�.....sq. ft.
z Other Distribution box ( ) Dosing tank ( ,r
Percolation Test Results Performed by.............. ., t�Y.. .Jb ......�..t.�..lb.4!E:.':�:.. Date:.....? ::.: ) ...i:.....
_ -
Test Pit No. 1........ ......minutes per inch Depth of Test Pit........3...P..• Depth to ground water......JLJ.M.9.....
w Test Pit No. 2.««...........minutes per inch Depth of Test Pit................«. Depth to ground water... .gcY.iJ:f,�, real
w ......... ......................«.«...«.«.« ......••.«.....«..........•.......... «.... .«
O Description of Soil..... .:.p«..`!.:.:�..�.w.�:4�:1a.....t6 «s..k: «.la 4::�?...... �..'3.L:!.{,:. a:1�...« :
V ....................................Gru�Ct".5.r«.S.g ......!Z.$.Q.....�,..1.:l. a:1.! Jx7... :L:2.t.1..............«...«�«»«..
W
............
V Nature of Repairs or Alterations—Answer when applicable.....
......1,.....A...�::.......................................«..«««.....«...
... .. .. .«..................•............««............«.....................«....«..««:.«..«...... / ......•...............................««............«...
Agreement:.•
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code-t The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss the Bard of health.
Signed,.....( ..« �!`: ...................... !% .1...�.._....
Dat
Application .Approved B -�- «
...:.::._..:ram:......«.«�:....«.... ���$�.......« .....,��.:.�:.. f« ....« '
ate.
Application Disapproved for the following reasons:....««....,...•...«•««•.•......•.•...................«..•.............«.....«««,.«««..««««
«.................«...«•«••«« ......«•••«.....'...•.«w•••••....••...««....w.:':ti.«w«ww•«««.«««.....•..•••.....•...•.........
..Da•
Permit No... .: .::«:.�.. .:«�........ ..«.. Issued........
.. �..` ....«....«
THE COMMONWEALTH OF MASSACHUGET S
W;rA1 Yu -
� '
THE COMMONWEALTH OF MASSACHUSETTS.
BOARD OF HEALTH
............OF.........•3a;.... .3t
.� �rltratiun- fur Movuuttl 31urfs Tvnutr�tun Frruat
Application is hereby made'for a Permit to Construct (�. r Repair ( ) an Individual Sewage Disposal
System at:
Wa ............ »»««.r... ».acitIiao.s.u... «A.d.drwfa .�
.......... ........... ....... a.v
»L«?�..:..�.....�....11et .-.:..... . .... ,.�"�.t-a.�.....L.d..�,.4t...
'.
Addsat
Type of Building C Size Lot....r..1}. »..Sq, feet
u Dwelling—No, of Bedrooms.......... .....Expansion Attic ( n Garbage Grinder ( p
aOther—Type of Building .. ...�i................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures •A . .
Design Flow....................................'�-� ..... � Ions...el...erson........................................................... ..........................
.... ...........
... P P per 4y. Total da#y Aow................` .......»...... �on�f
Septic Tank—Liquid'capacit ..�.��llons Length..lU..—.(�.. Width....&?... Diameter.l:). ...... De th... ..
P
x Disposal Trench—No,.... Width. Total Len Total leaching area............... s . ft.
3 Seepage Pit No.... �........... iameter....0 .::.�?.... Depth below inlet....E.:
....�... Total leaching area.. .. ......sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) _
Percolation Test Results Performed by ' c�.� y..................�.. .......Y.o.�.!l.�:.::...�..�.4A:L-!i:?:�. Date:.....��:'?.::..).�.-.............
Test Pit No. 1................minutes per inch Depth of Test Pit...... .til:?... Depth to ground water.... XtA.t2f..... "�
t=. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water... .g:Y.l� .i�li���
0 ....:.... .......................................................:r............................... .....................................
Descri tion'of Soil....« .:.o �•� �� c +� - 4 T"""""'
x p ...............�«y:? .4f1?....s ::1�. k.1......l.:.Q.......`.::.4?..�.......�... . :?!.{-...t:Q:tt.:. :.:..}........
V ........................ .....::N i:?..�...Fc:.��....,r.��.�...:.�. .r.tJ�.«fi..f:t :I:1.!!.t�
..........................................«::.................................................................... .................................................................
V Nature of Repairs or Alterations—Answer when applicable...........• .....A..:... ............................................................
