HomeMy WebLinkAbout0260 OLDE HOMESTEAD DRIVE - Health 260 OWE HOMESTEADVIN-A-
MILLSLi �JV\
I�
-�. TOWN OF BARNSTABLE
LOCATION� 4,te_S7`44D SEWAGE# ('?6
''<_-4 VILLAGE)nyi &0_5 ^t/,e ASSESSOR'S MAP&PARCEL ®1 _
INSTALLER'S NAME&PHONE NO
SEPTIC TANK CAPACITY l0®0
LEACHING FACILITY: ,
(type) O CW.4 k1 V;dC.S (size) / o�
A'
NO ORBEDROOMS
OWNERS.
PERMIT DATE `''COMPLIANCE DATE: 0 � u
,,.
Separation Distance Between the. `
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet r
.Private Water Supply Welland Feaching.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 1(a hin 1ity) Feet
FURNISHED B ' R <' a , /'t `e
,,:
Y O f
41
older ., K _ .
41k? 4 c C)
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OL
No. 2-10 l o Fee U cJl
` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01ppiitation for is os 6pstem Construction Permit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) []Complete System [individual Components
Location Address or Lot N AX
Z� '� Owner's ame Ad re an Tel. o
RV
Assessor's Map/Parcel 00 -� Zed O��
Installer'sCZ:D> Address, d Tel.N . V O� Designees Name��j�dre d Te1..N_q,
Type of Building:
Dwelling No.of Bedrooms v Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.requir d) CD gpd Design flow provided---- gpd
Plan Date Z7p �d Number of sheets l Revision Date
Title 1
Size of Septic Tank ype of S.A.S.
Description of Soil
Nature of Repairs o Alterations(Answer when applicable)
c
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 not to place the systerylln operation until a Certificate of
Compliance has been issued by this Bo h.
Signed DateNJ
1 '�
Application Approved by Date 2
Application Disapproved by Date
for the following reasons
Permit No. � Gf y Date Issued
T—�
-------------------------------------
4?,
No. 0 l o Fee (1/
THE COMMONWEALTH.OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Y•
Qpplicatlon for Mi�poSal 6pstPm Construction Vertu
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) O.Complete System [--Individual Components
Location Address or Lot NoZ� ( Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel Lj
Installer's Name,Address,apd Tel.N . z r Designer's Name,Address•and Tel.No.
Type of Building: y
f
Dwelling' No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons I Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.requir d) _�2J�J gpd Design flow provided — �f�/ gpd
Plan ,� Date _ I C. '" ao I C) "Number of'sheets r Revision Date
Title } ; ' ..
Size of Septic Tank A Type of-S.A.S. ✓
Description of Soil
Nature of Repairs oir Alterations(Answer when applicable)' i. _ l�
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 not to place the syste n operation until a Certificate of
Compliance has been issued by this BMW IHQ4%h.. ' !
Signed Date IC411LA 7 tW24
Na
Application Approved by Date I
Application Disapproved by Date
for the following reasons }'
Permit No.? G 1 GJ �.//y Date IssuedU.
r r
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTI'F�Y,,t�haat the On-site Sewage Disposal system Constructed( ) Repaired(V)� Upgraded( )
Abandoned( )by
at Zk0 Apal 20 _ has been constructed in accordance
with the provisions of Title 5 and the for Disposal stem Construction Permit No. u �I— dated b .2 f
Installer G (�� � � . Designer LE) A
#bedrooms t Approved design flow gpd
The issuance of th's permi shall not be construed as a guarantee that the system wil func n as designed. n f
Date I "i Inspector k (�J
No. a O I - l'/ (V Fee /DG'
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
mispoSal *pstem Construction Permit ;
Permission is hereby grz nted to Construct( ) , Repair Upgrade( ) Abandon( )
System located at 14nik 511t I U 1
42
and as described i the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction m st be co pleted within three years of the date of this permit. (`
Date / Approved by ln/
Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
Public Health Division
;9. Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Date:IV SSewage Permit# D Assessor's Map/ParcelIL
Installer&Designer Certification Form
Designer: 0r V0&,� Installer:
Address: 404 Address: QUIT
On4r) -
as issued a permit to install a
(da ) ins
septic system at �L� IM- based on a design drawn by
(address)
dated
(designer)
t
I certify that the septic system referenced above was installed substantially according to
-the design, which may include minor approved changes such as lateral relocation of the .
