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1579 RACE LANE - Health
1579 Race Lane,Marstons Mills A= a� TOWN OF BARNSTABLE Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF'BUSINESS: It -- BUSINESS LOCATION: ` INVENTORY MAILING ADDRESS: TOTAL A OUNT: TELEPHONE NUMBER: 6� CONTACT PERSON: m'1 EMERGENCY CONTACT TELEPHONE NUMBER: 56% - 3 b Goo - MSDS ON SITE? TYPE OF BUSINESS: INFORMATION / RECOMMENDATIONS: ' Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires,,a/license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous(please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash - WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's fignature Staff's Initials _._—a...._..._..u_._:r_.r.:,.:..rr.r..w+..xa.w.:avru:,¢ruse_::rrnv...r..t_„o,.yaawn�r_.�._.._=w,.a+ursrea,.w.rr.:i:..sr.r.x.•r_an•r.c.u.urus.�ure,-�...>.�uux..o;wweuv,.r+.smanr.rcwmm.arux,.r...-a......e.mmran.+....+.....��u..r....,+.nax-n+..:.,..w..�::.•,:........�..vm.:,.x.,�rv,�..s,mwv..r.a �o-..,>.na,...�....,.,.,,.�u..,.,,..:�__._. YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost�)40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do.by M.G.L.-it does.riot give you.permission to operate.) You must first obtain the.necessary signatures on this form at 200 Main St., Hyannis. Take the completed,form to.the Town Clerk's Office,1 st FL, 367 Main St., Hyannis, MA 026.01 (Town Hall) and get the Business Certificate that is required by law. DATE: ti _ S Fill in please: >diiF: 4f;.. ,I�. r• I NAME �l tx APPLICANT'S YOUR /S: i@r1:`rtt?rs )� r:cP BUSINESS YOUR HDMEADDRESS S ��� - r �rn (,..i �iio�'r37ue' �i.rr!1 ?f}vt.i 1V � ae`�>!y�' TELE i PHONE # Home Telephone Number 5 n rti r r: �v`iiu .�. OR EIN #: E—MAIL: {v s' . NAME OF CORPORATION: NAME OF-NEW BUSINESS rn l TYPE OF BUSINESS l5 THIS A HOME OCCUPATION? ES NO Assessin ADDRESS OF BUSINESS- 5 MAP/PARCEL NUMBER I ( 8) When starting a new business these are several thln.gs'you must do in order to be In CQmplience with the rules and regulations of the Town of Barnstable. This form is•irterid'od Eo assist you In obtaining the information you may need. You MUST GO TO 200 Main St. — [corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permlts and licerises required to legally operate your business in this town. 1. BUILDING COM ISSIDN R'S OFFIC _ This individ al heI: b i orm of ny a it re it a is th pertain o tl,istype of business. MUST COMELY WITH HOME OCCUPATION RULES ARID REGULATIONS. FAILURE. TO A'utF] rized et re*_* COMPLY MAY RESULT iH FINES. (30 N 5: �. .� --� -�' � 2. BOARD F LTH This indivi ual has been inform d ermit requirements that pei°taln to this.type of business, MUSS COMPLY WITH ALL ' Arized HAZARDOUS MATERIALS REGULATIONSS r COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY] This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature' COMMENTS: f w M ENVIRONMENTAL CORPORATION � { 83 Leadmine Lane Pti Fiskdale,MA 01518A Ph:508-207-8879 _J Fx:866-253-4004 3> ._c August 31, 2017 +gqnyL �d 1 Mark S. Elis, Town Manager Xh 367 Main Street Hyannis, MA 02601 RE: Permanent Solution Statement, RTN 4-26777 In Front of 67 Raspberry Lane, Marston Mills, MA Dear Mr. Elis: Pursuant to 310 CMR 40.1403(3)(f) of the Massachusetts Contingency Plan, 310 CMR 40.0000, the Chief Municipal Officer and Board of Health in the community(ies) in which a disposal site is located and any other communities which are, or are likely to be, affected by the disposal site shall �e notified of the availability of any Permanent Solution (PS) report filed in accordance with 310 CMR 40.1000. Jewel Environmental Corp. (Jewel)will be filing the, PS report with the Massachusetts Department of Environmental Protection for the above-mentioned location within 7-days of receipt of this letter. The package was filed in response to'a release/threat of release of oil and/or hazardous material, and outlined that a level of No Significant Risk and a Permanent Solution was ultimately achieved at the disposal site. Additionally, pursuant to 310 CMR 40.0960, a level of No Significant Risk to safety has also been achieved at the disposal site, and will.not in the foreseeable future pose a threat of physical harm or bodily injury to people. A complete copy of the PS Statement report package for the above-mentioned location/release, is available to you through the Southeast Regional Office of the Massachusetts Department of Environmental Protection at 20 Riverside Drive, Lakeville, MA, Phone (508) 946-2700. A copy cari also be obtained electronically by visiting the MADEP website at "http://public.dep.state.ma.us/Searchable$ites2/Search.aspx" and utilizing the RTN listed above. Sincerely, JEWEL V O NTAL CORP. K E. KI es, LSP P oject anager cc:-P I�Hebert;Board of Health LSP Services 24-Hour Emergency Spill Response Site Remediation Storage Tank Cleaning and Removal Oversight Hazardous Waste Disposal Regulatory Compliance and Permitting 1 ASTM Phase 1/11 0�7- - /3(v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1579 Race Ln. . Property Address CA Moreau ' Owner's Name Marstons Mills MA 02648 9/20/16 Cityrrown State Zip Code Date of Inspection IU (V Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information SI# 9 �a- 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9/20/16 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 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. ****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. 