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HomeMy WebLinkAbout0948 OST.-W.BARN. RD - Health 948 OsT� 0, r�, 4 Marstons Mills --- - - - — - - - A = 124 017005 - - f - Ij TOWN OF BARNSTABLE L.00ATION769 OS71-/I 16%11 41 .r_34 gdz W.d • SEWAGE #2410a JIi.LAGE ASSESSOR'S MAP& LOT/� INSTALLER'S NAME&PHONE NO. Ai2 Abe seav� j2 o 6 - SEPTIC TANK CAPACTI'Y _Zoa Q LEACHING FACILITY: (type) - (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: 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 4 within 300 feet of leaching facility) Feet:= Furnished by _ 1 i /l3 47 1 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Digpozar *potem Com5trurtton Vermtt Application for a Permit to Construct( )Repair( )Upgrade(V )Abandon( ) El Complete System 16,1ndividual Components Location Address or Lot No. 1�6 0S f a (t,—J�tpe4, & Owner's Name,Address and Tel.No. Assessor's Map/Parcel Pc--ff SU j Installe''rnn'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 r Design Flow S� gallons per day. Calculated daily flow c. -1 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank C�� /ace Type of S.A.S. Description of Soil: 14_2 ll� \ //W la ` iaiun Nature of Repairs or Alterations(Answer when applicable) k v �c9.�P� Qv✓S 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 E 'ronmental Code and not place the system in operation until a Certifi- cate of Compliance has b ea, Signed �✓ Date —0� Application Approved by Date Application Disapproved for the following reasons Permit No. ierv_.73 Date Issued 7 — �� No. Zen" - 17/ +- a Fee _THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - Yes Yg, ' PUBLIC HEALTH DIVISION - TOWN O.F..BARNSTABLEi MASSACHUSETTS Tipprtcation for 30i.5po.5af *p5tem Conztruction Permit Application for a Permit to Construct( )Repair( )Upgrade(V )Abandon( ) ❑Complete System 7�hdividual Components Location Address or Lot No. R ®ST e W_gV41}••ll 6 Owner's Name,Address and Tel.No. Assessor's Map/Parcel . Q Y`l> t �4 Sv''-J Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. tilti� o-taw Type of Building: �ZZ Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �J gallons per day. Calculated daily flow -3 I_kCrt gallons. Plan Date Numbei of sheets Revision Date Title Size of Septic Tank K5_' "�r-_ k A'v Type of S.A.S. k' Cam, Description of Soil: \ (so a if C e- ` hU d Nature of Repairs or Alterations(Answer when applicable) �-'C=- C(� A G c--k - �..� J �Z 6 e �t S`t�.2 O 1l-,,S 0 eS � Date last inspected: Agreement: s 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 ErVironmental Code and not. place the system in operation until a Certifi- cate of Compliance has b e y t is ea th. Signed Date Application Approved by Date 3� � Application Disapproved for the following reasons Permit No. 7 ze'" Date Issued Y-3 ` 0 " -------------------------- - ------------ THE COMMONWEALTH,OF�`MASSACHUSETTS BARNSTABLE;NIASSACHUSETTS Certificate of Com' iance THIS IS TO CERTIFY,that the On-site Sewa a Disposal System Constructed( )Repaired ( )Upgraded(' ) Abandoned( )by `0 -'G A S-e �C.— at q �4 17 OS t �:ed/1 ,(fJfc-:7r a has b en constructed in a cordance with the provisions of Title 5 and the for Disposal System Construction Permit No. T dated 1 ��� 74%V_C7 " Installer Designers , The issuanc f this c(nit sh4lLilot be construed as a guarantee that the sus ill-function as desie. Date Inspector No. 3 9 ---7..—£------------=` Fee THE THE COMMONWEALTH OF MASSACHUSETTS G` Z-q _o/7 PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS 30i!5possar *pgtemc Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(✓)Abadon( ) System located at 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 pe t. s Date:: 3/�/ �'� Approved by 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby.certify that the application for disposal works construction permit signed by me dated , concerning the property located at 9 q� QST� (�� ir 1�4y meets all of the following criteria: v This failed system is connected to a residential dwelling only. There are no commercial or business /uses associated with the dwelling. e✓ The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. ,/ There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. 