&slribution box and/or septic tank. Stripout (if required) was inspected and the soils
.were-Yound satisfactory.
I certify that the. septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of-any component
of the septic system.).but in accordance with State&Local R- -'-Lions. Plan revision or
certified as-built by designer to follow. Stripout(if rP -Acted and the soils
4ta
found satisfactory. �y-H OF Mks
DBID
er' Signature) g MASONN"'i
v � No.1066 C
�3T
q
esi er s Signature) �' \
PLEASE RETURN TO BARNSTABLE PUBLa.
OF COMPLIANCE WILL. NOT BE ISSUED: UN i iL Hsu 1 n i gib YORK AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
q:btFice form\dwiperwrffiication fonn.doc .
TOWN OF BARNS
STABLE ✓
LOCATION SEWAGE #
y,MLAGE C .S l `' 'ML—XSSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY ` y®
LEACHING FACIUT Y: (type) (size) (0 t LI
NO.OF BEDROOMS _
BUILDER OR OWNER �
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
P
AC
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f3� 37
gc sl
o 6 TOWN OF BA RNSTABLE
LOCATION tc4 Z. �� 44 C -74,,k ;SEWAGE #_ e66
VILLAGE 11Ll-,S54av%5 Wt i tLS ASSESSOR'S MAP & LOT 3 /
r INSTALLER'S NAME & PHONE NO.
SEPTIC TANK'CAPACITY ►DGo
` LEACHING FACILITY:(type) br-1,at, fl' (size) (`6�) a.f ljk,
t� 7
NO. OF BEDROOMS 7 PRIVATE WELL OPUBLIC WATER
BUILDER OR OWNER PJA S� �(�� ��Ln
DATE PERMIT ISSUED: /loll ',� , )q_6
DATE COLIPLIANCE ISSUED:
VARIANCE GRANTED: Yes No tl--,
`, <b,a ��
..
G r ��'
�o �;..
ANI)
LOCATION— ��_UVVL-q2J&�j�L `,hj'jgL-4L_. NO. P - 5dr
VILLAGE
DATL_ Ly -
APPLICANT FILE
ADDRESS P HONE, NO._?;?1-6C9z(Non-refundable)
ENGINEER M. t,0Af,-L,0tCW__ /4-SSOC pj.,,.j,FpjjONE NO.
DATE SCHEDULED
YApplicmlLls sigi.6A-
. . . . . . . .. . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ASSESSOR'S MAII Cz LUTNO :
p m A r SMJ1 LOG
SUB-DIVISION NAME �A4,6r5+4� If I m 1 7)
EXPANSION AREA: YES waxwu- saG ENGINEER
BOARD OF HEALTH
TOWN WATER�PRIVATE W1-:1J,
EXCAVATOR
SKETCH: (Street of :1 o t:, f?- xlc L lociLion of Lost holes and
percolation I (I.-.11.." , IocnLe iii proximity Lo 1:esL holes )
NOTE'S :
10-2 1�1
Aj
PERCOLATJON RATE:
'PEST HOLE NO: 1;1'VATI 0 H TEST HOLE 1,10: ELEVATION :
2 2
3 1 3
4
5 5
Mal .
7
9 tray/
12 12
14 14
1.5 1.5
16 16
SUITABLE FOR S U B-S U R FA Cl.: LEACHING FIE'Ll) LEAC111110 PITS
LEACHING TRENC -IES
" SEINAGE . RE'ASMS :
UNSUITABLF, FOR SUB-SUPI:!WE,
NOTE : E,NGINEIERING PLANS MUST SHOW 11UH13EIZ Ar,1,`.-;1GNED 014 PERC T1;:ST APPLICATION
ORIGIUAT.: C01jpTj'TFP V-1 Ff,lTT fly Il I;' ,\T11) J)PI ill Tl r.1) gy) 11 ):7\RT.) m" firm."ril
COPY: RETARlE'D hY APPLICANT
No. ' a ...I..C�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
--------------• -......-----------.... ...... ....................
ppliration for Disposal Works Tons�.rurtiutt
, rrlltit . '
Application is hereby made for a Permit to Construct (✓f or Repair ( ) an Inndividual Sewage Disposal
System at:
LO.%_ a .OL IDEE /'0InE s�E�9D A2 In4457eAlS M ILLS �-
... ......... ......•----• ---- --------- -•---------------- ----•------------•----• ----.........----••------...........•---•-
L cation-Address or Lot No.
