HomeMy WebLinkAbout1198 RACE LANE - Health 1198 Race Lane
Marstons Mills
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TOWN OF BARNSTABLE
LOCATION ,L�� �,,a SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT 3-- elr)l
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
4 . v
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER
B` R OR OWNER ZP A/' / 6'!��'✓1 `
DATE PERMIT ISSUED: l _—�5... �� 4 `•`° . ' `='
DATE COMPLIANCE ISSUED: U=/ � L�
VARIANCE GRANTED: Yes No
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TOWN OF BARNSTABLE
LOCATION /"J1 �.< <.� - SEWAGE
VILLAGE ��
`` ASSESSOR'S MAP & LOTS_'iY - C_cj
INSTALLER'S NAME & PHONE NO./'Ajrfjd;=�. `A,
SEPTIC TANK CAPACITYfG�l3 "
LEACHING FACILITY:(type) (size) , B �yCt�
6;
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER
BUftefiR OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUEDf
VARIANCE GRANTED: Yes No
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` , > 1<<:, �`�'•ems//T. � �I
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No. Fee 004Ye
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS
rication for Oig ogal bpotent Congtructiou 3permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 9�1 ^C c A a-C Owner's ame,Address and Tel.No.
6
Assessor's Map/Parcel �� ��� � � //V A-1(l. 49�:. � _
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
XV
3.A ej 130
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow JJ U gallons.
Plan Date JV--e�* Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil; //Mho/c✓rr !f q n.
Nature of Repairs or Alterations(Answer when applicable)
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 by this Board of Health.
Signed L/^ •C& � Date
Application Approved bya Date
Application Disapproved fo the following reasons
oe
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( _.,)Upgraded( )
Abandoned( )by ! � i -
at Reice n62 r fn has b constructed in accordance
with the provisions of Ti 5 f r Disposal System Construction Permit o. to
Installer P1�� �//� Designer e
The issuance of s rmit all pokbe construed as a guarantee that the s e wd n s e .
Date Inspector
_ t
No. ' x 0I Fee xUU'0.0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Ye
PUBLIC HEALTH DIVISION -TOWN OF"BARNSTABLE, MASSACHUSETTS
applitattbfi for mig ozal otemmY Conotrurtion Permit
/ Application for a'Permit to Construct( ),Repair( )Upgrade( )Abandon( ) O Complete`System ❑Individual Components
Location Address or Lot No. gaff Owner's Name,Address and y�/0 T 1.No.
�o g Qv6 G✓�jL On� 'r
Assessor's Map/Parcel..' 3 �"1 t �y�sf�� 6�j�
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �•.°
3.R G
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) r
Other Type of Building No.of Persons Showers( ) Cafeteria( ) '
Othet.Fixtures
` Design Flow gallons per'day. Calculated daily flow 3� gallons.
Plan Date /lam r 6- 6 Number of sheets Revision Date
L Title
Size of Septic Tank Type of S.A.S. '
Description of Soil �r�r�'' yr+ f Ci�✓�
Nature of Repairs,<or Alterations(Answer when applicable) f�6� ZlU ��/v�✓ p1-t f f/�
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 by this Board of Health.N ' ~
~ Signed .� �4 1 Date
Application Approved by !l` / Date
t -,
Application Disapproved fo following reasons thens
`t
Permit No. ' Date Issued 45
THE COMMONWEALTH OF MASSACHUSETTS
" BARNSTABLE MASSACHUSETTS
Certif irate of Com' pl ance 4 .
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( Upgraded( )
Abandoned( )b `%� �-- vi^ CG T-�-�-
at � �rce has b onstructed in accordance
with the pro isio,�nsofT,itle,55 and the for Disposal System Construction Permit o. tned�. s
Installer /J ;),� �tl V 1)k .. Designer i _ ►;v,/�
The issuance o 's emit all not-be construed as a guarantee that the s e w'll�u�iz�n- s d i�neclr �
c
Date Pg i %��Inspector
--- -------------------------
No. —— _ "— Fee /00 4c)
THE COMMONWEALTH OF MASSACHUSETTS '
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS , . . :
t� oar *pgtemu �ott.6trur is 30er it
Permission is hereby granted to Construct( )Repair( )Upgrade{ b� o"
System located at ,/��dc ��� IAN � 0 6 �' .._•;_
and as described in the above Application for Disposal System Construction Permit.The applicant recognizeAhis/her duty to-:
comply with Title 5 and the following local provisions or special conditions.
