HomeMy WebLinkAbout0041 OLDE HOMESTEAD DRIVE - Health 41 Olde, Home'stead bride
_--_ - Marstors Mills
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Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Olde Homestead Drive
Property Address
Edward D, James H, &Lesley A. Becker
Owner Owner's Name
information is required for every Marstons Mills, Ma. 02648 3/26/2012
page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.,
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Raymond Dumas I
use the return Name of Inspector
key.
Dumas Landscape Const. Inc.
Company Name
564 Old Stage Rd.
Company Address
a� Centerville, Ma. 02632
City/Town State Zip Code
508-778-0249 S 1437
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the irfs-Wtion. The inspe�o_tion
was performed based on my training and experience in the proper function and=tion
nance_of on siie
sewage disposal systems. I am a DEP approved system inspector pursuant 1540
Title 5(310 CMR 15.000).The system: 3 q�
® Passes ❑ Conditionally Passes ❑ Failsi
❑ Needs Further Evaluation by the Local Approving Authority .9
�y
3/26/2012
Ins ctor s- gnature .Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•11I10 Tdte 5 Official Inspection Form'Subsurfa Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Wj- -
41 Olde Homestead Drive
Property Address "
Edward D, James H, & Lesley A. Becker
Owner Owner's Name
information is required for every Marstons Mills, Ma. 02648 3/26/2012
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
0
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑� N ❑ ND (Explain below):
t5ins-11!10 Title 5 Official Inspection Form:SLdKuftm SB&2ga Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Olde Homestead Drive
Property Address
Edward D, James H, &Lesley A. Becker
Owner Owner's Name
information is required for every Marstons Mills Ma. 02648 3/26/2012
page. CityrFown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
D box is good
❑ 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 ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 41 Olde Homestead Drive
Property Address
Edward D, James H, & Lesley A. Becker
Owner Owner's Name
information is required for every Marstons Mills, Ma. 02648 3/26/2012
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than 1/day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Olde Homestead Drive
Property Address
Edward D, James H, & Lesley A. Becker
Owner Owner's Name
information is required for every Marstons Mills, Ma. 02648 3/26/2012
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ® the system is within 400 feet of a surface drinking water supply
❑ ® the system is within 200 feet of a tributary to a surface drinking water supply
❑ ® the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes".in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Olde Homestead Drive
Property Address
Edward D, James H; & Lesley A. Becker
Owner Owner's Name
information is required for every Marstons Mills Ma. 02648 3/26/2012
page. City/Town State Zip Code Date of Inspection
C. Checklist
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?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•11110 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 41 Olde Homestead Drive
Property Address
Edward D, James H, & Lesley A. Becker
Owner Owner's Name
information is required for every Marstons Mills, Ma. 02648 3/26/2012
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2011, 50000 gallons, 2010 125,000
Sump pump? ❑ Yes ® No
Last date of occupancy: Sept. 2011
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes 'El'
No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Olde Homestead Drive
Property Address
Edward D, James H, & Lesley A. Becker
Owner Owner's Name
information is required for every Marstons Mills Ma. 02648 3/26/2012
page. C4rrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Sept. 2011
Date
Other(describe below):
General Information
Pumping Records:
Source of information: As Per Owner tank pumped 1 year ago
Was system pumped as part of the inspection? ❑ Yes ® 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)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 41 Olde Homestead Drive
Property Address
Edward D, James H, & Lesley A. Becker
Owner Owner's Name
information is required for every IUlarstons Mills, Ma. 02648 3/26/2012
page. CdyRown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
May 13, 1987 Compliance issued
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 21 inches below top of foundation
feet
Material of construction:
❑ cast iron ®40 PVC Black ABS plastic
❑other(explain):
"Distance from private water supply well or suction line: approx 20 ft.
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
all good
Septic Tank(locate on site plan):
Depth below grade: 10 inches
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallon precast tank
Sludge depth: none
t5ins 11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Olde Homestead Drive
Property Address
Edward D, James H, & Lesley A. Becker
Owner Owners Name
information is required for every Marstons Mills, Ma. 02648 3/26/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle all water
Scum thickness none
Distance from top of scum to top of outlet tee or baffle none
Distance from bottom of scum to bottom of outlet tee or baffle none
How were dimensions determined? removed covers, visual inspection
and stick tank with a stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not needed at this time.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 or 17
y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 41 Olde Homestead Drive
Property Address
Edward D, James H, & Lesley A. Becker
Owner Owner's Name
information is required for every Marstons Mills Ma. 02648 3/26/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I allways recommend tank be pumped every 2-3 years,but not needed at this time.