1579 Race Ln•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 S �b �V � r� Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1579 Race Ln. Property Address Moreau Owner's Name Marstons Mills MA 02648 9/20/16 Cityrrown 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: ® 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: Pumping suggested every 3 yrs to prolong the life of the system B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: n/a ❑ 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 1579 Race Ln•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M 1579 Race Ln. Property Address Moreau Owner's Name Marstons Mills MA 02648 9/20/16 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: n/a ❑ 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: n/a C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 1579 Race Ln-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1579 Race Ln. Property Address Moreau Owner's Name Marstons Mills MA 02648 9/20/16 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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: n/a 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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. 1579 Race Ln•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s•''� 1579 Race Ln. Property Address Moreau Owner's Name Marstons Mills MA 02648 9/20/16 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® 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. 1579 Race Ln-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1579 Race Ln. Property Address Moreau Owner's Name Marstons Mills MA 02648 9/20/16 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 ❑ ® 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ 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. ® ❑ 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)] 1579 Race Ln•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1579 Race Ln. Property Address Moreau Owner's Name Marstons Mills MA 02648 9/20/16 Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® 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 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a 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: Last date of occupancy/use: Date Other(describe): n/a 1579 Race Ln•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1579 Race Ln. Property Address Moreau Owner's Name Marstons Mills MA 02648 9/20/16 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Pumped 2 yrs ago per owner 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): Approximate age of all components, date installed (if known)and source of information: Original septic tank from 1991, new d-box and SAS 2014 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No 1579 Race Ln-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1579 Race Ln. Property Address Moreau Owner's Name Marstons Mills MA 02648 9/20/16 City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 20"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) Inlet and outlet covers raised to 6"of grade If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000g Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness 2° Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? Measured 1579 Race Ln-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1579 Race Ln. Property Address Moreau Owner's Name Marstons Mills MA 02648 9/20/16 Cityrrown 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.): Pumping suggested every 3 yrs to prolong the life of the system, effluent filter at outlet Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): n/a 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a 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): n/a 1579 Race Ln-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1579 Race Ln. Property Address Moreau Owner's Name Marstons Mills MA 02648 9/20/16 City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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.): n/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 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.): No adverse conditions, H-20 box, cover raised to 6"of grade Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 1579 Race Ln•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 f , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1579 Race Ln. Property Address Moreau Owner's Name Marstons Mills MA 02648 9/20/16 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 16 infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Infiltrators were video inspected and are damp at this time, no indication of past backup, top of chambers approximately 2'6" below grade 1579 Race Ln-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 1579 Race Ln. Property Address Moreau Owner's Name Marstons Mills MA 02648 9/20/16 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 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.): n/a 1579 Race Ln•03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 15 TOWN OF BARNSTABLE LOCATION I51 FJ V AC!E. Ll e, SEWAGE# ` Q4CA- 3a`i VILLAGEM;v �av�c VY\MS ASSESSOR'S MAP.