Provided;Constructi n us be co Mete (within three.yeazs of the datetof this'
Date: /"' (� Approved by
TOWN OF BARNSTABLE
LOCATION /f l j heee SEWAGE # a%- S/Lt'
VILLAGE/#�`�'S' 4ASSESSOR'S MAP & LOT Y - e4:5;)/
INSTALLER'S NAME & PHONE NO. ���ly�`% A Afl�L�s�: /Tdi�"•� c�
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) %��e7 S®!1 Gy�1/ ���size)
t
NO.,OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER
Bbfti5SR OR OWNER GP/,/� /!� �"C.�/✓'
DATE PERMIT ISSUED: � '��"' �� ' a'• ` .: ,,,., ;..
DATE COMPLIANCE ISSUED: Z4� "/ y i
VARIANCE GRANTED: Yes No
7 �
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of1
Town of Barnstable r# L3?
Department of Regulatory Services
nt�►ss.
Public Health Division
Date
200 Main Street,Hyannis MA 02601
Date Scheduled D Xe— Timef . Fee rd.
Soil Suitability Assessment for Sewage isposal
Performed B I J 'Y 1 i` .
y:— D Witnessed By: e �i
O ATION& GENERAL INFORMATION
Location Address /'I /��� Owner's Name a D
Address '^'s✓
Assessor's Map/Parcel: / Engineer's Name -DA VID /�/y�AISO/ , °J
NEW CONSTRUCTION REPAIR V Telephone#
Land Use J"''t+ Ili Slopes(%) �a Surface Stones
Distances from: Open Water Body 7/aO ft Possible Wet Area�100 ft Drinking Water Wel�/o ft
Drainage Way ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands proximity to holes)
�y
-PoWk
Parent material(geologic) 0 V%ZA—) 6"j Depth to Bedrock I r
Depth to Groundwater: Standing Water in Hole: AJ'4 Weeping from Pit Flee
Estimated Seasonal High Groundwater V
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in. —Depth to soil-mottles: —
Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adi.factor— Adj.Groundwater Level
PERCOLATION TEST Date Thne,�
Observation 0
/'Hole# Time at 9"
Depth of Perc 7 Time at 6"
Start Pre-soak Time @ // i ime(9"-6")
End Pre soak
Rate MindInch AlI
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(1) week prior to beginning.
Q:\SEPTIC\PERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
consistency.% ravel
21 7
DEEP OBSERVATION HOLE LOG Hole# Z
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistencv.%Gravel)
DEEP OBSERVATION HOLE LOG Hole#
F Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consi to
Flood Insurance Rate Man:
Above 500 year flood boundary No_ �L'es
Within 500 year boundary No fifes
Within 100 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervi s maul exist in all areas observed throughout the
area proposed for the soil absorption system? 14
If not,what is the depth of naturally occurring per ous material? _..
Certification
I certify that on �� 9 (date)I have passed the soil evaluator examination approved by the
Department of Enviro mental Protection and that the above analysis was performed by me consistent with .
the required training,experti and exp ri nc described in 310 CMR 15.017. �,/ Q
Date �,� � / z��V
Signatur ,
Q:\.SBPTICIPERCFORM.DOC
6
�Cg V
S
x
Commonwealth of Massachusetts
Executive Office of ErMronmentai Affairs John Grad
D.E.P. Title V Septic hspector
Department of P.O. Box 2119
Environmental Protection Teaticket,��a2�36
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM OG
PART A
CERTIFICATION Pc'1
Property Address: 1198 Race Lane Marstons Mills Address of Owner:
Date of Inspection:11/04195 (If different)
Name of Inspector:John Grad Sulzman
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
_ Conditionally Passes
_ NeedjFurt r E uation By the Local Approving Authority
Fails
Inspector's Signature: Date: 1U4196
The System Inspector shall sopy 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.
