HomeMy WebLinkAbout0290 RACE LANE - Health 290 Race Lane
Marstons Mills. F/
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Commonwealth of Massachusetts
a Title 5 Official Inspec ion Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 290 Race Lane
Property Address
Christina Reverdy
Owner. Owner's Name
information is required for every. Marstons Mills MA 02648 10/12/12
page. City/Town - - - - - State Zip Code Date of Inspection -
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When fillingcomputerforms
A. General Information
on the ; I
��. .. .use only the tab 1. r. -
key to move your Inspector:
cursor-do not._ Ricky Wright -
use the return
key. Name of Inspector
B & B Excavation;lnc.
� Company Name
14 Teaberry Lane
VILA Company Address
Forestdale : : - MA .02644
City/Town State Zip Code
508-477-0653 S 14595
Telephone Number License.Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this ad dZe-Ss and that�the o
information reported below is true, accurate and complete as of the time of the insoection. THe insl*ction
was performed based on my training and experience.in the proper function andrm AintenancRof or iSte
sewage disposal systems. I am a DEP approved system inspector pursuant tobection T6.34(Rf
Title 5(310 CMR 15.000). The system: `may r
® Passes ❑ Conditionally Passes ❑ Fais rn
❑ Needs Further Evaluation by the Local Approving Authority
10/15/12
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or.DEP)within 30 days of completing this inspection. If the system it 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 approvi rig,authority.
****This report only Aescribes conditions at the time of inspection and under the conditions of use
at that time.This inspection does.not address how.the system.will perform in the future under
the same or different conditions of use.
t5ins•11/10 Title'Vnorm:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 290 Race Lane
Property Address
Christina Reverdy
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/12/12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 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.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 290 Race Lane
Property Address
Christina Reverdy
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/12/12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
distribution box is leveled or replaced Ej Y El N F1 ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 290 Race Lane
Property Address
Christina Reverdy
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/12/12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 290 Race Lane
Property Address
Christina Reverdy
Owner Owner's Name
informatics is required for every Marstons Mills MA 02648 10/12/12
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
f ..... ...... ..... ......
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M 290 Race Lane
Property Address:
Christina Reverdy
Owner Owner's Name
information i e
required for every Marstons Mills MA 02648 10/12/12
page. -City/Town -- - State Zip Code Date of Inspection
C. Checklist
Check if the following.have.been done. You must indicate"yes" or"no":as to each:of the following:
- Yes. No
Pumping information was provided by the owner, occupant, or Board of Health
❑ Z Were any of the system components:pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® : Were as built plans of the ystem:obtained and examined?(If they were not
I
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
Z El Was the site inspected for signs of breakout?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
- dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants:if different from owner) provided with
information on the proper maintenance.of Subsurface sewage disposal systems?
The size and location of the Soil Absorption, System.(SAS) on the site has
been determined based on: -
® ❑ Existing information. For example, a plan at the Board of Health.
El
® Determined in the field(if any.of the failure criteria related to-Part C is at issue
:approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential.Flow Conditions:
3 2 .. . _ .
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based.on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): 330
(Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Race Lane
Property Address
Christina Reverdy
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/12/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d n/a
9 ( Y 9 (9P ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: currentDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 290 Race Lane
Property Address
Christina Reverdy
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/12/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Race Lane
Property Address
Christina Reverdy
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/12/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
2002
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 118"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
>20
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in working order. No sign of leakage or blockage.
Septic Tank(locate on site plan):
Depth below grade: 8"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No
Dimensions: 1000 gal
Sludge depth:
4"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ,. 290 Race Lane
Property Address
Christina Reverdy
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/12/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
32"
Scum thickness
4"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? scour stick
Comments Iron pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appears to be structurally sound. No sign of back-up.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Race Lane
Property Address
Christina Reverdy
Owner Owner's Name
informatics is required for every Marstons Mills MA 02648 10/12/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/1 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
_ v Title 5 sect Official Inspection
on Form
p
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 290 Race Lane
Property Address
Christina Reverdy
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/12/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 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.):
At time of inspection d-box appears to be in good condition.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 290 Race Lane
Property Address
Christina Reverdy
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/12/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ 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.):
At time of inspection leaching was dry and appears to be in good condition. No sign of hydraulic
failure
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 ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 290 Race Lane
Property Address
Christina Reverdy
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/12/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage-Disposal System Form-Not for Voluntary Assessments
290 Race Lane
Property Address
Christina Reverdy
Owner Owner s Name
information is MarStonS Mills
required for every MA 02648 10/12/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanentreference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
El drawing attached separately
g
-Al
fl�- 45'
13� �
t5ins•11/10
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Race Lane
Property Address
Christina Reverdy
Owner Owner's Name
information�
required for every Marstons Mills MA 02648 10/12/12
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >7
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 11/13/02
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
1.