------'3,�...... --•---% G v�......._Ca:.......................... .......f' a.:._! �X.....�5.........................................................
. , ,e r/i LLE
--
Owner Address
w5 n? ...............•-----•----.................. .
,-�
Installer Address
Q Type of Building Size Lot..._�7,-G ---------Sq. feet
Dwelling—No. of Bedrooms_.______...................................Expansion Attic ( ) Garbage Grinder
pa., Other—Type of Building 4 a 4?..fRi?!nF_- No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures --------------------------------- -
W Design Flow.......................... per person per day. Total daily flow_____..._____33.0______________•._.._gallons.
9 Septic Tank—Liquid capacityMg0---gallons Length__E - ?____ Width.A.-/,e___ Diameter---Z! -_- Depth____5_..L-.7_'./
Disposal Trench—No. ...... Width.................... Total Length.................. Total leaching area-----N .....sq. ft.
Seepage Pit No-------- �_.. Diameter.._.. �Z_. Depth below inlet.3?--..f:s..._.. Total leaching area..2,4' .......sq. ft.
Z Other Distribution box (V5 Dosing tank
'—' Percola=ion Test Results Performed by---Aeug .. ------- !``!w!i �aate....¢................................
aTest Pit No. 1...... __.__minutes per inch Depth of Test Pit....../3....... Depth to ground water---ti�......__.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------_____-_-_•--_-_.._
O -----------------�-•- ---------v---... ..P tea/ ---
- ----
o `
Descripr_ion of Soil-------------------------------- ---- 1. L .........................
-----------
x '
------------ ----------------- -•-•-------•----•--••-••••. ••-••••--------------•-••----••-•••••-
UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
--•••--•.•-•----••••••••-----•••---•---••-•--••-•••-••••---•-•••-•••---•••--••----•-•-----•------•••••••.......•-----•--•-•••••-----•--•••••--••••••-•-•••••--•----•••-•-......•-••-•-••----•--•-......
Agreement: _
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i i'�
p S of the e Sanitary Code— The undersigned further agrees not to place the system in
operation until ertificate of C iance has been issSueed by the board of health.
/..........
Application Approved By.............................. `... ...................................................... ----� � a
Date
Application Disapproved for the following reasons-------------------------------------•------•-•--------------------------------...----.........................
---•••.....------•••--•-••---••••--••-•-...•--•-----••••••--••-----•--•-•-•••-•-••---------•-•------••-----•----•----••••-•---••--••••--•••••-••-----•••-••••-•-••••----••-----•-----
Date
PermitNo...............: ------.f Issued_--•------------•--•-----------..............---•-------
__ Date
Fuis ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........7().aj,Al-----------OF.......81191e,1157413L6
- ---------- ...................................................................................
Appliratiou for Biapatial lVarkii Tnuotrurtion rumit
Application is hereby made for a Permit to Construct (Z) or Repair an Individual Sewage Disposal
System at:
-1 04 A16' 11Ct71&: 5 1IS ,9 b bf� IY74 RS 7 a IV.5 1-IS
...................................................................................... ..................................................................................................
or Lot No,
........................... ................ ..........................................................
owner 4 Address
.................................................................................................. ..................................................................................................
installer Address
' /?� 0.2
cl� Type of Building Size Lot__ ...................Sq. feet
U
Dwelling—No. of Bedrooms........�A...............................Expansion Attic Garbage Grinder
Other—Type of Building No. of persons............................ Showers Cafeteria
A4 Other ............. .
fixtures ------------------- .....................................................................................................................
-< 4 -30
W Design Flow.................................s............gallons per person per day. Total daily flow_._............3.............................gallons.
1:4 Septic Tank—Liquid'capacit/90--gallons Length................ Width........_.__.... Diameter..__.........._. Depth.._..__.........
Disposal Trench—No. .................... Width.................... Total Length..._................ Total leaching area--------------------sq. ft.
Seepage Pit No..................... Diameter...____..__-:._..... Depth below inlet.................... Total leaching area..................sq. f t.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit............_...__.. Depth to ground water------------------------
raq Test Pit No. 2................minutes per inch Depth of Test Pit..._..........._.... Depth to ground water........................