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, 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.
(revised 11115195)
One Winter Street . Boston,Massachusetts 02108 . FAX(617)556-1049 a Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1198 Race Lane Marstons Mills
Owner: Sulzman
Date of Inspection:11/04196
Sewage backup or breakout or high static water level observed in the distribution box is 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 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 water
supply 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 is less than 100 feet but 50 feet or more from a private
water supply well, unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
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.
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 an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 11115195)
2
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1198 Race Lane Marstons Mills
Owner: Sulzman
Date of Inspection:11/04/96
D] SYSTEM FAILS(continued)
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 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:
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:
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 11115/95)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CH ECLIST
Property Address: 1108 Race Lane Marstons MIIis
Owner: Sulzman
Date of Inspection:11/04/96
Check if the following have been done:
X 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.
GaAs 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 existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/15/95)
4
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1198 Race Lane Marstons Mills
Owner: Sulzman
Date of Inspection:11104196
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms: 3
Number of current residents: 2
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: rVa
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL:
Type of establishment: n1a
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: n1a
Last date of occupancy: Na
OTHER: (Describe) n1a
Last date of occupancy:
GENERAL INFORMATION
PUMPING.RECORDS and source of information:
System has not been pumped in last two years.
System pumped as part of inspection:(yes or no)Yes
If yes,volume pumped: 2200 gallons
Reason for pumping: Maintenance.
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)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
8-25-77
Sewage odors detected when arriving at the site: (yes or no) No
(revised 11115195)
5
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1198 Race Lane Marstons Mllls
Owner. sulzman
Date of Inspection:11/04/98
SEPTIC TANK: X
(locate on site plan)
Depth below grade: s'
Material of construction:X concreate_metal_FRP_other(explain)
Dimensions: L 8'6'H 5'7"W 4'10•
Sludge depth:4'
Distance from top of sludge to bottom of outlet tee or baffle: 23'
Scum thickness:1'
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: 17'
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
Septic tank and all components are structurally sound.Recommend pumping system every year for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: Na
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: Na
Scum thickness:Na
Distance from top of scum to top of outlet tee or baffle:n/a
Distance from bottom of scum to bottom of outlet tee or baffle: nla
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.)
n1a
(revised 11115195)
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1198 Race Lane Marstons Mills
Owner: Sulzman
Date of Inspection:11104196
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: nla
Material of con struction:_concrete_metal_FRP_other(explain)
Dimensions: n1a
Capacity: n1a gallons
Design flow: n1a gallons/day
Alarm level: n1a
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
Na
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
rda
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
n1a
(revised 11115195)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C I
SYSTEM INFORMATION(continued)
Property Address: 1198 Race Lane Marstons Mills
Owner: sulzman
Date of Inspection:11/04/96
SOIL ABSORPTION SYSTEM (SAS):X
(locate on site plan,if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Na
Type:
leaching pits,number: 1,000 gallon leach pit
leaching chambers,number:n/a
leaching galleries,number: n1a
leaching trenches,number, length: rda
leaching fields, number, dimensions:n1a
overflow cesspool,number:n1a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
The leach pit is structurally sound and functioning property,it was 314 full at time of inspection
CESSPOOLS:_
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n1a
Depth of scum layer: n/a
Dimensions of cesspool: nra
Materials of construction: n/a
Indication of groundwater: n1a
Na 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.)
Na
PRIVY:_
(locate on site plan)
Materials of construction: n1a Dimensions: n1a
Depth of solids: n/a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PrivyComments
(revised 11115/95)
w
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1198 Race Lane Marstons Mills
Owner: sulzman
Date of Inspection:1t1041n
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
A .
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ht 15
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DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
11SGS Maps and Charts
(revised 11/15195)
L±O�CAl ION , SEWAGE PERMIT NO.