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4M 290 Race Lane
Property Address
Christina Reverdy
Owner Owner's Name
information is required for every Marstons Mills MA 02648 10/12/12
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
LOCATION �V C�LC.St, SEWAGE #
VILLAGE—.— �� S ���� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �yy�
LEACHING FACILITY: (type) `�C�S� (size)
NO.OF BEDROOMS \
BUILDER OR OWNER
PERMTTDATE: 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 1 �R�
nn 'J
. FI-
d
AA
yN
V. TOWN OF BARNSTABLE
LOCATION 0 R,A SEWAGE #001
VE,LAriE Ml ZilkS MU-i- ASSESSOR'S MAP & LOT f `'
INSTALLER'S NAME&PHONE NO. 4W d/ '1 43V
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 619UP (size) 0•�
NO.OF BEDROOMS
BUILDER OR OWNER Wfiyltr(11-11
PERMITDATE: #1 -d2 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
s
DICK
Jtuao �/�.t�i 7Y3r'��
��G'Audi
Fee—
THE COMMONWEALTH OF MASSACHUSETTS' Entered in computer:-L�
1-2 Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
rZ 01ppYication for 33igpogar *pgtent Con5truction Permit
Application for a Permit to Constrict( )Repair X)Upgrade( )Abandon( ) ❑Complete System ElIndividual Components
Location Address or Lot No. 4?_?O �A4WV O er's Name,Address and Tel.No.
Assessor's Map/Parcel o�9a AN�
?i !o �A C
Installer's Name,Address,and Tel.No. Designer's Name,Ad sVTe�
Type of Building:
Dwelling No.of Bedrooms 2 Lot Siz O 8U sq.ft. Garbage Grinder V)p
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow ���a gallons per day. Calculated daily flow 1�?,33 gallons.
Plan Date 0 T Number of sheets Revision Date
Title < �/ ggz,6
Size of Septic Tank eV 00 Type of S.A.S. F w Tdnle-
,� a K
Description of Soil
,t _ q •c_ 0 4 6
/ L
Nature f Repairs or Alterations(Answer when applicable) i /� (. r✓
r,a.
.0 h'
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 system in operation until a Certifi-
cate of Compliance has been issued this az of ``
Signed Date /—
Application Approved by Date /r=25`�-u 72
Application Disapproved for the following reasons
Permit No. Z 0 : Y y Date Issued C 2
(�i F No: s?' �7 1 �:;,� r _ Fee
�., THO ONWEALTH OF MASSACHUSETTS''-`a,� - Entered in computer: Y✓
E C
. :
es
PUBLIC.HEALTH.DIVISION"-TOWN OF'BARNSTABLES MASSACHUSETTS.
11ppricatfon for �Miopooal *p5tem Construction Permit.
Application for a Permit to Construct(.,.)Repair X)Up grade( )Abandon( ) •O Complete System D Individual Components
Location Address yor Lot No. O ner's Name,Address 'and Tel.No.
F- N T n/AFiE<�
Assessor's Map/Parcel 1-4 e E f'4ti'E M, I1'?ELs%es-j\ , 0. )
M �/11 l& �n C_< C .�.� s y - /-7
lr'staller's Name,Address,and Tel.No. , �y6t rE � Designer's Name,Address and Tel No.
Type of Building:
l4 b-v ►fir v.e.
Dwelling No.of Bedrooms 2— Lot Size-20 w U sq.ft. Garbage Grinder
1Other ! -Type of Buildmg No.,of Persons
Fixtures Shwes O Cafeteria( )
Other
Design Flow V,d gallons per day. Calculated daily flow �/y3 3 gallons.