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
`Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Olde Homestead Drive
Property Address
Edward D, James H, &Lesley A. Becker
Owner Owners Name
information is required for every Marstons Mills, Ma. 02648 3/26/2012
ipage. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert at level
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.):
Level and no evidence of carryover
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
6 ft. of riser on precast 600 gallon pit.Cover at grade
t5ins•1 U10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
ID
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Olde Homestead Drive
Property Address
Edward D, James H, & Lesley A. Becker
Owner Owner's Name
information is required for every Marstons Mills Ma. 02648 3/26/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:-
1,600 gallon
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: Precast
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
All good, 2ft of water in pit.
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 u
Dimensions of cesspool °
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-1 vio Title 5 Official Inspection Form:Subsurface Sewage Disposal System-page 13 of 17
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 41 Olde Homestead Drive
Property Address
Edward D, James H, & Lesley A. Becker
Owner Owner's Name
information is required for every Marstons Mills Ma. 02648 3/26/2012
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
All good
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31
41 Olde Homestead Drive
Property Address
Edward D, James H, & Lesley A. Becker
Owner Owner's Name
information is
required for every Marstons Mills, Ma. 02648 3/26/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below:
hand-sketch in the area below
® drawing attached separately
t5ins-11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Olde Homestead Drive
Property Address
Edward D, James H, & Lesley A. Becker
Owner Owner's Name
information is required for every Marstons Mills, Ma. 02648 3/26/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 30+feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
GWContours map @ 45 ft
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11110 Title 5 Official Irupection Form:Subsurface Sewage Disposal System•Page 16 of 17
.Commonwealth of Massachusetts
• Tithe 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments
M 41 Olde Homestead Drive
Property Address
Edward D, James H, & Lesley A. Becker
Owner Owner's Name
information is required for every Marstons Mills, Ma. 02648 3/26/2012
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
o
t5ins•1 V10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17
Assessing As-Ruih Cards 3/14/12 3:35 P
j TOWN OF BARNSTABLE
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VILLAGE_ Mc,t i All4 s L :L ASSESSOR'S MAP a LOT •
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INSTALLER`S NAME & PHONE NO. 7`7t-toy a
SEPTIC TANK CAPACITY
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LEACHING FACILITY-.(tgpe}
NO.OF BEDROOMS 3 PRIVATE WELL O PUBLIC CATER
BUILDER OR OWNER
DATE PERMIT LSSUED: IQ -? ,
DATE .'COMPLIANCE ISSUED: �f
VARIANCE GRANTED: Yes No
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http://t6wn.bamstable.ma.us/Assessing/HMdisplay.asVmappar=043052004&seq=1 Page 1 of
1
-jV7q� TOWN OF BARNSTABLE �
LOCATION �� 2-7 SEWAGE # S6- l642
VILLAGE Mc%i oy%S Wt:L ASSESSOR'S MAP & LOT A- -
INSTALLER'S NAME & PHONE NO. 7'7`-09 p
SEPTIC TANK CAPACITY 1 ,60�
LEACHING FACILITY:(type) LekcL, j4 (size) 600
NO. OF BEDROOMS 3n PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER �s,d� lU`�� �,�, G0,
DATE PERMIT ISSUED: 10
DATE .COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No /
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No... .'..... ....... ............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
............�d N---.....o F...... ��E'.t/..............................................................
Applira#ion for Digp,aiiaal Works Tonarurtinn Frrutit
Application is hereby made for a Permit to Construct ( � or Repair ( ) an Individual Sewage Disposal
system at:
,LOT
...............-........ ? -(LD -------1------•-�--•-E-----S•_.TLft/.......DR l,gl'S76!+/S---•----•---------/--L----�----5-----------...-..........._..
L cat on-Address
or No.
e' s---..._._�-.....r. ..._�..�
-----------------
Owner Address
a ---•---------------------------------- -- ........................................ ................................. ..
