HomeMy WebLinkAbout0210 OLD MILL ROAD - Health 2io OLD MIL � G�_i. ,� r Sz
A= ��. d�5 KkMAS
TOWN OF BARNSTABLE
LOCATION f/ SE ACE # -}- 7?o
Vv LAGE_ r1ci LA ASSESSOR'S MAY& LOT OL5-
IN7STALLER'S NAME&PHONE NO. X1,6 400 g- Te a-1,C- 77 0_6.r-L
SEPTIC TANK CAPACITY
LEACHING FACIL17IT: (type)} �i �, E; (.1K"s (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE:� -a'- ��`� _COMPLIANCE DATE: 116-1 i -4k
Separation Distance Between'the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Welland 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
4c
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114
».ham.
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,� y 3� pq
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No. t:__ _ Fee
Entered in computer: 1/
4 THE COMMONWEALTH OF MASSACHUSETTS p
Ye
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0[ppficatiou for rit-oo5af *pgtem Cougtructiou Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System 64ndividual Components
Location Address or Lot No.-,;i_�c 010 v\& 02, Own s Name,Address and Tel.No.
Assessor's Map/Parcel -0 e�` us
Map/Parcel � („"2 _61 y
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures ('
Design Flow IAI�ko gallons per day. Calculated daily flow `� � gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank IV-6--r 9c6v = WOO Type of S.A.S. c C;t tC.TP `rOQs
Description of Soil �I�►` c ! 1��
Nature of Repairs or Alterations(Answer when applicable) eLGt " k7
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and place the system in operation until a Certifi-
cate of Compliance issue y ea
Signed Date
Application Approved by Date [ — A7 1g
Application Disapproved for th How g reasons
Permit No. — 7 9d Date Issued
i
TOWN OF BARNSTABLE ;
LOCATION SEWAGE W GE # , 0Jd
VILLAGE
ti,. J/, ASSESSOR'S MAP 8c e _
INSTALLER'S NAME&PHONE NO. /*DL442 e le n-/e- 779- ej
SEPTIC TANK CAPACITY /_<—d 0
LEACHING FACILITY: (type) ruTDad'_ ' (size) 3
NO.OF BEDROOMS_
BUILDER OR OWNER g,,n 21,,.,
PERMTT DATE: 1, COMPLIANCE DATE:
i
Separation Distance Between the:
j Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
VAX,,_
s° �i3•� ��� 33'
_ .. � .. �..k_ "" e M J '."�-'.""t"w e.r"� w'. .. ,�..��...+•yJa-�. r. .t,..�,«.,y�y„r.nw..K..r n.r^—Y• .. .. w�a.wa*+. .
1 -
1� • y...�.-\am ► U`
• No. _ .,., �¢.. .�; Fee Cam/
J- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
0[pplication for M-4pogar *potent Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System XLndividual Components
Location Address or Lot No. V\& ` Own s Name,Address and Tel.
No.
Assessor's Map/Parcel (D
Installer's Name,Address,and Tel.No. Designer?s Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms�t'" Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures G
Design Flow gallons per day. Calculated daily flow ` gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 4�t 5fXI, k COO Type of S.A.S. �G, ���G<<`�_ icrr�l0 QS
Description of Soil VN&Q-0 .S
Nature of Repairs or Alterations(Answer when applicable) U` T+A-
6 C`t �� ck�rJ�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and n place the system in operation until a Certifi-
cate of Compliance leas-be�issu a��ealt .
Signed Date /�Ll
Application Approved by Date/f- - ►7 - g
Application Disapproved for the lowi g reasons
Permit No. F$ Date Issued
THE COMMONWEALTH OF MASSACHUSETTS _7
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded K)
Abandoned( )by 1 -'tri S g;: C _
at — CO 1V:) l v1 t RM has been constructed in accordance
with.the provisions of Title 5 and the for Disposal System Construction Permit No. - 790 dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will fuuction as designed.
Date Inspector
/� ' ———————————————————————————————
No.
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
lwisspogal *p.5tem Construction Permit
Permission is hereby granted to Construct( )Repair( )U grate( andon( )
System located at t
A e M
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: ?�I_7=��5' Approved by
1"197
y g
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
e e.
s 'CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
, hereby certify that the application for disposal works
construction permit signed by me dated 1� ��" � , concerning the LAV� meets all of the
`
property located at ako ®,� �a
following criteria:
cs• There are no wetlands located within 100 feet of the proposed leaching facility
!O•9 The are no private wells within 150 feet of the proposed septic system
- re d
There is no increase in flow and/or change in use proposed
V• There are no variances requested or needed.