Plan Date DC 7- ? Number of sheets Revision Date
Titled iTa' f��nl 2 ��-,J +Ji/Ja1�r,-o
Size of SeptiaTank STN /vpo L Type of S.A.S.4--4c
Description of Soil 0—/a7 '7/0
v s.
s' �s y ,
r — ,� Q do Sr
�J
F ;%r " l' SF.r ..i{ C 1 iYC_ F_i7�f" Aln ` c_
Nature of Repairs or Alterations(Answer when applicable). lF X'r.Ci i�✓i �Cl� �/`'•7" �^!T,�
-4 rh.01/ Xs r 4 yltxY '-v
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 system in operation until a Certifi-
cate of Compliance has been issued thisr�B'�of
Signed 0' /, - Date
j' ApplicationApproved'hy Date -it-f5=Q
Application Disapproved for the following reasons
Permit No.,, O o-1„- :�y 7 Date Issued 1)-t ':--U 2
———————-——————————————————————————————
THE COMMONWEALTH OF MASSACHUSETTS..
r ' BARNSTABLE,.MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( )
Abandoned( )by
has been constructed in r at o sttucted accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. �UU�-S H 1 dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as de i ned.
� p
P g Y S
Date 2o, dJ3 Inspector
No. f U�,� �/ � .F.. ,�?�. --------------------Fee
t'
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-, BARNSTABLE MASSACHUSETTS
0t!5Po5a11*p!6ten� Congtructton Permit
+Permission is hereby granted"to Construct(> )Repair( )Upgrade( "').Abandon
`x System located"at A,1' 1i cr fr r xJ"
Y a 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'rihiit�.
Date: ��- (� '�Z Approved by e '�
v .
a
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
> DEPARTMENT OF ExvIRONxENTAL PROTECTION
FAILED INSPECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A RECEIVED
CERTIFICATION
Property Address: 290 DACE LANE S E P 3 2002
MARSTONS MILLS MA 02649
Owner's Name: DEAN AND JENNHER WIrIKFIELD TOWN OF BARNSTABLE
Owner's Address:SAME �1 HEALTH DEPT.
Date of Inspection: AUGUST 24,2002 a� .l -7 0-7
Name of Inspector. Patrick M O'Connell MAP j
Company Name: Septic Inspection Services Co.
Mailing Address: 189 Cammett Road PARCEL ' - -- -
Marston Milts MA 02648 LOT
Telephone Number. (508)428-1779 � -
CERTIFICATION STATEMENT
I certify that I have personally inspect 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:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
X_ Fails
Inspector's Signature: .0 Date: (6��?-IO2— .
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Motes and Comments
****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.
Page 2 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 290 RACE LANE
MARSTONS MILLS
Owner. DEAN AND JENTN07ER WINKFIELD
Date of Inspection: AUGUST 24,2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
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 exfihration 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.
Page 3 of 1 l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 290 RACE LANE
MARSTONS MH.LS
Owner. DEAN AND JENNIFER WINKnELD
Date of Inspection: AUGUST 24,2002
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(l)(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 l00 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 aseptic 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 welt".Method used to determine distance
"This system passes if the welt 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:
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 290 RACE LANE
MARSTONS MILLS
Owner. DEAN AND JENNIFER WINKFIELD
Date of Inspection: AUGUST 24,2002
D. System Failure Criteria applicable to all systems:LEACHING PIT IN HYDRAULIC FAILURE.
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
X_ 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 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. [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.]
_YES_(Yes/No)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
lam-
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)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 290 RACE LANE
MARSTONS MII.LS
Owner: DEAN AND JENNIFER WINKFIELD
Date of Inspection: AUGUST 24,2002
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?
'Me 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.
_X_ ce_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distan is unacceptable)[310 CMR.15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 290RACE LANE
MARSTONS MILLS
Owner DEAN AND JENNIFER WINKFIELD
Date of Inspection: AUGUST 24,2002
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): ?_ Number of bedrooms(actual): 2_
DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms):_220_
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 ar no):
Seasonal use:(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 164
Sump pump(yes or no): NO
Last date of occupancy: CURRENTLY OCCUPIED
COMMERCIALINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,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: HOMEOWNER
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping: PUMPED WHEN HOUSE WAS PURCHASED
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
—ivy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)No
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:
INSTALLED 1970-1971 PER HOMEOWNER
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 290 RACE LANE
MARSTONS MILLS
Owner. DEAN AND JENNIFER WINKFIELD
Date of Inspection: AUGUST 24,2002
BUILDING SEWER X (locate on site plan)
Depth below grade: 1'
Materials of construction:_X_cast iron _40 PVC other(explain):
Distance from private water supply well or suction line. 24'
Comments(on condition of joints,venting,evidence of leakage,etc.): NO EVIDENCE OF LEAKS
SEPTIC TANK: X_(locate on site plan)
Depth below grade: 8"
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: 1000 GAL.4.5'X 8'
Sludge depth: 5"
Distance from top of sludge to bottom of outlet tee or baffle:26"
Scum thickness: 67
Distance from top of scum to top of outlet tee or baffle: 61/2"
Distance from bottom of scum to bottom of outlet tee or baffle: 13"
How were dimensions determined: STIONITH E NGE FLAP
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): TANK WILL BE PUMPED WBEN NEW LEACHING
FACILITY INSTALLED.BAFFLES INTACT AND CLEAR.
