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HomeMy WebLinkAbout1051 PUTNAM AVENUE - Health 1 151 PUTNAM.7Rv - A-057-5-6 TonS a 1 I 1 ASSESSORS MAP NO: 5'7 C) No. ..6 .�_jJ PARCEL NO.: THE COMMONWEALTH OF MASSACHUSETTS U� ( BOARD OF HEALTH - 7e-cVN.....OF..........,/3� -5T46 ... ... . . -• •---•-------•...............•--•- Allp iration for Dispniitt1 lgorkB Tnnitrartion Prrutit Application is hereby made for a Permit to `construct (L, 5 or Repair ( ) an Individual Sewage Disposal System at: Loc ion•Addr ss r Lot Ys Z_� Ei e t/11:GF_ ----------------------_Dj.......... 3 ...•_. •--•-- e-i/T� ! W Q 4n fer 5 ess Installer Address 6-Z r I d Type of Building Size Lot....__.__y�...............Sq. feet Dwelling—No. of Bedrooms...........3............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building .......... No. of persons............................ Showers — Cafeteria P4 Other fixtures . ---------------------- - Design Flow........................5-5 _.._...._.gallons per person per day. Total daily flow................�J__3.C_.................gallons. W. . ............ B 12 9 Septic Tank—I.iquld capac>ty../...__._ .gallons Length.l'I�P..... Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area..__........._._....sq. ft. Seepage Pit No......._I------------ Diameter....... ........ Depth below inlet.... ........... Total leaching area_Z�.7.....sq. ft. Other Distribution box ( � Dosing tank Z Percolation Test Results Performed by--- !S!1_'...�dlfIZ �_ r. ' G.......... Date.......z_-�7 Test Pit No. I.....1'------minutes per inch Depth of Test Pit......L ...... Depth to ground water......."............ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------------------------------------------•---------•--------------..........••••............_._......................................................... 0 Description of Soil............... Z...........'�e_-•-l.5�.!�-�S v 1 L --•--------•--------------•-•-•---•-•--....-•---------•-----•-•--....•---............. 2_-..1 z'..........N►....�.:.._��.<4N o....��� } v ---------------------•------------------- W -•-•---•-•••-----------------•-•--•-••-•-•------•••---•••••---•---------•----•--------•.....-•••••••--••••••---••-...-•--•-••-•--•-•--•-•••-••--•-•....•••..:•-••._........................----•---•--•. VNature 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 LI1PI.1: 5 of the Ve Sanita_ry Code—.The undersigned further agrees not to place the system in operation ntil a erti4cate of Hance has been `issued by the board of health. Signed..... =J ' at Applicati n Approved BY111\ lU ---......- Date Application Disapproved for the following asons:_......-•--••----•-•------••-----••---•-•••.._......•••-•-••-•-••----•-•-------••••-•-........_••----.....•..... .............................._--•••-.............�.....•••Sr•--•--.....••------•-•....•-----..............---.........----......••----•••--•-•--•-•••••---••--•••••----•-•----Date --•-•------- PermitNo.--�6..... ............ -•-----•-••--•--_. Issued....................................................... Date ..... ...o.. — — " — — ------ rc No.. ............�J� ��y�� ��" �� Fas......, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 .. �"....OF.......... r -------------------------------•-----•--------...........-- ApplirMtion for Disposal Varks Tonstrnr#fun Prrmit Application is hereby made for a Permit to Construct ( L,4 or Repair ( ) an Individual Sewage Disposal System at: l ( .... .�✓,_. �. .. .. . 4u ....................... �...... t �....-----......................ioe _ortI ..................•-•s ........W d,g er Ad�ess �✓9/'k ,.a ................ ...-- .....----.. Installer Address as rl3 c 2 Type of Building Size Lot...._...:..,�...............Sq. feet U Dwelling—No. of Bedrooms............ �............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building 41V100......... No, of persons............................ Showers p•l YP g ......:........... P ( ) — Cafeteria ( ) 04 Other fixtures ......--•--------------------------•---•---•-•-•--. .... W. Design Flow.........................-------------.__..gallons per person per day. Total daily flow.................?=':'.......__.........gallons. WSeptic Tank—Liquid capacity..f �gallons Length..?2.... Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No........I............ Diameter......_1 ........ Depth below inlet.....::.......... Total leaching area...LL 2....sq. ft. Z Other Distribution box ( � Dosing tank ( ) Percolation Test Results Performed by........ :--!)j.f�.!c«!!�•J.0 .`._...... .... Date........ :.! .. - . �' Test Pit No. 1--------.....minutes per inch Depth of Test Pit......._:....... Depth to ground water,...................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ........---- -•-••-....-•--••---•.....--... .----•------•--•....•--•---------•.............•-------•-----••-••-••......