If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will =be located less than fourteen (14) feet above the maximum adjusted
groundwater table elevation.
Please complete the following: Z
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map)
B)Observed Groundwater Table Elevation (according to Health Division well map) 5 to
b �-
SIGNED: 1 � DATE: `� 9...
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:eat .
i
G
v
��Ela Town of Barnstable
Department of Health, Safety, and Environmental Services
+ sARNSI'ABLE,
F a��p Public Health Division
367 Main Street, Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
TO: Mr. or Ms. Devlin
210 Old Mill Rd.,
Marstons Mills, MA 02648 DATE: November 19, 1998
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located at 210 Old Mill Rd., Marstons Mills, was
inspected on October 23, 1998, by John Graci, a Massachusetts licensed septic
inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• The liquid level was above the invert of the leaching pit.
• The distribution box was broken
You are ordered to bring the septic system into compliance within two (2) years of the
date of discovery. Therefore, the construction of replacement septic system component(s)
must be completed on or before October 23, 2000.
First, you must hire a licensed Town of Barnstable septic system installer to submit a
sketch diagram of proposed replacement septic system component(s) to the Town of
Barnstable Public Health Division Office (Town Hall, 367 Main Street, Hyannis) that will
bring the septic system into compliance with 310 CMR 15.00, The State Environmental
Code, Title 5.
In the meantime, you shall ensure that no raw sewage discharges onto the surface of the
ground or into any surface waters. You must maintain the system by hiring a licensed
septage hauler to pump the septic system whenever it is necessary.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
ZrOF 'THE BOARD OF HEALTH
as A. McKean, R.S., C.H.O.
Agent of the Board of Health
q\hn11h\&fiIo\tid0L&<. .
Town of Barnstable
Department of Health, Safety, and Environmental Services
+ BARN&rABM
r Public Health Division
fD N10� 367 Main Street, Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
TO: n/I r. D Or.-
2!O p i�A- Y\,kc(( Aeo- d DATE: AJ o f ( 91 !
Ctrs l��s 44:4 A (S
o 26 1-f rd
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located at 10 U4 yu �t( (2-J/
was inspected on Cpc f-Y,L-f Z3, /5yby a r?, ) —a Massachusetts
licensed septic inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: rr
��u OUP
•1'�1 �1 . _. d ��0�('���T11 c�'� ulC w�S r0✓l��'�
You are ordered to bring the septic system into compliance within two (2) years of the
date of discovery. Therefore, the construction of replacement septic system component(s)
must be completed on or before 06,3W , 'ZO(DO I --
First, you must hire a licensed Town of Barnstable septic system installer to submit a
sketch diagram of proposed replacement septic system component(s) to the Town of
Barnstable Public Health Division Office (Town Hall, 367 Main Street, Hyannis) that will
bring the septic system into compliance with 310 CMR 15.00, The State Environmental
Code, Title 5.
In the meantime, you shall ensure that no raw sewage discharges onto the surface of the
ground or into any surface waters. You must maintain the system by hiring a licensed
septage hauler to pump the septic system whenever it is necessary.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
q%=1th\dbfi1a\itle5i.d«
TOWN'OF BARNSTABLE
LOCATION � °; t IA 1- SEWAGE #
VILLAGE N\M�CNS. M4,S, ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY r
LEACHING FACILITY: (type) J6oe� ��� 5) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMPTDATE: COMPLIANCE DATE:
Separation.Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
i .
Commonwealth of Massachusetts
Executive Office of Enviromnental Affairs
Dept. of Environmental Protection Jolm Grad
One winter Street,Boston,Ma. 02108 D.E.P. Title V Septic Inspector
P.O. Box 2119
Teaticket, MA 02536
(508)564-6813
WILLIAM F.WELD
Governor
ARGEO PAUL CELLUCCI
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 210 OLD MILL RD.MARSTONS MILLS MAP 063 PAR 15 LOT 279dress of Owner:
Dare of Inspection: 10/23/98 (If different)
Name of Inspector: JOHN GRACI DEVLIN
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes This Inspection Is based on criteria defined In Title V
code 310 CMR 16.303.My findings are of how the system is
_ Conditionally Passes performing at the time of the inspection.My inspection does
_ Neeiubmit
F ther Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the
septic system and any of its components useful life.
x Fail
Inspector's Signature: Date: 10124198
The System Inspector shall a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C,or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair,passes inspection.