GREASE TRAP:—(locate on site plan)
Depth below grade:—
Material of constriction:— —
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 scurn 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 related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 290 RACE LANE
MARSTONS MILLS
Omer. DEAN AND JENNIFER WINKFIELD
Date of Inspection: AUGUST 24,2002
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: Rallons
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: NOT PRESENT (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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.):
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.):
Page 9 of 1 l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 290 RACE LANE
MARSTONS MILLS
Owner: DEAN AND JENNIFER WINKFIELD
Date of Inspection: AUGUST 24,2002
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X_leaching pits,number:_l_
leaching chambers,numbe.:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovativelalternative system Type/name of technology:
Comments(note condition of sail,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.): LEACHING PIT IN FAILURE.FULL TO TOP OF STRUCTURE HIGH WATER STAINING INSIDE
RISER DAMP SOIL ABOVE.PIT. GREEN VEGETATION AROUND PIT
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
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.):
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: 290 RACE LANE
MARSTONS MILLS
Owner- DEAN AND JENNIFER WINKFIELD
Date of Inspection: AUGUST 24,2002
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.
�1 z
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Page It of It
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 290 RACE LANE
MARSTONS MILLS
Owner. DEAN AND JENNIFER WINKFIELD
Date of Inspection:AUGUST 24,2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water: MORE THAN 15 FEET.
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-Ifchecked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet.of SAS)
Checked with local Board ofHealth-explain:
Checked with local excavators,installers-(attach documentation)
X Accessed USGS database-explain: CHECKED GIS CHARTS AND USGS TOPO MAPS.
You mast describe how you established the high ground water elevation:
COMPARED USGS CONTOUR MAPS TO GIS GROUNDWATER CHARTS
PROPERTY @ EL. 56 GW.@ EL.40.
NOV 0 SENT').
�oF.► rotti Town of Barnstable P# 3t s-
Department of Regulatory Services
BABIJSTABLE, l o d
MASS. Public Health Division Date
f6Jy. 1b
A�f Mp't 200 Main Street,Hyannis MA 02601
Date Scheduled l b d u� Time Icry rat Fee Pd. )ov—
Soil Suitability Assessment for Sewage Disposal
Performed By: �Tra xen.../R z4cl—z Witnessed By: �Avi %9 n�- f✓ �
- ';d;;+!;,::•:�i•:,;n!aa..,4�.,!.�.n,x.t,7�e�!I rt ..a:r w.�,..I .k � '�a s �
r i�! 9na i! ;dYSG!.4 i YT criz IF a'S5¢1 l4J Il'+J!. ) I 7•r"^�:a "4 xB:!4��Ef ." '4
t= �..II_..al.__.u��a. ....�r..� i !le9Mrasw tv sw '.. - r !kri,," m;.a:.L:.rn "kr a U_ 3v? .�
Location Address d Owner's Name p er,2wt/i�'�,�
Address .Z)o RAK—e—r 4-4 ,=
Assessor's Map/Par I: Engineer's Name ��LL �S�leC Z22 �7E7-XOn�R.