P1 ..............................................................................................................................................................
0 Description of Soil.............................................................................................................................................
............................
W
U .........................................................................................................................................................................................................
--------------------------------------------------------------------------------I........................................................................................................................
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 I. ; 5 oi the State Sanitary Code— The undersigned further agrees not to place the system in
operation until Certificate of Compliance has been issued b the board of health,
I "I Certificate
y
ed........ ...... ..................... --------
69-
4?1!yD1
A "Ji"
Application Approved By......................................................; .... 1*7!.....------
Date
Application Disapproved for the following reasons:...............................................................................................................
.........................................................................................................................................................................................................
Date
77��Permit No............................. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Illy
.... OF.......I........................T11I5. I.& ................................................. ....................... .... ....
T.Lrrtifiratr jaf
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed �,/') or Repaired
.............................................................................................................................................................................
Installer
at-.A...0. 7-.. 04...b F- A/&..tij....5.r/54i) )&- V//- -15
.............. ....................................................................................................................................
has been installed in accordance with the provisions of TTL'LIE 5 of The State Sanitary Code as. describq�_Lin the
application for Disposal Works Construction Permit No.. .... ......L -O dated -------- ---C>1
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT VNE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE._..._...... _.... ....................................... Inspector....... -�Q
p ......... .......... ---------------------------
THE COMMONWEALTH OF MASSACHUSETTS
(-`bOARD PF---HEALTH
..................OF.............................................. .................
FEE...L.��........
Disposal IV�rkii Tvalnutrurtiatt V rmit
Permission is hereby granted.....2.. ..... 4 4.5 ,
. ..................................................................................................................
to Construct or Repair an Individual Sewage Disposal System
d)?, - 'MA� IS 1 t t5
at No-A&I....., 4 i ,
....................................'pi ,71"A
..........................................................................
.c; .......1.
Street
as shown on the application for Disposal Works Construction Permit DO ............... at d......
:4 L..... - ------ ..... ---4ZaZ:Z------------------------
DATE w/ A
Board of Health
J -;sz r. -15,
-------------------- ------------------------------------
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
i
i
1
S/TE PL A N SHEET l of z
SCALE: /„= -7
i
1
s
I .
7
ESf
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a6 ��
I\
V\ LOT
� � �� � •� �6, , � /oao GrAL s�D,
' � �D�s3ai! O ;{� P.eECA57 Cane
SE.71G 7WAIX
� f i 1 � o�E0,5'37 c'oNB
0'570NE
' •`` ) \ /cam�70 .EXt'•9N5/On/
VA OF
�rZr vL
�o WILLIAM
a M.
WARWICK
No. 19771i�o
��•rs G1ST.ER`���
L LAND?
REGISTERED LAND SURVEYOR
FOR
6'N E
PLAN .REF_ OuT of M,qv �-/3 PG'L, . / DATE 0C7ac34F2 8 , /96 4,
BENCHMARK DATUM 1-15,05 /909 Msz, 1->,g 7-41,A-1 WM. M. WARW/CK B ASSOC., INC.
DOMESTIC NEATER SOURCE 72::'wN Lt/LI'TFl2 BOX 80I - NORTH FAL MOUTH
FLOOD ZONE. /-/d^-/- H.99,9RD "C '' MASS. 02556 - (6/7) 563 -2638
LEACHING BASIN SECT/ON NOT TO SCALE Shec/ e �f z
24"C.I.MH COVER
EARTH ILL BRICK AND MORTAR COURSES AS REO D• TO BRING
_.r• ._ _ COVER TO GRADE
INLET B FLOW LINE'
-— --=. 2 �"TO%"WASHED PEASTONE FREE OF IRONS,
' PIPE FINES AND DUST /N PLACE
rr /r OPENING W/TH 4%g" L 4 TO I%2' WASHED CRUSHED STONE, FREE OF
i 53 -43 • '• 7 OUTER DIAMETER IRONS, FINES AND DUST /N PLACE
.. AND /3/4„ INSIDE
DIAMETER I. CONCRETE TO BE 4000 PSI 28 DAYS
i 2. REINFORCED WITH 6%6" NO. 6 GA. W.W.M.