-••--....---...... O Description of Soil--------------6 . .._................ .1 �. .....:'J V -------------- •--- ...........'G.:: 1 -• u i r? l �" G-f (� l�.�..L..__..._........ .....................•--------•------•......--....._.._•---- W -•-•-------•-----------------------------------•-------------•-----•---..............--•-•---......---•-----••---------•-------....... ------........---..:--------•-------------•--•-----•--•- -.... V 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 TI TALE 5 of the Sanitary Code—.The undersigned further agrees not to place the system in operationil e-rtiq'cate of Co nce has been issued by the board of health. Signed .. 1.....� ' / 6 ...................••---.................... - ate 5pplicatilApproved By. --•---•---------- ---------------•-....... ------ ............ - r --••-------•-- Date Application Disapproved for the following r osons:......................•---.------•---.....-----..--.--.------------- ......................--- -••---•}.----------------•-------------.....-•--•-`---•---..S..........-•--------------------------------••------•------- ------------- 1 Permit No....Lk ..............._ Issued-.......-.......................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............2 AW ........OF...... ' _T/ d �, ...................................................... (In#ifiratt of Tomplin rr THIS IS ) CERTIFY, That the Individual Sewage Disposal System constructed ( 14 or Repaired ( ) by........ ........... G't :....................................................................................................................................... •........ Installer at........................................................ ... ' 67....... ' 1�. T i �' r'fi �f%-'a--D 5 ;--� �6. ------------- . . ------------------- has been installed in accordance with the provisions of TI F 5 of The to Sanitary Code as described in the G application for Disposal Works Construction Permit No...... _.1 ...... I...�.5 dated___./.U..:,.. ._(...................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH G!l,J of rJf! 7 �I. 'jam FsE..............:........ Disposal or Tunstrnrtiun f rrmit Permission is hereby granted.... = `= = --•:............ .........._..........._....._...... ......._.._.. to Construct ( t,;f or Repair ( ) an Individual Sewage Disposal System at No....4%.0_�.......L.......?1J1 ........./1k........................._.. 1IR 514 A, =-`-W./Ll_`S.............---- street as shown on the application for Disposal Works Construction Per' No.. L!J.��� Dated.-.' ,..��Z... .�Z....... • •J..`l --------------------------•- � Bard of Health DATE........ ._ C �.......... - 1..'............... ......... .. I FORM IN A. M. SULKIN, INC.. BOSTON ! SITE PL A lV SHEET I OF 2 SCALE: / = 5O , 1 3 F f LOT E - �yo.00 t �� ^ � : C"� ► 1 0 i3$ '�'------5 To .7 a,v . z y' \ 4-b a I ooa 4A 2z'c N �• iood �t�, P,T i v�J vE , of.MAssc T WILLIAAA M. WARW ICK;. If �rGISTER`�� 'N RE6/STEREO LAND SURVEYOR FOR Pj A �.r 1 f P V -F?) 26N E M A fz 5 T'a r.l 5 NI I L-L� M A 1—i,S-, PLAN .REF, M,4.P�a7.t'A 2T.�� ��L.. �, DATE z61 BENCHMARK DATUM -.AS��.�M © WM. M. WARWICK 8 ASSOC., INC. DOMESTIC WATER SOURCE '�c.UN 1l�<''-t I� 80X 80/ - NORTH FAL MOUTH FLOOD ZONE. ��'J ` A �� a �� MASS. 02556 - (6/7) 563 -2638 LEACHING BASIN SECTION NOT TO SCALE Shee,/ e e� Z 24 C.I MH COVER EARTH f/L L BRICK AND MORTAR COURSES AS RE0'0• TO BRING 4 COVER TO GRADE INLET +B FLOW LINE_P/PE y"TO��� WASHED PEA STONE FREE OF IRONS, •. •'�i is'i .T; I I ', FINES AND •DUST /N PLACE I '• OPENING W/TH 4%8" 1 •' 3�4 + TO I%2"WASHED CRUSHED STONE FREE OF 7 / OUTER DIAMETER IRONS, FINES AND OUST /N PLACE A NO //4„INS/OE . . D/AMETEK I• CONCRETE TO BE 4000 PSI 28 DAYS 2. REINFORCED WITH 6%6" N0, 6 GA, W.W.M. 3. 2'AND 4' SECTIONS ARE AVAILABLE FOR 1 GREATER' DEPTH REQUIREMENTS MIN I-- Z --{----so `Q , 'Z I--� 4. NUMBER OF PITS REQUIRED C1J EFFECT/VE DIAMETER NOTE: EXCAVATE TO ELEVATION OR (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 TYPICAL PROFILE GRAVEL TO DESIGNED GRADE. 71 /8STD. Zr WGT. C.I.MH COVER 4"C./PIPE 4"8IT.F18ER PIPE DWELLING FLOW LINE TIGHT ✓O/NT OUTLET LEVEL r y p TO FIRST ✓0/NT (OS•SO 14 (c! �I o 0 1 1 0 �0 0 If C.I. TEE (o,7- ` 1 1 0 1 00 11 (OZ• " 1 ',,SsTD. PRECAST CONC. (a7� It000 00 11 11 I p/ST. BOX TO BE (p 11000 00 to I I —GAL.SEPTIC TANK. INSTALLED ON LEVEL 7 1 1 1 0 00 0 0 0 1 1 1 ;e ; STABLE BASE 1 1 1 0 00 O 0 1,1 I I £PT/C TANK To BE 111 100 0 0 1 1 1 1 1000 001111 ; INSTALLED ON LEVEL, 11I 100I 0 0 1 1 STABLE BASE. 1 1 1 10 0 0 0 1 1 1 1 11100I0 0 1 11 1 LEACHING BASIN Qp BASE.To BE LEVEL i 0 10 0 0 0 1 1 1 , el- - SOIL AND PERC. DATA 15 ..PERC. RATE : __z._ MIN./IN. TEST PIT NO. .I 0�� TEST PIT NO. 2 0 TEST BY: FEE UGC-_ Nc-,VD Z� �P�dw/svor WITNESSED, BY:' T AA G V I't' 1k _,1 M �u1uM 5i4ND TEST PIT OR. EL. u DATE: 27--07-04, '12- �i•�7 i i DESIGN DATA