NEW CONSTRUCTION REPAIR V Telephone# _ 6 r7
Land Use _�i�g/1J Slopes(%) LE,✓ L Surface Stones /✓���
Distances from: Open Water Body aft Possible Wet Area�a ft. Drinking Water Well /✓one ft
Drainage Way /V O+ C— ft Property Line r�Qft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
I �
2Q 706 sQ Fi j
Parent material(geologic)� tn) Er�i�i Depth to Bedrock S� t
Depth to Groundwater: Standing Water in Hole:Htsr/t' f�VL Weeping from Pit Face fV6
Estimated Seasonal High Groundwater /vt)T L.,/c
Y il:10
vwgg
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level
La - !I.cC M1 tis!P- ti x-s y T 7•"sl§' cy a cry e� y °!:.Li#i` ^, l4 ,-
Ail
! h I C !n 'F ,i
,x. r 4 s-Y r tr)Pt I xrll I ] t}�HM1tY 4 I of M1: �, I sk aKT T M1 �CfI a l' 4. iTM cTi7 s
6:a� �,h°'�'r48L�,"t��w�
Observation
Time at 9"
Hole
Depth of Perc
Time at 6",
Start Pre-soak Time® / Time(9"-6")
End Pre-soak
Rate Min./Inch �a2Mi�✓ � 7
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN)
Original: Public Health Division Observation Hole Data To Be Completed on Back--------
Q:HEALTH/WP/PERCFORM
5 9 'vn 4a ! III a: �l t'i4`1�:rri Prk�4ntt!k 1hry.,KY alw ura Any ��kPl rcFs I!. '�'
irQIQ�,
.�.i,��.rz d ,�r.ab'sa>?.kErh,�.t. , 7iSak,4i•. WY."c34 _.-:!:4.tx..H!K.r�t�•Aq:t9_:t'�Y ,n......at3m
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders.
Consistenc %Gravel
r�
e . � s:��.F:A.t,s, "pu KISBN'
BN'`� d kcfi�:hl„
�CiRIA b4, � d�P�:,'I:;�i i''ti�.t`,3!:ry,�1'r•w1:r ui_tl.6vM i@ .?—
t.u!,
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders.
Consistency.%Gravel
CS I
7sT. P !.. `''Is:i,ml"iu:-:'III •�
,.'If y("a1�A� r i !.4!j Yi aJ;fit,-:�•r r r�r€r src
,.i.;... rtr: .GN�n• rurr�1 '.: .'I!al.r.'F4ajr:,l ra:.:Fa��•a�r!�'n,'!'s:!"+y
kl 6`r �✓ __ • i ! a r
r r_h,w:,al tld ,,,lF ..,.,t5E!'_.:Y1...•!kk'lrrl�.'h...zr!'�L.,.1!:>:Si. u.u,:.>r,i!4'1;:�,.•_'.L[Consistencv.
_ f,';r:�:z• ..a.._�!II�._,:�4:- I
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders.
%Gravel
r:
III .�;r..t.,;::�.:_r::.::r:.! �w:'y:� ,f •m w. n :._.� ,:i.; "6' � .::�:,:x-:[;:r.'s. +ir. v.� R} _.u,:,R z:�i',{ r r'r 4a�...%.�r�'r hl•:Jiir to:P,rA!i:�r.,,,!;il7:cgl-�a!r!:I,a��ky r .}�/� =��. ,r, d n Y !t) r Ir i .�'�;':%! !' ,I �xJ� a �'�t .:N,a.,I.•.y.._..: 1t d�r
x .a
i'•..�hYr.!::NrnY�[>rRS ° ..6 wa.,k
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders.
Consistency.%Gravel
Flood Insurance Rate Map:
Above 500 year flood boundary No_ Yes
Within 500 year boundary No_ Yes
Within 100 year flood boundary No_ Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring perviquis material exist in all areas observed throughout the
area proposed for the soil absorption system? �S
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required train' x ertise�and ex pe 'e described in 310 CMR 15.017.
Signatur Date
Q:fIEALTH/WP/PERCFORM
TOWN OF BARNSTABLE
LOCATION® � SEWAGE #O
ASSESSOR'S MAP & LOT Iva-
INSTALLER'S NAME&PHONE NO.
i p
SEPTIC TANK CAPACITY < _ o
LEACHING FACILITY: (type)�" (size) s
NO.OF BEDROOMS
BUILDER OR OWNER s f4A
PERMIT DATE: l� COMPLIANCE DATE:
Separation Distance Between the: Feet
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist Feet
Ion site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility (If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
i
Awo G IVIlaq r#'uk
9
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
One winter Street,Boston,Ma. 02108 John S-epti
D.E.P. Title V.�S,eptic Inspector
P:U::B,LW119,
Teaticket, MA 02536`,
WILLIAM F.WELD (508)5z4-6813
Governor
iITECEIVE
ARGEO PAUL CELLUCCI t
Lt.Governor A U g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM •� 1998
PART A rDWNOFBARNSTABLE
CERTIFICATION HEALTHDEPT i
Property Address: 29D Race Lane Marstons Mills Address of Owner: `
Date of Inspection: 815/98 (If different) ®j 6
Name of Inspector: John Graci Arthur Thomas:Box 715 Centerville Me.02632
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X Passes This Inspection Is based on criteria defined InT@le v
_ Conditionally Pas e5 code310CMR15203.Ny findings are of how the system Is
performing at the time of the Inspection.lAy inspection does
_ Needs Further aluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity ofthe
Fells septic system and any of its components useful life.
r
Inspector's Signature: Date: t1151g8
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair,passes inspection.