'indicate yes,no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
CoThpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection, or
the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exhitration, or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(reyf:baoanr>9�I .
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 210 OLD MILL RD.MARSTONS MILLS MAP 063 PAR 15 LOT 279
Owner: DEVLIN
Date of Inspection:10123199
— Sew.age backup or.hreakoutor hiah.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
—The system required pumping more than four 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
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 the public health, safety and the environment.
1.) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
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.
2i SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
— The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
— The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
— The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
— The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must Indicate either"Yes"or"No"as to each of the following:
x I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
_ _X_ Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
_ x_ Discharge or ponding of effluent to the surface of the ground or surface waters dire to an overloaded or r,lnpged
cesspool
x_ — SAS is in hydraulic failure.
(reylsed 0427197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 210 OLD MILL RD.MARSTONS MILLS MAP 063 PAR 15 LOT 279
Owner: DEVLIN
Date of Inspection:10123199
D] SYSTEM FAILS(continued)
Yes No
x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
x Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
—X. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
x Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
x the system is within 400 feet of a surface drinking water supply
x the system is within 200 feet of a tributary to a surface drinking water supply
_ x 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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
trevlaed 04RT197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 210 OLD MILL RD.MARSTONS MILLS MAP 063 PAR 15 LOT 279
Owner: DEVLIN
Date of Inspection:10123198
Cheek if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
,c_ _ Pumping information was requested of the owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
— flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
x — As built plans have been obtained and examined. Note if they are not available with N/A.
x The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
_c_ — The site was inspected for signs of breakout.
x All system components,excluding the Soil Absorption System, have been located on the site.
x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected
for condition of baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge,depth of scum.
r. The size and location of the Soil Absorption System on the site has been determined based on
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
— — unacceptable)]15.302(3)(b)]
(revlaed 04J2 i MT)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 210 OLD MILL RD.MARSTONS MILLS MAP 063 PAR 15 LOT 279
Owner: DEVLIN
Date of Inspection:10123199
FLOW CONDITIONS
RESIDENTIAL:
Des gn flow: 440 9 P d./bedroom for S.A.S.
Number of bedrooms: 4
Number of current residents: 3
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Ye:
Seasonal use(yes or no): No
Water meter readings, if available:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy: nla
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: nra
Last date of occupancy: nfa
OTHER:(Describe) r9a
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
nla
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: Na
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date Installed(if known)and source information:
SYSTEM WAS INSTALLED IN 1986
Sewage odors detected when arriving at the site: (yes or no) No
(revlaed 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 210 OLD MILL RD.MARSTONS MILLS MAP 063 PAR 15 LOT 279
Owner: DEVLIN
Date of Inspection:10f23198
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 2'
Material of construction:x concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age ale . Is age confirmed by Certificate of Compliance No (YeSINo)
Dimensions: Le'5--H5•7--w4-10'-
Sludge depth:10'
Distance from top of sludge to bottom of outlet tee or baffle: 24"
Scum thickness:V
Distance from top of scum to top of outlet tee or baffle:5"
Distance form bottom of scum to bottom of outlet tee or baffle:e"
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND THEN MAINTAINED EVERY TWO YEARS.
GREASE TRAP:
(locate on site plan)
Depth below grade: rda
Material of construction: concrete metal FRP Polyethylene_other(explain)
Dimensions: rda
Scum thickness:rva
Distance from top of scum to top of outlet tee or baffle:Wa
Distance from bottom of scum to bottom of outlet tee or baffle: rda
Date of last pumpingn*
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
rda
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2-6--
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction line•rOWN
Diameter: rda_
gr�mments: (conditions of joints,venting,evidence of leakage, etc.)