VI LAG E
rU - Tel s r�`1 t L L 5
INSTA LLER'S` NAME & 'ADDRESS
1 .56V
B ItDER OR WNER
DATE PERMIT ISSUED /
DATE COMPLIANCE ISSUED �j' �e �,'�
1
1
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No..= =... � \ FxB.......... ............._
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
... OF...............................................-.........
.A Iirtt#i�an f.nx �i.s nsa1 Von ks Towuurtinn Vanfit
Application is hereby made for a Permit to Construct ( ) or Repair (A) an Individual Sewage Disposal
System at: /S./, O�-f r
at, -Address or Lot No.
Owner Addres
Installer Address
UType of Building � Size Lot............................Sq. feet
Dwelling—No. of Bedrooms_______�___..........................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building No. of ersons____________________________ Showers
w yP g ---------------------------- P ( ) — Cafeteria ( )
Pa Other fixtures -----------......................................................
WDesign Flow.......r_.................................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.
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 No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2___.............minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -•----••----------•---------- •---••.......:.............................•------•----••-•-••--•••--•••-••• ............................................
0 Description of Soil__________________________ _______________________________
Wsa�_ol_y... . ------------------------
----.•---------------------------•-•.-----------•-----•--------.-..----•---- - .�----------------------------------•-------------------------------------------•--------•-------
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 TITU . 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 of health.
SignedG ..........
Date
Application Approved By-- ------/4=`=-••----•-•--••---•--------------------------•--------------------..._....__
Date
Application Disapproved f o he following reasons:...................................•.......................................................Da.t.e..............
...............................................................•-•--..:......-----------.....-------...-----------------------------------------------------.---------------------------------.........
J � L
Date
Permit No... 1 ---..... Issued---/` / ��------ -- -•--.._.. • -•-•-
Date
r
No......�_`.a�.----.. FEs.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF.......................................
Appliration for Disposal Works Tonstrnr#ion rrmi#
Application is hereby made for a Permit to Construct ( ) or Repair (*A) an Individual Sewage Disposal
System at: *,revsL'� r�"/s��c
cation A re s or Lot No.
lf
Wa ! Owner Addrew j t
. .......__...................... ............ ......................... --••-------•-----------------------•--•-•----••---•------ --- ----._......---=--....�.....�._.r.j.--
Installer Address
Q Type of Building x, Size Lot............................Sq. feet
Other
Type-of BB d iooms.._. ----'-'"-No. of eE onsnsioii-'•Attic�- Showers Garba Cafet derF(i )
g— P ( ) g
Pali g p ' a ( :F) rr(# )
Q Other fixtures - .......... ........... ........... � t a -----
W Design Flow ___ .. .gallons per person per day. Totaf dadl flow ;. _ .....gallons
WSeptic Tank Liquidcapaclty gallons Length....... ........ Width_' � . Diameter Depth....
x Disposal Trench ,,:Vo ......... Width.................... Total Length...................... Total leaching are �..................sq. ft-
Seepage Pit,`N'o: ............... Diameter.................... Depth below inlet.._..................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Perfor,""coed by............................. Date.........................................
�--7 _,; .
Test Pit No. 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........................
Ix ------------•-•---------••-•-------•-•---•--•--•....-••----•----------------•-•-•-----•--------•---•........................................................
0 Description of Soil........................... .. ....
............
UW ---------------------------------------•----•--•-•••-..........----•-..... ....„......--------------------------------------------------------------------------------------•---=-
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 TIT,1Z- 5 of`the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Cornp)iance has been iss'u'ed by the board of health.
Signed' .............................................
Date
ApplicationApproved BY--....- A--------------------------------------------------------------------------------
Date
Application Disapproved f o the following reasons:.........................-......................................................................................
-••---••--•-••-------•--•-•..............•-----•••-------•-•-..............-•--•-----........---•-...------------...----•-•------••---------•-----•-•-•--•--•--•---•••-------------- ----------•-•.
Date
Permit No.._._ - Issued.......................................................
Date
` THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.... ....................................................