Indicate yes,no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
— Co7hpliance(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 conforming septic tank
as approved by the Board of Health.
perused DUMP)
One Winter Street • Boston,Massachusetts 0210E • FAX(617)556A049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 290 Race Lane Marstons MIAs
Owner: Arthur Thomas:Box 715 Centerville Ma.02632
Date of inspection:915109
_ Sewage backup or.breakout or high.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
—The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must Indicat6 either"Yes"or"No"as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
_ — Backup of sewage in 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 on overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 0412707)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 29D Race Lane Marstons Mills
Owner: Arthur Thomas:Box 715 Centerville Ma.D2632
Date of Inspection:915J99
D]SYSTEM FAILS(continued)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumper•.
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 cesspoo 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:
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
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a
public water supply well
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 290 Race Lane Marstons Mills
Owner: Arthur Thomas:Box 715 Centerville Ma.02632
Date of Inspectlon:111511118
Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner,occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
— — flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this
inspection.
— x As built plans have been obtained and examined. Note if they are not available with N/A.
x — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
_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.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is
unacceptable)[15.302(3)(b)]
I
(revised 04127)97)
hd
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 290 Race Lane Marstons Mills
Owner: Arthur Thomas:Box 715 Centerville Ma.02032
Date of Inspection:815198
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom for S.A.S.
Number of bedrooms: 1
Number of current residents: t
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy: Na
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: nra
Last date of occupancy: nra
OTHER:(Describe) Na
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Na
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: Na
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records,if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date Installed(if known)and source Information:
46 years old.
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04127)87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 290 Race Lane Marsions Mills
Owner: Arthur Thomas:Box 715 Centerville Ma.02632
Date of Inspection:815198
SEPTIC TANK: x
(locate on site plan)
Depth below grade:6"
Material of construction: concreate metal FRP Polyethylene—other(explain)
If tank is metal, list age nia . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: Le'6"He'7"w4'10"
Sludge depth:t"
Distance from top of sludge to bottom of outlet tee or baffle:33"
Scum thickness:0
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle:0
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 and functioning properly.Recommend pumping now and then maintained every year.
GREASE TRAP:
(locate on site plan)
Depth below grade: rda
Material of construction: concrete metal FRP Polyethylene_other(explain)
Dimensions: Na
Scum thickness:He
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle:rUa
Date of last pumpingn-
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
nra
BUILDING SEWER:
(Locate on site plan)
Depth below grade: v
Material of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction lineto-
Diameter: nia
(rOmments: (conditions of joints,venting,evidence of leakage, etc.)
I
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 290 Race Lane Marstons Mills
Owner: Arthur Thomas:Box 715 Centerville Ma.02632
Date of Inspection:815199
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: Ma
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: rda
Capacity: rda gallons
Design flow: rye allons/day
Alarm level:-.rda Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nfa
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.)
rVa
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_ve.
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
rda
(revised Odrt7l97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 290 Race Lane Marstons Mills
Owner: Arthur Thomas:Box 715 Centerville Ma.02852
Date of Inspection:815199
SOIL ABSORPTION SYSTEM(SAS):x approximated by non-intrusive methods)
(locate on site plan,if possible;excavation not required,but may be
If not determined to be present,explain:
rda
Type:
leaching pits,number. '00pgellon leach pit
leaching chambers,number:Na
leaching galleries,number: nla
leaching trenches,number,length: roe
leaching fields,number,dimensions:rda
overflow cesspool,number:nla Name of Technology:_nla
Alternate system: rda
Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach pit Is structurally sound and functioning properly.The leach plt had V of leaching left at the time of the Inspection,recommend pumping system.