(reYleed 04127,97)
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 210 OLD MILL RD.MARSTONS MILLS MAP 063 PAR 15 LOT 279
Owner: DEVLIN
Date of Inspection:10123199
TIGHT OR HOLDING TANK:
(Locate on site plan)
Depth below grade: rda
Material of construction:_concrete_metal_FRP_Polyethylene_ other(explain)
Dimensions: rda
Capacity: rda gallons
Design flow: rda gallons/day
Alarm level:_nta Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rva
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: nla
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
DISTRIBUnON BOX IS BROKEN AND MUST BE REPLACED
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_ve:
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
rda
pevreed 04.27l87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 210 OLD MILL RD.MARSTONS MILLS MAP 063 PAR 15 LOT 279
Owner: DEVLIN
Date of Inspection:10123199
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Na
Type:
leaching pits, number: 1000 GALLON LEACH PIT
leaching chambers,number:Na
leaching galleries, number: Na
leaching trenches, number,length: Na
leaching fields, number, dimensions:Na
overflow cesspool,nurrber:Na
Alternate system: Na Name of Technology:_Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
THE LEACH PIT IS IN HYDRAULIC FAILURE,URUID LEVEL IS OVER INVERT,PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING. `
CESSPOOLS:
(locate on site plan)
Number and configuration: Na
Depth-top of liquid to inlet invert: i1a
Depth of solids layer: -Oa
Depth of scum layer: rva
Dimensions of cesspool: Na
Materials of construction: Na
Indication of groundwater: Na
inflow(cesspool must be pumped as part of inspection)
Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Na
PRIVY:
(locate on site plan)
Materials of construction: Na Dimensions: Na
Depth of solids: Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Na
(revlaed 04127-197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contlnued)
210 OLD MILL RD.MARSTONS MILLS MAP 063 PAR 15 LOT 279
DEVLIN
10/23198
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
pe&
a
AA
A-R a-7L
M '3y
A� Li6
Pay ! of 10
{revlaed 04R719T)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
210 OLD MILL RD.MARSTONS MILLS MAP 053 PAR 15 LOT 279
DEVLIN
10123/99
Depth of groundwater 12.
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping.records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS MAPS AND CHARTS
(revised04127197) rate 10 at I0
OCATION r SEWAGE PERMIT NO,
_-�2 7
VILLAGE
INS LLER'S NAME i ADDRESS
@ 6/ !-r
S U I DER o OWNER
L-LDATE PERMIT ISSUED
M
"DATE COMPLIANCE ISSUED
��. . ��
_ � -�y�
�`: �
s i
No.. .... ��..�. a'�� ' F�s....... . P...._.....
THE COMMONWEALTH OF MASSACHUSETTS . .
BOARD OF HEALTH
1 .5
................................OF............... .
Appl ration for Disposal Works Tonstrur#ion rrrmi#
Application is hereby made for a Permit to Construct (7) 0r Repair ( ) an Individual Sewage Disposal
r
System at:
..... _MIL ...._ ....................................... .......................................... -7- --•••.........................••-••••••--
Location-Address + e or Lot No..
................ _.... _./Aa.ZkX------------------- ----•------------_ .' ................... ........-•.........•----...--••-_..-••-••---._..................--.....
Ow er •-•- Address
........................ ••... ....�_'k S).ej....---•----•--------•-•.... ................... •----..........
Installer Address
Type of Building Size Lot...QQf.CSq. feet
U Dwelling—No. of Bedrooms...........0...........................Expansion Attic ( ) Garbage Grinder
Other—T e of Building No, of persons............................ Showers — Cafeteria
Aa Other fixtures ..............................
Design Flow.................//`_ ................gallons per set per day. Total daily flow................. .6.0..............gallons.
W [aD(� i .. i /. i ii
WSeptic Tank—Liquid ca.pacity.l...._.__._gallons Length.$_.fo..._.. Width .._/..._._. Diameter................ Depth_c5_..�.....
x Disposal Trench—No..................... Width.................... Total Length...... Total leaching area...................sq. ft.
Seepage Pit No---------f._...:... >ameter.__..� _. Depth below inlet........... Total leaching area..Z��..�.sq. ft.
Z Other Distribution box ( ✓) Dosing tank ( n
o_4 -Percolation Test Results Performed by........... ., .. _ �u_ Date.....9:nL6o._._-,F_3......
a Test Pit No. L.�-.4k.._minutes per inch Depth of Test Pit.......Z— Depth to ground water
Test Pit No. 2................minutes per inch Depth of Test Pit.......:------------ Depth to ground water........................
w - ----------------------------------------------•-----------•.--------•------------•-----•-------------.-------------••-------------••--
O - n
Description of Soil.... ;� �;....�A.... '.. C� ----�� - ------------------------------
c.�
W ........................................:.................................................................................................................................................................
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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
Tt �untillate of Compliance has been issued by the board health.