....................................................................................................................... ...... . „-..................................................»....
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--r The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue ,br the oard of health.
Signed...
Application Approved B -
Application Disapproved for the following reasons:.................. ... Date
/...........................................................„«»«
».............Permit No. .:::-..,,.« --7
......... ..........�.. .....D ...........„
45
.............. »...:.:..»» Issued................ .......... ..
« ate ' •••
THE COMMONWEALTH OF MASSACHUSETTS
BOARD_ 7F HCML T H
..........O F..................................... ....:..... ..
...... .... ............................
• f�rr#�f�c��r of f�uut�l��nrr•. .
F�%IS TO CERTIFY That the In`�jlvidual Sewage Disposal System constructed., ( ) or Repaired ( )
d.... S.».««........:.....I .5�. .:..........:.�......«.....:c: .......»..»..........»»«»»»»«
........... .............................IaWler..............»..... ...........:.........:..... ...«.........«..«
.. ..,..................................................
has been installed in accordance with the provisions of , �T e Sanitary de as described in the
application for Disposal Works Construction Permit'� 'E� �•1 •Statw... . .... ..
. , :::...«::: :......: Y,..r..:. -dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BB CON UED AS A GUARAN THAT THE
SYSTEM WILL FUNCTI��1 SATI O Y.
.. �.............. ...... ... ... ...
DATE.. « 'Inspee r.» ....��':�;:: . .. .
THE COMMONWEALTH.OF MASSACHUSETTS
BOARD OF HEALTH
�tu�uuttl lurks f�unuix�xxfuxri���rrutt� �.
Permission is hereby granted .4_y. I!• ...........�•,: •E/�•E:d •-•��+2? ...........
to Construct ) or Repair ( ) an Individual Sewage Disposal Sys?em «««�•
at NU.... ............4}svl.S:4 .. .......'
Street .• v^' l r ....................�-
as shown on the application for Disposal Works Construction Permit `"' ��--�............. Dated: . »�l...........
FORM 1255 A. M. GUI.KIN, INC., 808TON ,
TOWN OF BARNSTABLE f
LOCATION SEWAGE
VILLAGE ASSESSOR'S MAP & LOTg —Q�
INSTALLER'S NAME & PHONE NO. r,'. �,
SEPTIC TANK CAPACITY /; C
LEACHING FACILITY:(type) 'PA e cAs"r- (size) sl 7
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
Dot OR OWNER %i d.�
DATE PERMIT ISSUED: [
DATE COMPLIANCE ISSUED: �"
VARIANCE GRANTED: Yes No
�`Lr�C3o�
olv
-36 �
s
t
ELEC. M.H.
I LOT 16
80 40 00" (w
LOT 15
340
r' - p
_ ( � p l �A of 41 �An Ur '�4r
1� - .31
O I�Rj ¢� E' c/ �o PAUL �`y s � IOHN
�'jy`4Y -' ° l /w MERITHEW N LANDERS-CAJLEY y
,1 LEACHING o PROPOSED / Q No. 32098 e CIVIL
61 , ol� SE AND � �� 11 l ,� � c; No.35101 -/
PITS o
GGA� 'Pf'EIST
9' 104.,2' '/ ','/ ,j O sue'"cu LAW
RESERVE AREA PROJECT LOCH T/ON
/!
CTILITIES. � C B.
CABLE, TEL & Co / / �� '� �� LOT 15 MISTIC DRIVE
.
ELEC. NO MARSTONS MILLS, MA.
A 6 4
.
ASSESSORS NO. 80-13
S8O 40,00,� - 4 42 _ 40' �'�i
Cs APPLICANT- __ _
/ �� 3� �� no e (�(fin
335 �S� I
NAIL IN PINELOT 14 74.
ELEV=50. 00 (ASS.) ' YANKEE SURVEY CONSULTANTS
�l P. O. BOX 265
UNIT 5, 40B INDUSTRY ROAD
y MARSTONS MILLS, MA. 02648
PH (508)428-0055 - FA X(508)420-555J
e ISCALE.- 1 "=40' DA TE.• . 08- 19-94 {
4 '
F
REV.• REV. 08-24-94
JOB NO. 5055J ,SHEET 1 OF 2.