GENERAL NOTES BEDROOMS NO HEAVY EQUIPMENT TO RUN OVER SYSTEM. DISPOSAL t�O SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD EST. TOTAL DAILY EFFL��62 PD. PRECAST REINFORCED CONCRETE UNITS. SEPTIC TANK L6'e'2 GAL, ALL .SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE SIDEWALL 'AREA2' TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE, �} SGAL./SQ.FT, MINIMUM' REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF ll BOTTOM APEA 1'� GAL./SQ.FT. SANITARY SEWAGE EFFECTIVE ON JULY 1 , 1977. LEACHING REQUIRED 172 SQ.FT. ANY CHANGES 'TO THIS PLAN MUST BE APPROVED BY THE BOA ACTUAL LEACHING AREA OF HEALTH. BOARD �QQ.FT, AT -COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION: PITCH ALL SEWER LINES 1/4� / FT UNLESS INDICATED OTHERWISE. �tvi OF 41 S a�(, ti SEWAGE DISPOSAL SYSTEM MARTIN FOR- I?5A i MORAN H IF23417�q�� �T lO P.UT D`1 A AA '1 ss/oUA1 ENGti,�� _M )� IZST-OIL! -i AA I LC.S /A S tip SCALE AS INDICATED DATE . WM. M. WAROVA' 8 ASSOC., /NC. 8OX 801 - -NORM FAL MOUTH ` PROFESSIONAL ENGINEER MASS. 02556 - (6/7) 56.E-2638 �a d�! TOWN OF BARNSTABLE �II LOCATION Zp % ;T ��/�i tRWM 4}JC. SEWAGE # VILLAGE,/11,9�S�p/�r "!f 3. ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.�'� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) fieti,C h P-^% (size) alece NO. OF BEDROOMS PRIVATE WELL OR UBLIC WA E ` BUILDER OR OWNER �-R-e*,gke4 Deb Cdep DATE PERMIT ISSUED: NOV c— ll?c DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No L./ .. �' ®� v �� � `i � �� ���ve w` Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection One Winter Street, Boston MA 02108 (61 n 292-5500 M, S-7 , a®�' Ti"Y COXE 9-4 Secretary ARGEO PAUL CELLUCCI '�� /Lf� d DA& �V�ID B.STRUHS• Governor /I ommissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR1 �`r PART A CERTIFICATION 4^ ''• <10, Property Address: 1051 Putnam Avenue,Marston Mills,MA Name of Owner: Bruce Lee(Executor) Address of Owner: Date of Inspection: March 9, 2000 - Name of Inspector:(Please Print) .lames M.Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: James M. Ford Mailing Address: P.O. Box 49, Osterpille, MA 0265541049 Map: Telephone Number: (508)862-9400 Parcel: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes Conditionally Passes Needs Further Evaluatio y the Local Approving Authority �ail ` Inspector's Signature: Date: March 10, 2000 I The System Inspector shall 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 P . y v { revised 9/2/98 Page Iof11 Primed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1051 Putnam Avenue,Marston Mills, MA Owner: Bruce Lee(Executor) Date of Inspection: March 9, 2000 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: 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. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of 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 exfiltration,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. 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 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 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1051 Putnam Avenue, Marston Mills, AM Owner: Bruce Lee(Executor) Date of Inspection: March 9, 2000 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 15.303(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 a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WELL 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 to 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 1 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 (approximation not valid). 3) OTHER , revised 9/2/98 Page 3of11 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1051 Putnam Avenue, Marston Mills, MA Owner: Bruce Lee(Fxecutor) Date of Inspection: March 9, 2000 D. SYSTEM FAILS: You must indicate either"Yes"or"No"as 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 Backup of sewage into facility or system component due to an 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 1h day flow. 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable„attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria 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 — — 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 is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA or a ma Zone H of a public — — the system (In ) PPS water supply well The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1051 Putnam Avenue,Marstons Mills, AM Owner: Bruce Lee(Executor) Date of Inspection: March 9, 2000 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health. ✓ _ 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. ✓ _ As built plans have been obtained and examined. Note if they are not available with N/A. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. ✓ _ All system components,excluding the Soil Absorption System,have been located on the site. ✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions 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: ✓ _ Existing information. For example,Plan at B.O.H. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)]. ✓ _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. M revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1051 Putnam Avenue, Marston Mills, AM Owner: Bruce Lee(Executor) Date of Inspection: March 9, 2000 FLOW CONDITIONS ,. ., RESIDENTIAL: Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): 3 Number of bedrooms(actual): 3 Total DESIGN flow 549 Number of current residents: 2 Garbage grinder(yes or no): No Laundry(separate system)(yes or no): No; If yes, separate inspection required Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last two year's usage(gpd): 1999-95,000 gals.: 1998-90,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied. COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gM(Based on 15.203) Basis of design flow 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: OTHER: (Describe) . Last date of occupancy: � Y: GENERAL INFORMATION PUMPING RECORDS and source of information: Pumped on Jun. 25199-per Treatment Plmu System pumped as part of inspection(yes or no): No If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM ✓ Septic tank/distribution box/soil-absorption system.-.. s Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) 1/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information: 1988-per as built card. ; Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1051 Putnam Avenue, Marstons Mills, AM Owner: Bruce Lee(Fxecutor) Date of Inspection: March 9, 2000 ' BUILDING SEWER: _ (Locate on site plan) Depth below grade: Material of construction: _cast iron 40 PVC _other(explain) Distance from private water supply well or suction line Diameter Comments: .(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 15" Material of constriction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 1000 gal. Sludge depth: 1' Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: I' Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How dimensions were determined: - Measuring stick 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.) The baffles were present. The liquid level was even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (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: (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.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1051 Putnam Avenue,Marston Mills, MA Owner: Bruce Lee(Executor) Date of Inspection: March 9, 2000 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or 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 -• Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: ✓ (locate on site plan) Depth of liquid level above outlet invert: -- Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was located, but not dux up. There were no suns of failure in the pit. PUMP CHAMBER: None (locate on site plan) Pumps inworking order: (Yes or No) Alarms in working order: (Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Pagesofll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1051 Putnam Avenue,Marston Mills,AM Owner: Bruce Lee(Executor) Date of Inspection: March 9, 2000 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan, if possible;excavation not required, location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits, number: 1-6'x 6' leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.) The pit had 4'of water on the bottom. There were no sirens of failure. The bottom to grade was 9'. CESSPOOLS: None (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 constriction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection). Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Continents: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1051 Putnam Avenue, Marstons Mills,MA Owner: Bruce Lee(Executor) Date of Inspection: March 9, 2000 Map: Parcel. SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) `3 -, rya- a s rya- 3`-I A3- 3� 3 133' y3 t revised 9/2/98 Page 10ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1051 Putnam Avenue, Marston Mills, MA Owner: Bruce Lee(Executor) Date of Inspection: March 9, 2000 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth:Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 60 +/- 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 z r •, Checked FEMA Maps Checked pumping records Check local excavators, installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. Must be completed) Using the Barnstable topographic maps and water contours maps, the maps are showing approximately 60' +/- to groundwater at this site. Using the Cape Cod Commission Technical Bulletin, the high groundwater adjustment for this site(SDW 253, Zone C, 2100)was Z 1'. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. revised 9/2/98 Page 11of11