6e The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] �• If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: // S A) Top of Ground Surface Elevation(using GIS information) l�t t B) G.W. Elevation +the MAX. High G.W. Adjustmentt� _ `�o, DIFFERENCE BETWEEN A and B �'1 SIGNED : DATE: [Please Sketch o osed plan of system on back]. NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert l �� c �� © a .� �� ��� CA \ Jv� Q�� �wQ Q`� _� � �� i ^. 1� L f TOWN OF BARNSTABLE LOCATION 7y SEWAGE #260a IVILLAGE if � � ASSESSOR'S MAP & LOT/'P / 41 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /0.0 Q LEACHING FACILITY: (type) 4d.±2!�/l`!(f/ 4 _� (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: Jam" S 0752,_COMPLIANCE DATE:' i 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" f leach ing lung facility. Feet Furnished by. i • -C 17 z f COMMONWEALTH OF MASSACHUSETTS z v EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION o, �o °1M 5�a RECEIVED MAR 0 8 2004 TITLE S TOWN OF BARNSTABLE HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A , CERTIFICATION MAP Z Property Address: 948 Osterville-West Barnstable Road PARCEL Marstons Mills,MA 02648 LOT Owner's Name: Mr. Samuel Jensen Owner's Address: 948 Osterville,West Barnstable Road Marstons Mill,MA 02648 Date of Inspection: February 28,2004 s,{of JOHN L. �a Name of Inspector: (please print) John L.Churchill,Jr.,P.E. 0 CHURCHILL Company Name: JC Engineering,Inc. JR. Mailing Address: 2854 Cranberry Hi hway No 41807 East Wareham,MA Telephone Number: 508-273-0377 y 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evalu 'on by the Local Approving Authority Fails �_. Inspector's Signature: Date: d The system inspector shall submit a copy o i inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments Cesspools are an automatic failure due to Local Board of Health Regulations. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 ' Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 948 Osterville-West Barnstable Road Marstons Mill,MA 02648 Owner: Mr. Samuel Jensen Date of Inspection: February 28, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Titla.0 Tnc„artinn Tynan ail Ci�nnn 2 f Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 948 Osterville-West Barnstable Road Marstons Mill,MA 02648 Owner: Mr. Samuel Jense Date of Inspection: February 28, 2004 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: T;tl. S/')0n 1 3 f Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 948 Osterville-West Barnstable Road Marston Mill,MA 02648 Owner: Mr. Samuel Jensen Date of Inspection:February 28, 2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to 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 N/A Liquid depth in cesspool is less than 6"below invert or available volume is less than %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 X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (YeslNo)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• 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) ye.s 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. Titles G 1,c,anti—17n—r/1 C/)nnn 4 L Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 948 Osterville-West Barnstable Road Marstons Mill,MA 02648 Owner: Mr. Samuel Jensen Date of Inspection: February 28,2004 Check if the following have been done. You must indicate"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 Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _Was the facility or dwelling inspected for signs of sewage back up? X _Was the site inspected for signs of break out? X _Were all system components,excluding the SAS,located on site? X _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? X _Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems'? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS T41. c T„o —fi—F,.,,,,All 5 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 948 Osterville-West Barnstable Road Marstons Mill,MA 02648 Owner: Mr. Samuel Jensen Date of Inspection: February 28,2004 FLOW CONDITIONS RESIDENTIAL 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 '_Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use: (yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 110 epd Sump pump(yes or no): No Last date of occupancy: Current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,soil absorption system _Single cesspool _ Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Tank—21 yrs. D—Box and SAS 4 yrs. Were sewage odors detected when arriving at the site(yes or no): No Tifli s rno. Linn 17-All ci')nnn 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 948 Osterville-West Barnstable Road Marston Mill,MA 02648 Owner: Mr. Samuel Jensen Date of Inspection: February 28, 2004 BUILDING SEWER(locate on site plan) Depth below grade: 22" Materials of construction: _cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: >150' Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) Depth below grade: 10" Material of construction: X concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8.5' x 4.83' x 5.66' Sludge depth_ 1" Distance from top of sludge to bottom of outlet tee or baffle: 2' 5" Scrum thickness: Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 1' 3" How were dimensions deter-nined:_Field Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as.related to outlet invert, evidence of leakage,etc.): No evidence of leakage,concrete baffle removed when previous upgrade was done GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as r-.lated to outlet invert,evidence of leakage,etc.): OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS Tula G Tnan f;4 V-1—411 S/Innn 7 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 948 Osterville-West Barnstable Road Marstons Mill,MA 02648 Owner: Mr. Samuel Jensen Date of Inspection: February 28, 2004 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0" 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.): Box level,no leakage in or out good shape PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): Tit]. G Tno —ti— P— 411 r,i')nnn 8 I Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 948 Osterville-West Barnstable Road M_ arstons Mill,MA 02648 Owner: Mr. Samuel Jensen Date of Inspection: February 28,2004 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ X leaching chambers,number: 4(Plastic Infiltrators) leaching galleries, number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: _innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Fails Due to Local Board of Health Regulations 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.): ' Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 948 Osterville-West Barnstable Road Marstons Mill,MA 02648 Owner: Mr. Samuel Jensen Date of Inspection: February 28,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A 0 0 22, y 20, -7 ` 2 21, 2 as T�raA s t ...ti-,F,,—r1i1 ;11nnn 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 948 Osterville-West Barnstable Road Marstons Mill,MA 02648 Owner: Mr. Samuel Jensen .Date of Inspection: February 28,2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater >12' Please indicate(check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 1983 Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local.Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: New leaching area installed in 2000.Used design Plans&Town Groundwater Man for groundwater elevation. T;tl. c r­A +;, Pr,,,411 rilnnn 11 k" No.. . Finc............................. " ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..'ZOOV-1v................OF....... ...................... Appliration for Dhipoiial Workii TouBtrurtion ramit Application is hereby made for a Permit to Construct or/Repair an Individual Sewage Disposal S s at* • -0�/ 4 .�V 5 .... 2v, 4 4.)� .................... --------------------- ------------ ...... I t ld�r ss No., Wo n .............. ....... A, Owner A,44 Fes. ....... ... ......................................................... e_- :0!3 ]?e--- -------------------------------------------- �4 Installer Address PO 1� Type of Building Size Lot... U Bedrooms.._______ ___________________________Expansion Attic 922�1...Sq. feet Dwelling—No. of Bedr( Gartrage Grinder ( ) Other—Type of Building .Adm:No. of persons....A................... Showers Cafeteria ( ) P4Other fixtures ..................................................................................................................................................... Design Flow.....AW----7_10__----------gallons per person day. Total daily f1ow__.Jd ............................gallons. — 1 17 apagt Width._4.