Instalier Address
PQ� Type of Building Size Lot___��_P?3______Sq. feet
U Dwelling—No. of Bedrooms..................3......................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building
yp g No. of persons..............>'o_----------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ..................................
W Design Flow.........................-5.7 .........gallons per person per day. Total daily flow........_330_ .._______._________.._._gallons.
CY Septic Tank—Liquid capacitv_lPdV.gallons Length._----� Width................ Diameter---------------- Depth................
Disposal Trench—No. __________________ Width.._..__ .._._._.. Total Length____......._._i�._ Total leaching area___._---_- ________sq. ft.
Seepage Pit NO------------ ----- Diameter-___--_-12 Depth below inlet.... .__.._. Total leaching area-��•- ._sq- ft.
Z Cther Distribution box ( K) Dosing tank ( )
aPercolation Test Results Performed by--gym�wrt _. _.__.
a Test Pit No. 1....... ____minutes per inch Depth of Test Pit S_ ...... Depth to ground water...._.—..............
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-____.____--_-_----•___-
-••------•---7.........................
-----•-•................................
xDescription of Soil...........r��..l - pr JJ� -�!!-&
U --------•------. ................--------------•-�_'�'"F�5 V 64jSD.............................................................................................
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 ii I .:
p 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.................................. ..........................................
..._._...!1Q4.? /1b---
Date i
Application Disapproved for the following reasons:-------•----------------------------------------------------------------------••-----------•-•-----------_.._..
........................................................................................................
Date
PermitNo....................................................... Issued-.......................................................
Date
T S
t- Y
No................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� � ....OF.....151)'e V,� 71 > l-/�,
......................•............_..--
k Appliraation for Diopooaal Workii Tomitrurtion "rani#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
'L 0 �- ...�.... t .... "1_ ....._f�l !r1
...... •--
c�i� Address. or t N
..--••-•-- •----------------- o.
Owner Address
Installer Address
Of 3
UType of Building Size Lot...._....;................Sq. feet
Dwelling—No. of Bedrooms..........................................Expansion Attic ( ) Garbage Grinder ( )
004 Other—Type of Building+`!'.��-'!�.��'�>87�. No. of persons..............�............. Showers ( ) — Cafeteria ( )
QI Other fixtures ----- -••--••------------------•-•-•--•-----••-•-
W Design Flow......................... ..........gallons per person per day. Total daily flow........ -�'-�'.........................gallons.
1:4 Septic Tank—Liquid capacity/lAlt'...gallons Length._.._./_...._._ Width................ Diameter---------------- Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area------..i__.-------sq. ft.
Seepage Pit No-----------/------- Diameter......J2-_..... Depth below inlet...zy ....... Total leaching areal.._...I.....sq. ft.
z Other Distribution box (K) Dosin tank ( )
Percolation Test Results Performed by4 A j,V&V C.K..` ..._vel l'5�G.................. Date
..✓��.__�� __.___.._..._..
Test Pit No. 1..........minutes per inch Depth of Test Pit-_1�t_�I.__.. Depth to ground water___________________
rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water___________-____--______
a' .............
--------------------•-•- ......------------------------------------------------------
---------------------------------------------------------
ODescription of Soil..........C � D Il. _5 U � L---•------------------------•--•------...---------------------------...---------•------•-•-----.
V --------------- �V!1�...��
W ...............-------------- ................--•----•-------------•----------------•-•-------•-•--•-•-----••-••---•--•---•--------•-•--•--•-----•••---••--••--•-----•......-•---••-•-•-------------.
UNature of Repairs or Alterations—Answer when applicable................................................................................._..............
-----•-•--------------------------•------••--•-------------•-•---•-•-•--•-••----•-•............---•-•---........------•------•--•-•-------•--------•---••-----•--•••--------••--•--•-•.................
Agreement:
The undersigned agrees to install the aioredescribed Individual Sewage Disposal System in accordance with
the provisions of TI.TI E j o: 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. ,
'Z f
'{ 1
Signed.----- --... .._--=--•------ ----------------•--------...---------•------- �.
Date
ApplicationApproved By..................................... -- ---------------------------------•--------------------- ----•--•!o..I....--�-- ------�----
Dat
Application Disapproved for the following reaso s:..............................................................................................................