Signed.... ... G`"¢� f / o
Date
Application Approved By..... --•-----------------
Date
-Application Disapproved for the following reaso :.........................••---.........•-•-..._.......••••...•••••-••--•----•---•-•...._...-••••--••••••.._...
•.........................................................................................................----------------------------------.........----------------------------------------------•••---
Date
Permit No......... 4 g-N Issued_._---•-------------
........................................... •- - •--
Date
r; /..�.f.C. / i` ✓
No.. F>l ... .....
Y THEOCOMMONWEAL'TH OF MASSACHUSETTS �'•
" BOARD OF HEALTH `
4-�;� ` � /�,Q _
5 ,TZ�C.IJ..CJ .. ....OF............ . ...rl..tt=.!.; ....vC. 1f
ApplieatWu for Disposal Works Tonsiruition Omit -
Application, hereby made for a Permit to Construct` ( ) or Repair ( ) an Individual Sewage. Disposal
System at: ;
........................................ . 4' ....: ..................... ........................................
tF� 4_1
{ Locatlbn--Adddress or Lot No.
.._ <i 4.ir.'•f- - T' 'I"....................................... ..............................................................................................s'
Ow er Address
W .- ,� .11..D.ln.l.4�``.,r ---- .................................
-= $ - --•-•---...---••--•......... .............•--••----•........---- -----
;`` Installer --,Address '
\` Type of Building Size,,l;o0LQQ�. Sq. feet
Dwellin No. of Bedrooms S3...........................Expansion Attic ( ) Garbage Grinder (A410
\. g
p, Other—Type of Building ............................ No. of persons......................... Showers ( ) — Cafeteria ( )
W`S 1 Other fixtures .-----_-------.---_-_--- .
......................................
Design Flow---. --•------ ----------------gallons per peFsoR per day. Total daily flow---. ... .__s7ry_ _C ..............gallons
.
WSeptic Tank—Liquid capacity./ Qgallons I. ngth R__lam`.... Width_._/U.--- Diameter................ Depth: :--------- ;
x Disposal'Trencli No.--_---------------- Width.. I!..... Total Length........ . Total leaching area....................sqQ ft. r
Seepage Pit No........ . ........ iameter-....1�_._... Depth below inlet..... ... �_. Total leaching area_?f�..�.sq: ft. l
Z Other Distribution box ( r/) 'Dosing tank ( )
Percolation Test Results Performed by........... r_5 ... .-Dke Date..... - _.-_-.
•-mow
,tea Test Pit No. L. _.6_..minutes per inch Depth of Test Pit......f`....... Depth to ground water7....Lz-
fi, Test Pit No. 2................niinutes per inch Depth of Test Pit.................... Depth to ground water..........._............
_
O ; Description of=So :��.. - 11 45l�.�f------------------------n....----------•-------.............._....--•-- ---- .
;
W F`
U Nature of Repairs or Alterations—Answer when applicable................................................................................_.__..........
y
Agreement: '
The undersigned agrees to install the,aforedescribed Individual Sewage Disp so al System in accordance with
the rorisions of TITLE 5 of the State Sanitary Code— The undersigned further'agrees not to place the system in
ratigountil a Certificate of Compliance has been issued by the board o health.
/-
Signed.... ' .Gtr2`�.............................
Application Approved By,...... .. .._ ............... ...........•--......._ .....------....._..Date
Dare
Application Disapproved for the following reaso -----------------•---...............------------....----••-•---------------------....--•------•---•---_._...
Date
4 ,
Permit No...... � ----------------- Issued.......--------.....-- ..-•--•-
+• .._ Date - .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD -OF -HEALTH -`
..........................................OF.................................................i.Itk............................. .
Trr#ifkatr of faoutlrlittttir
THIS IS TO CE TIFY, That the Individual Sewage Disposal System constructed (.,�) or Repaired ( )
I
Al
b -- - .. --------------------------------------------f-----•-----------------••---------•--•---------••---._.!....-
3 Installer
t.._..._.. a._ ..9... C .�-------------------------•--------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. .S_y�..�_�/___..__.. dated._....: :....................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE_ ' } . ' •.
��-- .
y ................. Inspector....___
_ve ... _ -__ `
THE COMMONWEALTH OF MASSACHUSETTS
x
BOARD OFHEALTH
.r .r .r•
No.. -. OF......................:...... FEE.... ...............
w. �t ltu�tl ox Tons#rudiott 10Pruttt
Permission is hereby granted.................. ----...._. o...........••-- :--- .._.....
to Construct (' ) r Repair ( ) an Individual Sevtraget Disposal Syst
at No... = =f f---------- --- /........... ........