A
o „
51. 7 'PROPOSED
TOP OF FOUNDATION
20' MIN. k,
10' min CONCRETE COVERS
a
51.0 PROPOSED 51.5E�� 51.5E EXISTING
CONCRETE COVERS 50.0E EXISTING 1ST PIT
j'
12'VAx / / / , i', , , , , / / 52.5E EXISTING 2ND PIT
4"" CAST IRON /
OR SCHEDULE 40 4" SCHEDULE 40 P. V.C. 2"LAYER OF
P. V.C. PIPE I DIST. M N 1/8""_112"'
S=0.02, FLOW LINE
S=0.02, D=105' BOX WASHED STONE
D=25.8 1O"" 5=0.02, D=15
Z. MIN. 19 c PRECAST LEACHING PIT
INVERT 1
EL.=_48.92_ 2" w
q o
INVERT EL.= 48.15 LEVEL o0
EL.=48.40 ° 5' v 0 3.�sH D STUNS
. 1250 GALLONS J EL.=__46.05 EL.=_45.90 EL.= 45.60 00 : oc
SEPTIC TANK ---- ° c� C
EL.=_40.6_
3"I LEACH PIT 13" ---
4 6" .y
PROFILE OF 12'DIAM.
SEWAGE . DISPOSAL SYSTEM
NOT TO SCALE BOTTOM OF TEST HOLE OR VSGS PROBABLE WATER TABLE EL= 39.5_
ALL ELEVATIONS ARE ASSIGNED BOTTOM OF TEST HOLE # 2 IS 13 FEET BELOW SURFACE.
SOIL LOG
J. LANDERS-CA ULEY,PE * THE LEVEL OF HAMLIN POND WAS DETERMINED TO BE AT
WITNESSED BY: J. DUNNING OR BELOW ELEVATION 20. 0. IT IS OUR OPINION THE UND
WATER ALMOST THE SAME AS THE POND. tJA of
P�f 8258 `
GENERAL NOTES PERCOLATION RATE _2 MIN./ INCH 4 LANDEASHCAULEYy!r4
1. THIS PLAN IS FOR THE CONSTRUCTION OF A SEWERAGE DISPOSAL SYSTEM. No. 351 GJ y
01
2 PLAN REFERENCE BOOK 203 PAGE 53, LOT 15 BARN. REG. DEEDS. DATE 08-11-94 DATE �SFpiSTER�G\��``4
3. THIS PLAN IS FOR INSTALLATION/ REPAIR OF SEPTIC SYSTEM TEST HOLE 1 TEST HOLE 2 roN N
AND NOT TO BE USED FOR SURVEYING OR ZONING PURPOSES. DESIGN DA TA.'
= 52.5 �
4. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO R E.P. EL EL- =
TITLE 5 AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS FOUR
0 0.
FOR THE SUBSURFACE DISPOSAL OF SEWAGE. WOOD LOAM NUMBER OF BEDROOMS
5. ALL COVER TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 1.0'
12" OF FINISHED GRADE. SUBSOIL GARBAGE DISPOSAL NONE
6. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY THE 4.0' j SAME AS TOTAL ESTIMATED FLOW 440 GPD
SAME, UNLESS NOTED BY FINAL CONTOURS. 5.0' COARSE SAND
7ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE TEST NO. 1
( _IIO _GAL./BR./DA Y x _4__ BR)
OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER
OR WITHIN 10' OF DRIVES OR PARKING AREAS. H-20 LOADING SEPTIC TANK CAPACITY
SHALL BE USED UNDER OR WITHIN 10' OF DRIVES OR PARKING.
MED. SAND
UNLESS NOTED. f LEACHING AREA REQUIREMENTS
8. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL �_2_ 266*2 5=565 d
SIDEWALL AREA �-�6_ GAL./S.F. gP
BE MORTARED IN PLACE. 13.0' 113 113*1. 0 =113gpd
NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH BOTTOM AREA ____ GAL/S/F
i DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO LEACHING CAPACITY (BOTTOM & SIDEWALLJ 67B*GAL
OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY.
10. THE EXCAVATOR�CONTRACTOR SHALL VERIFY THE LOCATION OF ALL UNDERGROUND * CAPACITY PER PIT
UTILITIES PRIOR TO ANY EXCA VATION. THE WATERGATE WAS NOT FOUND, THE GENERAL RESERVE LEACHING CAPACITY 678* GAL.
CONTRACTOR SHALL VERIFY LOCATION WITH WATER DEPARTMENT. 50553
{ SHEET 2 OF 2. JOB NUMBER_- ---- _____