E'G77• X.` . ' 3. 2'AND 4' SECTIONS ARE AVAILABLE FOR
GREATER DEPTH
�= ?, `---{ o" �--) 4. NUMBER OF PITSRREQU RED REQUIREMENTS I
4'0 s
" � �_
MIN' I NOTE: EXCAVATE TO ELEVATION 73.o R
' EFFECTIVE O/AMETEK � O
(NOT TO EXCEED 3 TIMES EFFECTIVE DEPTH) LOWER AS REQUIRED TO REMOVE ALL
WArER. TABLE - LOAM AND CLAY BENEATH PIT. REPLACE
EXCAVATED MATERIAL WITH CLEAN
TYPICAL PROFILE GRAVEL TO DESIGNED GRADE.
/B'STD. LT. WGT. C.I. MIl COVER
96.o
tl •'r
4"C.I.PIPE 4"BIT FIBER P/PE
TIGHT JOINT OUTLET LEVEL
DWELL/NG FLOW LINE TO FIRST JOINT
11 0 00 1
C.I. TEE AZ• �,l. 7 I l 0 1 0 0 1 1
it O o 0 00 1 1 1 1
8Z.7- 'STO, PRECAST CONC. £�!•" �pjST BOX TO BE 1 ( 000 O 0 1
GAL.SEPTIC TANK g!'�� 1 1 1 000 00 0 1 1 1
INSTALLED ON LEVEL, 1 1 1 000 00 0,1 11
B •• ..:..:: STABLE BASE 1 11 000 0 0 1 1 1
y�S£PT/C TANK To BE I l I 0 0 0 0 0 0 1 1
INSTALLED ON LEVEL, 1 11 1001 0 0 1 1
STABLE BASE. I I I Q p 0 0 0 0 1 1 1
I I I pQ0 0 0 1 1 1 1
LEACHING BASIN , 1 1 0 Qp 0 0 0 0 1 1
BASE TO BE L EVEL 1 1 I o O I O 1 1 1 , :EG.77.9£5
SOIL AND PERC. DATA
PERC. RATE Z MIN. /IN. O�� TEST PIT N0. I eG Ole TEST PIT NO. 2
TEST BY
WITNESSED. BY: _ 7-
TEST PIT GR. EL. 9L 6'
�.C�.9CE �Gre.9✓EL.
DATE: `.ell Zs,
� o-sss8
DESIGN DATA GENERAL NOTES
BEDROOMS 3 NO HEAVY EQUIPMENT TO RUN OVER SYSTEM.
DISPOSAL SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD
EST..TOTAL DAILY EFFL.33d6PD. PRECAST REINFORCED CONCRETE UNITS.
:'.SEPTIC TANK 142d GAL. ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE
SIDEWALL, AREA LEGAL./SQ.FT. TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE,
MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF
BOTTOM AREA /•&• GAL./SQ.FT. SANITARY SEWAGE EFFECTIVE ON JULY 11 1977.
LEACHING REQUIREO2oc SQ,FT. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD
ACTUAL LEACHING AREA OF HEALTH.
99, �.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.
► 0
' s�q � SEWAGE DISPOSAL SYSTEM
MA07-IN
E. �:• FOR' !
w MORAN H
J23417�Q L ^T
G/ST I•c`R a`��` •`Mf9.C.5-rc.V 5 �rl i/
ell'NAL ECG
;!•: , to SCALE AS INDICATED DATE
WM. M. WARWICK 8 ASSOC., INC.
80X 801 - NORTH FAL MOUTH
PROFESSIONAL ENGINEER MASS. 02556 (6171 5 63 -2638
L
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 260 OLDE HOMESTEAD DR. MARSTONS MILLS 0'4 3- b0 �-
Name of Owner JANICE LATTA 1 /
Address of Owner: BOX 412 SAGAMORE MA.02661
Date of Inspection: 11/12/99
Name of Inspector:(Please Print)JOHN GRACI O �f /via 1
I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) �`C � 6 19 �
Company Name: n/a 9ty 9
Mailing Address: n/a MfVOF g Nf
Telephone Number: n/ao�
+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:
X Passes The inpectlon is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is
Needs Further Eval tion By the Local Approving Authority performing at the time of the inspection.My Inspection does
_ Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of Its components useful life.