_
•-----------------------••-•-------•--.....--•---•-•-------------------------------...----•-----------._.._.........------------------------------------------------------------------------------------.
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............7** .........OF...... Ja1 ! ..................................
C�rr�ifirat#r of (�om�liaaatr�e
TH'S TO CERTIFY That the Individual Sewage Disposal System constructed (/) or Repaired ( }
by ......SGG.. ...........•-•--...--••------•-------•---•-----•-•----••-------•----•----•-••--••--------•-----------••---...-------••----
Install
at 1 D� ..........................e Dr �Y Cr.✓7iF 57161 1) p5'� 44 f1Ys?�T,1/4,' -4-'--1.lC 15
has been instailed in accordance with the provisions of T1TIE j of 4he State Sanitary Cod as d scribed in the
application for Disposal Forks Construction Permit No.....86.-_..Ll._..__. ?..:..... dated......
_2."�_ __:-----------------------
THE
ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAN EE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................4-.. •---1 n...1.1-------------------- Inspector--- �(�
DESIGNING ENGINEER MUST SUPERVISE
THE COMMONWEALTH OF MASSACHUSET&SSTALLATION AND CERTIFY IN WRITING
BOARD OF HEALTH THE SYSTEM WAS INSTALLED IN STRICT
. ACCORDANCE TO PL,W
No.�a (. ..........OF..---•• r��/ t..!. c
................... I FEE........................
Roposaal Workii Cnoatstrur#iort rrmft
Permission is hereby granted..._ ._.1
to Construct (t4 or Repair ( ) an Individual Sew ay DispQs System
at \'o.. 7 _d.. L f t� U ? _...1� ......• ----------•/ 7.'�a� .
.... ... -
Street
as shown on the application for Disposal Works Construction Permit No&6.-_!�4� Dated.._._ip .z---I---.6......._....
---•-------• -------- .....Q......................................................-
�� Board of Health
DATE.......................
a ... .............
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
a
„f
SITE PLAN SHEET I OF 2
{; SCAL E: I z '
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ti (000� % �► Norr.s
----' - I lo'A f�v►�D Fi•t' �s N� 1r
�4j inIhURE TIAAT Prr 15
4or Z6 t�-
o00,
�rF 11n v
of
.. l�2rz3
No. 10,71 .
'GISTE��
FOR ) p
REGISTERED LAND SURVEYOR
�Y �' fi t" r'c, cy.'
t 26NE 1Z M A g-,,i T a r-J h MIL.GS M � -
PLAN .REF. M A C-1 4?� PA 9 T-0r" rc I. 52- DATE 5
BENCH MARK DATUM 1e22G2 M SL 2/\1 JA WM. M. WARW/CK 8 ASSOC., INC.
DOMESTIC WATER SOURCE'22W iJ WA
BOX 80/ - NORTH fA L MOUTH
} FLOOD ZONE. N(eA G MASS. 02556 - (6/7) 563 -2638
LEACHING QASIN SECTION NOT TO SCALE
24C.I.MH COVER
EARTH FILL BRICK AND MORTAR COURSES AS REO'0• TO BRING
COVER TO GRADE
' INLET +B'FLOW LINE /
PIPE -— -- `• - 2'- TO/'WASHED PEA 5TONE FREE OF IRONS,
I ', FINES AND DUST /N PLACE
OPENING WITH 4%B" 4" TO I 12 WASHED CRUSHED STONE FREE OF
OUTER DIAMETER IRONS, FINES AND OUST /N PLACE
ANO / /4„INSIDEY: DIAMETER
'
' I., CONCRETE TO BE 4000 PSI 28 DAYS
+^` '• 2. REINFORCED WITH 6%611 NO. 6 GA. W.W.M.
f r � '3. 2 AND 4 SECTIONS ARE AVAILABLE
•^-_, . ,� �' ILABLE FOR
I 1 GREATER DEPTH REQUIREMENTS
410" —6 3=-� 4. NUMBER OF PITS REQUIRED ON6
MIN. I NOTE: EXCAVATE TO ELEVATION 76•4
EFFECT/VE DIAMETER QR
} (NOT TO EXCEED 3 TIMES EFFECTIVE DEPTH) LOWER AS REQUIRED -TO REMOVE ALL
WATER TABLE - LOAM AND CLAY BENEATH PIT. REPLACE
EXCAVATED MATERIAL WITH CLEAN
TYP/CAL PROFILE GRAVEL TO DESIGNED GRADE.