(9rdifirFatle of Tout rliatnrr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Ijepaired ( )
by = I ��...... _ y*�j' -- ------�11. � _._._..00df". r"_
Installer /1
at
has been installed in accordance with the provisions of TITLE 5 of,The State Sanitary Code as des rib®yh r>A the
application for Disposal Works Construction Permit No.__ ................... dated ....... ........
THE ISSUANCE�OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. _
a
DATE.......... f j t ��, Inspector `rite ` ( `
•
; .
{ ._
- 5 yk �p n _T�
�.;-nN �>'' F$L„'vh. �fiti4' .tz� ,.�.!i �.�n' a.i,�rr3..,,.L+= .0 -a`
a, 14a .I. ex
(� THE COMMONWEALTA,OF MASSACHUSETTS aaf
BOARD OF WEALTH 11_;1_ i
. .+ �a..fj^ ram.
No... .. FEE... ' ci.....
Disposal Works Tnnstr ion rruti#
Permission is hereby granted---------- -,r-�-'-F-""'---° - Kl!��.............•••----•-•--•--•••••-•--------...•-•----------•--•--------•------•--••-
to Construct ( ) or Repair C( ) an Individual Sewa a Disposal Stem ���
at No. f✓" `� 4, p
3 M5„tl,� �' Street
as shown on the a lication for,Di§ osal 'vN orbs Corrstructron Permit No._........ ...... Dated.._._ .:.___...� _._._....
y j Board off Health
FORM 1255 HOBBS &•-WARREN1 INC PUBLISHERS - '
t
No. -- ------- Fee------ ------------
BOARD OF HEALTH
rr � � TOWN OF BARNSTABLE
2pplicat ion,forVell Con5tructiouperuut
Application is hereby made for a permit to Construct ( � Alter ( ), or Repair ( )an individual Well at:/
Location — Address Assessors Map and Parcel
Owner/ e q Address
--- A
Installer — Driller _ Address
Type of Building
Dwelling ------—--.----
Other - Type of Building --- ----__ No. of Persons------_____—__--_ ___
Type of Well y ------- Capacity --------------_---�
Purpose of Wells,
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation uVaCeficabeof Compliance has been issued by the Board of Health.
Signed
4t�
e
Application Approved Bywow— �%Affulb�'/ E
date
Application Disapproved for the following r asons: --------.---- -------— —_
- -- --------- — date
Permit No. Issued
date I
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate Of (Compliance
THIS IS TO CERTIFY, Tha the Individual Well Constructed (. Altered ( ), or Repaired ( )
by— — b1`4c�.. �� -- --- ---- -- — —
'� Installer
at A c
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. -------—Dated----THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE— Inspector
P 7
No. --- - ------- Fee------ -=----------
BOARD OF HEALTH
/1 C/1 �I TOWN OF BARNSTABLE
0ppYicationArlVell Congtruct ion Permit
Application/ids hereby made for a permit to Construct ( ✓j, Alter ( ), or.Repair ( )an individual Well at:
Location — Address Assessor's Map and Parcel
v z-,6 U1, .., i
� 1 i
Owner Address
Q
2/. ' t I lnx— 5_K_ G
Installer — Driller ��—� —— Address
Type of Building
Dwelling
Other - Type of Building--- ____ No. of Persons----_—______—_--___.
Y Type of Well ---—__-_ Capacity -------
Purpose of Well—I�'�
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Cer;fic a.of Compliance has been issued by the Board of Health.
i
Signe n
� to
Application Approved —
/ date
Application Disapproved for the following r asons: -------- __
date --
Permit No. — Issued —____ __ _----_-__-_
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( "j Altered ( ), or Repaired ( )
by
/ Installer
at -----
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. ----- Dated---- ---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector------------ _—_—_--_____
BOARD OF HEALTH
TOWN OF BARNSTABLE
Pelt Con5tructionpermit
N -_ �.�
' U Fee----
Permission is hereby granted 0/g fc6wi
to Construct (e/), Alter ( ), or Repair ( ) an Indivi Well at-
No. �7
/g g e4 c . L^U M
------_---------------
street
as shown o . t e a li tpn for a nstruction Permit
No.- —--- Date -- -- -
,,
DATE —
-- - Board, f Health
ASSESSORS MAP : _-4i . TEST HOLE LOGS NOTES:
1> 1 PARCEL: .._.. .__.....i- .�>'avi $, t�?�q,��.t Gyp
FLOOD ZONE: SOIL EVALUATO�t . � -�'
a • --- ca` w -- --.... ... ..._...__._... WITNESS : ! "fl�}t1Ttn 1) The installation shall comply with Title V and Town of Barnstable Board of
REFERENCE: -- � Health Regulations.