CESSPOOLS:
(locate on site plan)
Number and configuration: Na
Depth-top of liquid to inlet invert: nia
Depth of solids layer: rda
Depth of scum layer: nla
Dimensions of cesspool: nla
Materials of construction: rda
Indication of Groundwater: rda
inflow(cesspool must be pumped as part of inspection)
nfa
Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
nra
PRIVY:
(locate on site plan)
Materials of construction: Na
Dimensions: ❑ra
Depth of solids: nla
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.
rda
(revised 0427197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
290 Race Lane Marstons Mills
Arthur Thomas:Box 715 Centerville Ma.02632
815198
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
to !l
4q
8
v
(revised0A)2T19T) Page 9 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
290 Race Lane Marstons Mills
Arthur Thomas:Box 715 Centerville Ma.02632
915199
Depth of groundwater 12
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
(revised04)27197) Pogo 10 of 10
1 i
5
LOCATIO�N K , SEWAGE PERMIT NO.
IZ7g YIO
VILLAGE
INSTALLER'S NA ADDRESS
ems..._.. OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
i y �
l'
a .,:
` �l � f
C'
S`1C 1
�'� �,�
\�� �
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH-
. ....................O F.......................................---------------------....._..............---.......
Appliratiun for Diupuial Works Tonutrnrtiun thrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
(1 y
.....-•------------------------------• ----./ kA�` � ...................
...
��ff c�- Locatedress or Lot No.
_ ... -
... --...------...•............................
Installer Address
d Type of Building Size Lot..LL .....Sq. feet
U Dwelling A�'No. of Bedrooms...,.a____________________________________Expansion Attic ( ) Garbage Grinder ( )
'k Other—Type e of Building No. of persons.................•.......... Showers — Cafeteria
Pk YP g P ( ) ( )
W Other fixtures ----------------------------•-•. .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit 1\o. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
GG . -------- • ...............................................................................................................................
O Description of Soil-----.. G!.�_. ...........................
V -------------
•--••---------
.-----•----------------------•--------------
----------------
•-•---------_------ . •----------.--------------------•-•-----•------•----.........._........-----•-----------
W ....-•------------------------------ -----------•-----------------------------•--- r
V _ Nature of Rep,�irs or Iterations—Answer when applicable.. f ..4 p
-----------_-----_---..:....
Agree
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITL% 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the
board/ f, halth
Si ne ............ ----
Date
Application Approved B -• ......................... ........................................
Date
Application Disapproved for the following ons:..............................................................................................................-
----•-•-----------------••---------...---••----------------------........--•----•---.........................------------...--•--•-----------•-----••--•------------------------•----------••---•...-•-•-
ate
Permit No..... z.� L._..._.. Issued, ..............................................
Date
I--------------- -------------------------------
No..-...... -.��¢� Fizz..........................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 'OF• HEALTH
................:... .............._.....OF..........................................--------......-----.............................
Appliratiun for Biupuual Workii Tonotrur#inn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at• 45
. ....
....: . . --... l�r�± . . ...... ..............................
�..
ocation-Address or Lot No.
..... ...... .. .' ..................................... . ............._....... ............. ..---
n r
,v w t Address -----•-�
� Installer Address
of g Size Lot. Sq. feet
U TypeDw ll n Building
No. of Bedrooms._....................................Expansion Attic ( ) Garbage Grinder ( )
`4 04 Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other fixtures -------------------------------•--•--•----.....
W Design Flow..........................:.................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft.
3 Seepage, Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a . ...... .................................................................................•---..............----..........................•.
0 Description of Soil..------ -----------.............•...............................................................................................................
x
--•--•-- ...------••-•••-------
x -----••••-•--------•--------•-----•••-•---•-•--=------•-- ........................... ........ ........... .................
--•-•-••-----------•--•-----------------
UNatur---d of R-epirs or, terations—Answer when applicable._.t,Q . . . -P_s._ t_.__ ..................................._..
--------- AA......------•- ---------------------------••-----....--•--.......••---------••------------••...-•--•-••----------•----...••......-•---------•......--•.....
Agreem nt:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by he board o health.
Signed----
-------------------•--••---....
Date
ApplicationApproved By....-............................................................................................. ........................................