lB"STD. LT. WGT, C.1.MH COVER
°>�•o '' �°' gam'
4"C.IPIPE' 4"B/T FIBER PIPE
OJI'EL1INS FLOW LINE TIGHT JOINT OUTLET LEVEL
p TO FIRST JOINT
/ /4 00 110 00 11
C.I. TEE 86 ` 1 1 0 1 0 0 1 1
" I I 1000 00 1 1 I I
3• $(p.(o 'SFT PRECAST CONC. �� D/ST. BOX TO BE ' I 1 0 0 0 00 1 1 1 1
0 `�' �/.: AL.SEPTIC TANK INSTALLED ON LEVEL, 11 1 000 00 0 1 1 I
• STABLE BASE 1 if 000 0 0 /,1 1 1
1 11 100 0 0 1 1 1
\SEPTIC TANK TO•BE 1 If 000 0 0 1 11 1 ;
INSTALLED ON LEVEL, I I 1 10010 0 1 1 1 1 ;
STABLE BASE. 1 1 1 0 0 0 0 0 1 1 1 1
r 111100 001111
A N6 BA /N 1 11000 0 0 D I I I
BASE TO BE LEVEL I Igloo O 1 1
SOIL AND PERC. DATA p SSQ�3
PERC. RATE Z MIN. /IN.
011 TEST'PIT NO. I I� TEST PIT NO. 2
i n{�SoIC, O TEST BY �e1Mov� (v'
! ' �vtZ yG� L�I� 7, ��p�yot(� O- Ow
WITNESSED. BY: _I�/� M� �C�41 H
TEST PIT GR. EL. OZ. d
AA �171vM
j �_�� h A IJ D
DATE: J4,S/
.DESIGN DATA GENERAL NOTES
BEDROOMS NO HEAVY EQUIPMENT TO RUN OVER SYSTEM.
DISPOSALS SEPTIC TANK DIST BO
X AN LEACHING BASINS TO BE STANDARD
EST. TOTAL DAILY EFFL: � GPD. PRECAST REINFORCED CONCRETE UNITS.
SEPTIC TANK loyy GAL, ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE
I.
TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE,SIDEWALL AREA Z'SGAL./SQ.FT, MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF
�I BOTTOM AREA I'� GAL./SQ.FT. SANITARY SEWAGE EFFECTIVE ON JULY 11 1977,
i LEACHING REQUIRED Zoo SQ.FT. ANY CHANGES TO THIS PLAN MUST BE
APPROVED BY THE BOARD
ACTUAL LEACHING AR!
OF HEALTH,
Q.FT, AT 'COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE
BOARD OF HEALTH SHALL BE NOTIFIED FOR, INSPECTION.
PITCH ALL SEWER LINES 1/41 / FT. UNLESS INDICATED OTHERWISE.
OF VYIPSEWAGE DISPOSAL SYSTEM
MARTIN �� r� ����1 co
FOR'
w MORAN
2 L-O 27 OL-DE
•e .p t1 34171q��� l-�Olvi. 5�'�D P P.
SCALE AS INDICATED DATE L
' WM. M. WARWICK 8 ASSOC.,'I NC.'.
8OX 801 - -NORTH FAL MOUTH
PROFESSIONAL ENGINEER.
MASS. 02556 - (617156.3-26,38
i
TOWN OF BARNSTABLE
LOCATION LZ4_- Z� O�e a s-�c�� —SEWAGE # S b
VILLAGE 1Mlat5Aov%s 441lt5 ASSESSOR'S MAP 6i LOT y.3 S.1
INSTALLER'S NAME & PRONE NO, �•Z. OEC 5 Gold 7)�-(y {
SEPTIC TANK CAPACITY , doo G �Loti 5
LEACHING FACILITY:(type) L e Kc,(% Q,4 (size) 6 a O
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER 6, 14 P7u,U.-"� G0,
DATE PERMIT ISSUED:
DATE .COUPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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