Inspector's Signature: Date:11/16/99
The System Inspector shal submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 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.
NOTES AND COMMENTS
THE SYSTEM'PASSES TITLE V INSPECTION. RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS.
revised 912/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 260 OLDE HOMESTEAD DR.MARSTONS MILLS
Owner: JANICE LATTA
Date of Inspection:11/12199
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
_ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
12& 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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(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 exriltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
n(a Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass Inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
_ obstruction is removed
distribution box is levelled or replaced
n& 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
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 260 OLDE HOMESTEAD DR.MARSTONS MILLS
Owner: JANICE LATTA
Date of Inspection:11112/99
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 IN ACCORDANCE WITH 310 CMR 16.303(1)(b)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 surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nbL(approximation not valid).
3) OTHER
nla
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 260 OLDE HOMESTEAD DR.MARSTONS MILLS
Owner: JANICE LATTA
Date of Inspection:11/12/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described 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 into 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 due to an overloaded or clogged SAS or cesspool.
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).
Number of times pumped n1A.
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 I 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 ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
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 upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/9B ; Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 260 OLDE HOMESTEAD DR.MARSTONS MILLS
Owner: JANICE LATTA
Date of Inspection:11112/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks 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.
X 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.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the .field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[1 5.302(3)(b)[
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 912/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 260 OLDE HOMESTEAD DR.MARSTONS MILLS
Owner: JANICE LATTA
Date of Inspection:11/12199
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-M g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):I
Total DESIGN flow: 1.
Number of current residents:A
Garbage grinder(yes or no):NQ g
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):JLQ
Water meter readings,if available(last two year's usage(gpd): n&
Sump Pump(yes or no): NO
Last date of occupancy: 9/1/99
COMMERCIALIINDUSTRIAL
Type of establishment: n(a
Design flow: n&gpd(Based on 15.203)
Basis of design flow: n&
Grease trap present:(yes or no):JM
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:n(a
Last date of occupancy: n(a
OTHER: (Describe)
n&
Last date of occupancy: n&
GENERAL INFORMATION
PUMPING RECORDS and source of information:
THE SYSTEM WAS PUMPED TWO YEARS AGO
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped n[a- gallons
Reason for pumping: n&
TYPE OF SYSTEM
XSeptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: n&
APPROXIMATE AGE of all components,date installed(if known)and source of information:
THE SYSTEM WAS 9 YEARS OLD.
Sewage odors detected when arriving at the site:(yes or no): NQ
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 260 OLDE HOMESTEAD DR.MARSTONS MILLS
Owner: JANICE LATTA
Date of Inspection:11112/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2E
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nLa
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK: X
(locate on site.plan)
Depth below grade: M
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
DLa
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): No
nla
Dimensions: L 8'6"H 6'7"W 4'10"
Sludge depth: Z
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:1"
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: ]Z
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 EVERY TWO YEARS
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
Wa
Dimensions: Wit
Scum thickness: Wa
Distance from top of scum to top of outlet tee or baffle:iLa
Distance from bottom of scum to bottom of outlet tee or baffle Wa
Date of last pumping: WA
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.)
nta
4
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 260 OLDE HOMESTEAD DR.MARSTONS MILLS
Owner: JANICE LATTA
Date of Inspection:11/12/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nLa
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
nla
Dimensions: nLa
Capacity: nLa gallons
Design flow: nLa gallons/day
Alarm present: NQ
Alarm level:jila- Alarm in working order:Yes_No_ NO
Date of previous pumping: nLa
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nLa
DISTRIBUTION BOX: _
(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.)