.. - 'ram?'! ;
Street
as shown oil the application for Disposal Work `Construction Per No______________�____ D' 'd.
.. . -- . ... ............................................
r-!
b ° B r of Health 4.
s
DATE..........- .........f .............................. =o
,s s
20 FT MIN
TOP - OF FOUND. --- __ - -- .
- ---- ---
_'`C EL 10 FT MIN. -
-�-_ CONCRETE
4 SCH. 40 PVC —CLEAN SAND
COVERS PIPE- MIN. PITCH CONCRETE
- /// I/8 PER FT ` COVER
4" CAST IRON I — _ 2 LAYER OF
/ PIPE - MIN. PITCH 12 MAX --- - - \ I/8"- I/2 WASHED
1/4" PER FT _ STONE
_:t
LOW LINE \ i
t1 z
MIN. EL = - -
EL = a EL = r "
EL.= q!, •-7
D I S T EL.= w I
LOCATION MAP
° a �` >
n
BOX =3/4''- 1 1/2" 0 ��° w ~ o a
\\�'3 WASHED STONE d b'o w o
p u U- p 0 D v
` W G ° o
J(J CU GAL PRECAST LEACHING --A --EL
� SEPTIC BASIN OR EQUIV. n ( --------
s. �R TANK
o PROFILE O F GROUND WATER TABLE EL =
SEWAGE DISPOSAL SYSTEM
nT T
SCALE
DESIGN CALCULATIONS SOIL TEST 4
1 TLcf�T' ro'' NUMBER OF BEDROOMS DATE OF SOIL TEST
GARBAGE D'JPO SAL UNIT_
_ WITNESSED B 1`, _ -
TOTAL EST'
^ATED FLOW 3ERCULHi iUN RATE =MIN./INCH
f L:i .r-,f�4 _-- -�—# �`7 ./''// i �► ( GAi /BR./DAY x 8R. _: GAL./DAY
L. -� OBSERVATION HOLE 1 OBSERVATION HOLE 2
REQUIRED SEPTIC TANK CAPACITY... ? � GAL.
III woo ��� 1„ .� ,ter , ;� ACTUAL SIZE OF SEPTIC TANK ,/J� GAL. ,- ELEVAT;Ofi� = 1��' + r-ELEVATION =
! " s
LEACHING AREA REQUIREMENTS
SIDEWALK AREA GAL / S F.
BOTTOM AREA GAL /S.F. _
LEACHING CAPACITY ( BOTTOM + SIDEWALL) . `aJ GAL.
rS - r ' . "� 1 0 3. ''+-� x `D k, k ,to 5,14 ,K
�. f
RE FRVE LE4 H,NG CAPACITY ..... GAL--- - -- . v
NOTES
�� _ I. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM
-f �' TO D E 0 E TITLE 5 AND THE TOWN OF f r -
RULES AND REGULATIONS FOR SUBSURFACE DISPOSAL
S OF SANITARY SE WAGE
�
2.COMPLIANCE WITH ZONING REGULATIONS SHALL BE
ss_p, DETERMINED BY BUILDING INSPECTOR OR BUILDING BUILDING SETBACK REGULATIONS PER BUILDING
f i COMMISSIONER INSPECTOR OR BUILDING COMMISSIONER
1 MIN. FRONT SETBACK
3.EXISTING AND FINAL GRADES SHALL REMAIN ESSEVTIALLY
MIN. REAR SETBACK
THE SAME
-/X5 - ':, V.r1 : �+ 7- INS #�4f -?oi - MIN. SIDE SETBACK
—
ar�E17r,
hG'?. APPROVED = BOARD OF HEALTH
DATE AGENT
-
PROJECT LOCATION
APPLICANT
LEGEND SCALE DR. BY DATE ; '
EXISTING SPOT ELEVATIONS 0OxO
JOB NO APPD. BY REV.
EXISTING CONTOUR - -- - - - 00 - - - - -
FINAL SPOT ELEVATIONS o0.0 R J O�HEARN
FINAL CONTOUR S ., INC. DRAWING
SOIL TEST LOCATION REG. LAND SURVEYORS- REG. SAN/TARIANS NO. '
- SITE PLAN 1348 ROUTE /34 - O. BOX /263
F EAST DENNI S MASS. O F _
I