Date
Application Disapproved for the following reasons---------------------•=----------•--•---•-----------------------•---------------......-•---•------........------
......-•---------------------•---•-----....---------------------------------------•--------••-•-----•--.........----.........----------------•----•--------------------------------------------•••...•---
Permit No.. - _ Issued.y�. ..............................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Tntif iratr of Tontpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by..............•....A L---...---•.:.''-- L. .�..------.... :...-•------------...---.....---•-----------••-•-•........---•-........--
Installer
at...... a 4....................... --------------------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No........ 5------ ...... dated.... --------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................ -._2.5---------------------- Inspector............. . ..---- --- _ .�... .....---•--...--- .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
a
Dinpnsal or�k-•u Tontrnrtion 'prrntit
Permission is hereby granted............. L` _ .,�.�,. ----•---------..............._...-•--------...........................--••-------
to Construct ( ) or Repair (,K) an Individual Sew a Disposal S stem
�gg��
at No............ b---••----i _t .Z4t t ...............�:�r Sry :1.1 ►' ......................
Street
as shown on the application for Disposal Works Construction Permit No ''j;.'Dated..... ........
--•--...--•-----•••-......-•--•. . -- -
x,
-; •- Board of H lth
DATE.......--•=.J.' - 1 -------------------------------•--------
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TOP OF FOUNDATION
O CONCH E I`c COVERS ✓�L F4/<' 7
_:
�� G1f ✓ G`f�i�_ F'� '^` , M •,�,9 " 4"CAS7 IRON 9'�
,�; OR SCHEDULE 40 "
^!� ' Z4 7-4.z / FrXo. . � . , 4 SCHEDULE 40 Rv.C. (ONLY) LEACHING TRENCH ( )RED. t
P.V.C. PIPE MIN. PE_ 9. MtN • I/8 - I/2 WAS STONE "
PITTCH I/4 P.R.r i• " �• 36 MAX. :
r1 PITCH 1/4"P .FT _
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INVERT v GAS BAFFLE- a. L_J ,L7-1p If Y=1=•rL7%4,' C1 :f —�. 4
\ !. EL7y.9�.. SEPTIC TANK E�7pa7' 6" o,EEL7.�'� ' c7i'r�',=3; ;-EW"t,i r�i�v"" r�;• 24'
f/avS� INVERT EX/S7-/rVC- <$� C�,,O, C5; r�-OYp
GAL.. INVERT DIST, _ - - 7Q.7�
„' �=
1 * _L.7�r> ... INNER` St 0 -11/�. EL .��..4 Precast 5 0 Gal.Leach 3/4 2 .�
rn/O FL. f 6"CRUSHED STONE �_7r Z� (e) RED. Chamber WASHED STONE
t LaT �- '• PROF LE OF 2s- z
1 l a �- rz7c,7o," A r - -
I \ 2 , 7oo.�c1. / _ '''�' - O D WATER ,AZLc Ei✓L
i I SOIL LOG SEWAGE DISPOSAL SYS i EM TYP CAL CROSS SE0710N
LEACHING
DATE ./.o.l!eV44.. TIME NO SCALE TRENCH .
N 0 G^_A Lr
CST HOLE I TEST HOLE
► ► , �`� ` \,v- n - �.'. .. . . E ?. ... DESIGN DATA
C / ` 9 diN. ylrSHED -36"MAX
r - ROCh!S �C�'Y . 3 T SivN
' J � C
!6 TG7AL ESTIMN7-c0 FLOW .. .• gyp. ... GALLONS/DAY ' 8.r
a , ,Q 4
BOi,OM L=4CXING AREA ,��(�.��. SO.ri./TRc=NCH 24"
SIDE LEACHING AREA
G
GARBAGE DISPOSAL . .eYO. . ..(50°o AREA INCREASE)
r ; ,`I 1 \ `�` o• '. Gog Sr--r'g V, TO7,AL LEACHING AREA
6 PERCOLATION RATE . L�M,.y�/N4!"!- P=R. INCi
i/l `� \`_ _ - — - - - - - - - •� � �cs,g f/_r7�n/T G` �i-/�n/� LEACIING AREA PER PERCOLATION „ --:JI 3 SO.FT
t �`i27.07 X 7` "— Zl a GRCCNO w,;TER T..3L= c .
• L - - - - APPROVED . . . . . . . . . . .. .. 8CA-o OF HEALTH h
o _ ( _ h IE Q��H Gf �'°,SS,lt .NQ .n' iER E,NCOUN T EREC 0
��--;; E 1 f v o�� ED�AtMR' , Gr � 0 7E y1 p
C� �+ t r E. ' ' WITNESSED BY AGc�: o= INSPECTOR `
ICELLEY T r -
N0. 261(JO �� ✓'•+.�' -/ft/[{y✓ r�5,� L* BOARD OF =.^LiH
EDSP Q,
EVAL�Pt�
P=,171ONER