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
Wa
revised 912/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 260 OLDE HOMESTEAD DR.MARSTONS MILLS
Owner: JANICE LATTA
Date of Inspection:11/12/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n&
Type:
leaching pits,number: 6'K LEACH PIT
leaching chambers,number: -n&
leaching galleries,number: -n&
leaching trenches,number,length: n(A
leaching fields,number,dimensions: n&
overflow cesspool,number: n&
Alternative system: NA
Name of Technology: ja/A
Comments:
(note condition,of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONINC PROPERLY THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION NEVER
MORE THAN 112 F
CESSPOOLS: _
(locate on site plan)
Number and configuration: n/A
Depth-top of liquid to inlet invert: WA
Depth of solids layer: WA
Depth of scum layer. WA
Dimensions of cesspool: n/A
Materials of construction: n/A
Indication of groundwater: WA inflow(cesspool must be pumped as part of inspection)n/A
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Wa
PRIVY: _
(locate on site plan)
Materials of construction:n/A Dimensions:n/A
Depth of solids: WA
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
WA
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 260 OLDE HOMESTEAD DR.MARSTONS MILLS
Owner: JANICE LATTA
Date of Inspection:11/12/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wellswithin 100'(Locate where public water supply comes into house)
n/a
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og
o e A� yj�
SA 3S�
EC5
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 260 OLDE HOMESTEAD DR.MARSTONS MILLS
P Y
Owner: JANICE LATTA
Date of Inspection:11/12/99
NRCS Report name: n&
Soil Type: nLa
Typical depth to groundwater: nLa
USGS Date website visited: Wa
Observation Wells checked: MQ
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated.Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.)
_ Determined from local conditions
Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 912198 Page 11 of 11
__._.- _
ASSESSORS MAP: 414
.;
TEST HOLE LOGS 1) The installation shall comply with the State Environmental Code Title V and Town of C, f'
PARCEL. 005` 00 Board of Health Regulations.
.—. SOIL EVALUATOR: f2. 2) The septic.system as proposed on this plan shall not be installed until a licensed town installer
FLOOD ZONE:
WITNESS : receives approval and an installation permit from the applicable town.
REFERENCE DATE: 3j Prior to installation,the installershaltverifythe location of utilities,sewer inverts,sewer lines.
�, ,, PERCOLATION RATE: ,G 7 lJUtt 1 a and existing septic components prior to installation.
"
le
7 �t wT_ . ..... . �
� • � �,�. Al
' 4) All gravity sewer piping is to be 4 inch schedule 40 PVC at 1/8"per foot. The first 2 feet out of
7H- I TH-2 the distribution box shall be level. All piping connections to be glued.
+ ! Z.-1 f f 5) This septic design plan is not to be utilized for property line determination or for any other
i 10
� -
purpose other than the proposed septic system installation. ,
.. 6) All Title V components are to meet Title V specifications.
- � � � .�. � 7) Parking shall be prohibited over Title V'components unless components are H2O loaded.
�
r
314 8j The existing leaching or cesspools shall be pumped and filled witfi material per Title V
LOCATION MAP PL' ` c.�. �
{
��'j 1 I + `� � abandonment procedures.-Leaching and cesspool(s)and contaminated soils within the
I'ifJ -
; proposed SAS.shall be removed and replaced with clean sand per Title V specifications. A
q
9) Septic components are to be 10'from a water service line.Sewer lines crossing a waterline shall
be sleeved with an appropriately sized schedule 40 PVC with ends grouted. The water service
�?r. o ,r line or the septic line can be sleeved with the sleeve being a distance of 10'on both sides of
P ---1
crossing the line.
10j if a garbage grinder exists in the structure,it is to be removed if the septic system is not
^4 designed to accommodate a garbage grinder.
_
a
N L O�- SEPT
� T �r► T 11) The installer is responsible for care of excavation around all utilities on the property and
+7 E P' 1 SYSTEM 1 E E31�t ` protecting the structural integrity of all structures during the installation process of the septic
system.
FLOW ESTIMATE 12)This plan only represents that a septic system can be installed on the property meeting Title V
�` �--► -•_ requirements.
` ,✓ BEDROOMS AT ,I O GAL/DAY/BEDROOk GAL/DAY
_ 13) The property owner shall review design criteria to approve the total'number of bedrooms and
x design flow.Installation of the septic system as proposed and receipt of payment for the design
SEPTIC TANK
shall be deemed approval of the design criteria by the property owner or agent of. .
_� ` GAL/DAY x 2 DAYS - GAL
14) The validity of this plan shall expire with the expiration of the town installation permit issued for
B ;> this plan or the validity of this plan shall expire on the expiration of the Certificate of Compliance
USE GALLON SEPT I C TANK 1
issued for the installation of the proposed system on this plan.
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SITE AND SEWAGE PLAN
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LOCATION : 4M 0,W, rvtA
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DAV I D B . MASON,R DATE./�
DBC _ENVIRONMENTAL DESIGNS
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DATE HEALTH AGENT
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