—�.' ."Diameter................ Depth___':1:4 Septic Tank—Liquid a. y/ gallons Length.O.:!d. .. Disposal Trench—No. .......... Width....':=.......... Total Length___.............. Total leaching area.._._._.-',o.....sq. ft. Seepage Pit No.-/.............. Diameter...Z ......... Depth below inlet... ............ Total leaching area td�sq. ft. Z Other Distribution box Dosing tank,( Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. L.Zf.0...minutes per inch Depth of Test Pit...Z ......... Depth to ground water.."h' .4P44&R5._..__ Test Pit No. 2................minutes per inch Depth of Test Pit______.............. Depth to ground water._._................___. ............................................................. 0 Description of Soil.........a— 1�e............7-0 U ....................................... ;ez . ....... -0-VI.0................ ........................................................ ------------------------------------------ZZ...... ........................................... ........................................................................................... 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 TJIT1 LE 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issued byVt board of h Ith. igne ................. . ...... ....... .................... .......................... Date ApplicationApproved By.--- ..... •............ ...... ... ........ I..... .................................. ........An,__1— Date Application Disapproved fo th following reasons:................................................... .......................................................... ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued........................................................ Date y • G� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH `ts. ✓-........I.....OF........ _ .:..... Aplifiration for llhipoiial Works Totes nctiutt Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposall,-•••, System at: a -Q, Loc ti No Add s Lo f 2 _ Owner Z -•--••-•....................................•..... ..........................�/ G I' .......................................................... Installer Installer Address U Type of Building Size Lot---- � .5'__..Sq, feet ,-, Dwelling—No. of Bedrooms........... ........Expansion Attic ( Garbage Grinder ( ) aOther—Type of Building tTo. of persons.._..�4................... Showers ( ) — Cafeteria ( ) d Other fixtures Design Flow...................... Ions. 9 Septic Tank—Liquid'capacity��?°�agallons Length_._ Width__`;�/'"/Q Diameter________________ Depth.__.- -�r Disposal Trench—No. .! ......... Width....... .......... Total Length...._..:".......... Total leaching area..__..""�"r.=_sq. ft. 6 `i � Seepage Pit No.../.............. Diameter....!` ..__..... Depth below inlet.____....__......... Total leaching area_.�:.__ sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by......................................................................... Date........................................ Test Pit No. 1--- t_t"./_-..minutes per inch Depth of Test Pit----f ef'.-...._... Depth to ground water---11;3/e ..'-'-_.__- fX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ................................ .-•-- q-..... 0 Description of Soil......._. —._zd.............. ... °` x -- ---------------------------------------------------------------------------------- x ------------------------------------------- = - '-----•------------------------------------....---------------------------------------------------------------..........--- 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 TIT1Z- 5 of the State Sanitary Code—The undersigned further agrees not toAlace the system in operation until a Certificate of Compliance has been issued b t board of he lth. P P y eve7, Signe(,-""\ ---•-- Date Application Approved BY ...........................•. ---•--•---------••...........:.•----•--........... Date Application Disapproved f or/theVf ollowing reasons` �................................................................................... ..........•. -•.....•------•..............................•-•--....•-•---......----•-....-•-----•••••••-----•-•-----•-'-------•------•----•-------•-•----•-•••••••-••---•----•-•••••-•---•--•-•----------•-----•-..... Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.......................................... Tntifiratr of Toutphattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by. ------- --------------/----- ------------------------------------- ------.._._.......•-•--•-•-•••-•.........---••....._._....•--- --- - ------- _ r/ ` , ✓�! Installer/ 1' - -----------••------------•-- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code des�e`ribed in the application for Disposal Works Construction Permit No.___`....1..:. '. ................ dated_.-./_ _-/.j_ �___(�.`.'._.............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST ED AS A GUARANTEE THAT THE SYSTEM VV ,, UNCTION SATISFACTORY. DATE...I. .a ............... ..................•----•--•-- Inspector. . ------.--.... THE COMMONWEALTH OF MASSACHUSETTS . BOARD OF HEALTH %`i ..........................................OF.................-................................................................... c�(} No.... ....:..... FEE...:..'...:............ Raposal 10orkvCnl�tt rttr i�tn eruti Permission is hereby granted.....__.'r' '% .....I .. to Construct ( ,)lor Repair ( ) an�Indivi ual Sevc�age-Disposal System at No. = ........... 7 Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... DATE............................... ....����...--------•--•---- Board of Health FORM 1255 HOSES & WARREN. INC., PUBLISHERS �' ...-.w •+G..v.-W- ..w _ _ 1 Y r � f` I � /I,r dr yqs Y �:.. i wit-00 � 47 Z . . .. j f q 3 , i • N 3 V v-PI T I c .3Z� 0 F f, c M _ d1 N q 5 � ^� ^1 58* n 9 VV i M 1 fig$ M74 � ( I t 16 I �r 1 ' A silo, .4 1 OF q'5' Or4VLeML°r/ �� �- M1l.LL V LAM LEGEND A� CERTIFIED PLOT PLAN EXISTING SPOT ELEVATION ®x0 { c,7 '��� r EXISTING CONTOUR --- O --- �ti sq, L oT. �Al /3e,2'Y" 1LL �ZD. ' FINISHED SPOT ELEVATION (� ALB �� Mh j2 s 7Tv /y `' itz I' s FINISHED' CONTOUR 0 o sIN o.10951 O APPROVED s BOARD OF HEALTH FFs�/0tiA1 DATE AGENT SCALE' / = I D . DATE � � Z-1 v E^ 13 A,21,!-FD Lo 1!e 4LDREDGE ENGINEERING CO ON CLIENT 1 "CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO. 2Z BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS : + . ENGINEER URVEY R •BY OF ®ARNSTA8 E, M SS. 712 MAIN STREET CH. By `J. HYANN I S, MASS. - SHEET I OF Z. 4A —E R LAND SURVEYOR T r�C 20 FT MIN. .. 11lOTF /F E/T.YER 7s�,/ES�PT/C AN OR E %EAG.�//rvG P/T'.4rtE MORE 7WA,-/ IZ"SELOJN /At. rRAOE, 2Q'O/AM ETER CONCRETE FOYER _ SNALL BE BROUGHT TO GRADE. (:-4,v EiYTrPi�1 CO/VCftGTE 4�PYC P/Pl t/EAVY CA ST /rPON Go{/�R SN.4 L L C3E USED Gim S /N DoR/VZ=WA y cL= COVERS �9 pE.Q F7 - 2�J• MiN. CG�/VCR�TE A ,.. Gh.�oE Cd VER C'L EAN .SA/V O UQ[//O LEVEL •._ � .:r• ,. � _ a LAYER 4.CAST IRON pa/PE 0,- b M/ YA SHPO S7rJNE Al..P/TCN GAL. • e 1 • • • • • • • • > •• SEPTIC TAN/C _ D/sT. • s • • • • • • • • • • • + BOX o • � $ ► • • • • � .�• • s• • ,lD. 1 1 •EFFECT/✓C ' . � •r 3/a'_ / %2.. • 1 0 • DEPTH• • • • v a WA5,YE0 STDNE P '78' 'ems • 1 • • • • • • • • POP PREC.4.ST SEEPAGE 1Nf/eRT C'LEYAT/ONS P/7- C/f^A-cr7 Y _ 55 �"�" v'°}% s �. • ► • . • . . • e o PIT OR EQU/V. . r ' a EL= 8�.0 INVERT.AT Ov/LD/NGs FT. INLET .SEPT/G T�4NK q 3 3 FT n FT. VIA M- TJ ON � C SEE TABULA > OUTLET SEPTIC TANK AFT. /NLFT D/STR/B!/T/O)v BOX q2 `i FT. GROUND Xol47.EK TABLE SECT/ON O F .. DUTLETD/STR/BtJT/ON.BQX 92.-7 /NL.ET LEACHING P17' 92. O FT. SEWAGE 01,S/O05A4 SYSTEM LEACHING PiT TABlJLAT/OnI Sc.�LE DIMENSION A 3 FT. DES16,V CR/TER/A D/,•Y.ENS/aN. NUMBER OF 9EDROOMS. 3 DIMENS/ON C -,�K FT. LOGGIA 015PO.SAL'UNIT SOIL LOG SD/L TEST SO/ TaTAL E.?TIMr�tTEG FLOW 3 3 v GAL.1DAY SO/L TEST�/ L TLFST 02 . 1 ,VUMBER 0,w LEACNINa P/TS_ f`ELEY. 94•a "ELEY, GATE OF SOIL TEST DES 14 , 19 SIL E SIDE LG'ACH1,V PER PIT l t'r&� Sa /'T. �P RESULTS i•V/T/VESSED 8Y E-WS!' J Ag,='g I i 90 TTOM 464 CN/NG PER P/T 7 $Q. pT. o- 8 Hof L PERCOLAT/0N MATE IIE/ J sS ^1,1JV/JNCN i TOTA[ LEACH/NG AREA �'G S47 FT. 1 JtCOLAT/O/V RATE 2 �''r M/N.1INCI+/ RESERVELEACNINCrAREA � SQ. FT. /� IL o �A"A AaD } t%Of MAJ.. ��CN ut o AL ,� 'e\ � �� !� S�7-0IV.S � : a fj A(. o iei.i s i (v �VCRSE t =1; o A o.1Q951�� ; o ELOREDGE FNG/N.EFR/JVG CO,/NC. c n.s ss c► r E � � - 7/ wrvis. .q sT � � �-� 82.4 z J►!A�/Y sr. , s,�Ya OIN Y/i4TC COTERED LE v SU 0,NM- N HO-c VI zli GRO UNO LvATE AT EL EL/ 'WI Z2 2.=S— SHEET a-OF