_.�C�o ...45<# /(�a�I ra''S1rr DATE: I
"71 - - PERCOLATION RATE: -C 2-W11 ` 2) The installer shall verify the location of utilities, sewer inverts and septic
L� �2Z-0_W/_
L•��`�� components prior to installation and setting base elevations.
_ .. 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first
TH- 1 TH-2 two feet out of the d-box to the leaching shall be level.
All Lv~1D 4 A �a Z 4) This plan is not to be utilized for property line determination nor any other
purpose other than the proposed system installation.
I-0i4 tit 5 All septic components must meet Title V specifications.
,� �Zb �,� /O�r'L6� � 6) Parking shall not be constructed over H10 septic components.
�2' 3 7 The property is bounded b property corners and property lines.
p P Y YP p Y P p Y
LOCATION MAP 5 � 8) The property owner shall review design considerations to approve of total
0600/ � �, �•lv''�IiJ design flow and number of bedrooms to be considered for design. Receipt
b rJ 1 f payment for the plan and installation based on the plan shall be deemed
� � � G Z i 7� � 'It ° paY p
-t `.�`'(71 approval of the design flow by the owner.
9) The existing leaching or cesspools shall be pumped and filled with material
D� a �� per Title V abandonment procedures. Those within the proposed SAS shall
1��t ' It�i� .� f be removed along with contaminated soil and replaced with clean sand per
Title V specs.
10)System components to be 10 feet from water line. Sewer lines crossing the
yq�` � GR�1t-tV, P,DIT water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if
SEPTIC SYSTEM DESIGN applicable. The proposed SAS is being installed below the water service
\ line. The line is to be sleeved as aforementioned and maintained in place.
11) If a garbage grinder exists it is to be removed and is the responsibility of the
FLOW ESTIMATE owner to ensure such.
• eXI T \ ' 12)The installer is to take caution in excavation around the gas line.
BEDROOMS AT I� GAL/DAY/BEDROOM - cJ,-DGAL/DAY
13)The installer shall verify the location, quantity and elevation of the sewer
aX9 lines exiting the dwelling prior to the installation.
• ` � \ kEPT IC TANK
TAN
O RELOCATE
SHE 0 /�
3 GAL/DAY x 2 DAYS - GA`
USE )C:'DO GALLON SEPTIC TANK
so17AMAPT!ON syslfw
L
CNV
:0AYIp
O `. �:.
2 / rn
SIDE AREA: Z•�C 16 t 2-t.� �c, �'�( r`1 � / `��b '�'' A�9AASQN W
�• �� r? (� BOTTOM AREA• /t3 �i z•q X d t� = t$ ' :sou loss r�
b
0.75 (+/-) ACRES j P
SEPTIC SYSTEM SECTIONWC
EXISTING HOUSE `,
AND PORCH : Y��^ •I
` I ,
FRONT SETBACK LINE 4 ry0 Vs)(1
��}1 F{� rOn t
• \>. 1C00 GAL
SEPTIC TANK — l 'Y % Y� �O`�+JJ
39.267 ,
SITE AND SEWAGE PLAN
r "T~ /� �� LOCAT I ON :
.� 5 NOD
PREPARED FOR : I = wi�L,Pa v
JOB
SCALE:
DAV I D B . MASON R, DATE: D
DBC ENVIRONMEN�fA DESIGNS
EAST SANDWICH . MA
DATE ,, HEALTH AGENT ( 508 ) 833- 2 177
• O