&PARCEL I-(7 3 C, INSTALLER'S NAME&PHONE NO. —QZ SEPTIC TANK CAPACITY LEACHING FACIIdTY:(type _ Lpr : (size) I`��c��<n�4e Cm,�5 NO.OF BEDROOMS o,sa'K n^ OWNER ��o�.� V r \oC e Act PERMIT DATE: Q 0 k COMPLIANCE DATE: Separation Distance Betwan the: Maxim=Adjusted Groundwater Table tote Bottom of Leaching Facility . Fat 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 fat of leaching facility) Feet FURNISBEDBY QR�J" C*�� .K (34- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 1579 Race Ln. Property Address Moreau Owner's Name Marstons Mills MA 02648 9/20/16 City(rown 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: >10'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: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: per elevation of home 1579 Race Ln•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 -` � TOWN OF BARNSTABLE 1 LOCATION�5'`� ,�C Pl i. SEWAGE# VILLAGE( bPSLo�N-S �(Y\`���5 ASSESSOR'S MAP.&PARCEL L( � 3 INSTALLER'S NAME&PHONE NO.��.A�Q��e;�3'-r�ke�V�io�•.�-SOg SEPTIC TANK CAPACITY QOO CA- ( g G©SS v LEACHING FACILITY.(type'T— '',-LsWvJr-�; Ct h, (size) 1( NO.OF BEDROOMS a " 'Z)(D�^ OWNER C—) PERMIT DATE: COMPLIANCE DATE: L Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility . 1 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 ID 0 a� e No.ul 1 — 5 Fee �C�CJ CPO THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftpliLation for Disposal *pstrm Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade(Abandon( ) ❑Complete System &Kndividual Components Location Address or Lot No. Owner's Name,Address,and Tel.No.S g-3GY- SSC�o Y`��J"�Oh.3 ..]o\..w t��-.v..�vte. ✓ham s'Ga�- C.o r r��b Assessor's Map/Parcel (3 Installer's Name,Address,and Tel.No. 57ai?-??7`GCD5.5 Designer's Name,Address,and Tel.No. 3j=-33 Q.ce.�Sa�R�o�Y�-•- �+�.a u�"�� �M�C�zr San.s,�+nG Type of Building: Dwelling No.of Bedrooms Lot Size a�-( �gs sq.ft. Garbage Grinder( ) --r Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33o gpd Design flow provided C) gpd re Plan Date ` Number of sheets Revision Date Title Size of Septic Tank �• �ype of S.A.S.-�.r� � rus , �n Description of Soil 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 Certificate of Compliance has been issued by this Board of Health. Si Date Application Approved by Date O �/ Application Disapproved Date for the following reasons Permit No. �1M �2� Date Issued q l io!zo l q No THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for bisposal *pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade(Abandon( ) ❑Complete System Et dividual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. J� we- 04N<3 T- r-i--m r�b.r�or•._S Assessor's Map/Parcel IDI( 3 �; •� s Y•n O Installer's Name,Address,and Tel.No. 'a-6`Tl Designer's Name,Address,and Tel.No.Wig-3.=-33 I Y`^e���r- So�S,=,r.O Type of Building: Dwelling No.of Bedrooms Lot Size a L(, '�(`�5 sq.ft. Garbage Grinder( ) Other Type of Building , No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33 CZ) gpd Design flow provided Q gpd Plan Date 9 3 O(L` Number of sheets Revision Date Title _ , Size of Septic Tank '�jypeofS.A.S.�,IL,t�4— Description of Soil Nature of Repairs or Alterations(Answer when applicable) "E'�`f��( l tn�coj \ 1� j�j r—{.`t & t L� h C 7r1 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 Certificate of Compliance has been issued by this Board of Health. Si pi Date Application Approved by Date v ZO/ Application Disapproved Date for the following reasons e Permit No. �2 T Date Issued q110 j?mil�{ ---------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS - BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded(t� Abandoned( )by �� �� at �� 1� ��.P _ Ls�,"o _ Vy),M y has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NoZO/q-'571 dated 91/a IZAPI q Installer,�_h_vx '��r' '�1� 0 k,, �s Designer #bedrooms _ Approved design flow and The issuance of this permit shall not Jbe construed as a guarantee that the system will rf�anction as desig e . r �. Date f 't Inspector v --------''-JJ----------------------------------------------------------------------------------------------------------------------- No. 1 vl _ 3 Z� Fee ��y V�� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposar 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( v,)"' Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permi. Date C( o/'Lo Iq Approved by i i Town of Barnstable Regulatory Services Richard V. Scali, Interim Director 1 BARNSCABLE. s MASS. Public Health Division " Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: WIl-4 Sewage Permit# -3a7 Assessor's Map\Parcel 47�I�L Designer: e,4,,11,1 -4 ��J 1Y)L, Installer: Address: 00c) g�/ Address: v was issued a permit to install a (dat ) (installer) septic system at LA-il based on a design drawn by (address) 1 S dated I fi (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the terms of the IAA approval letters (if applicable) OF o D M: �n (Installer's Signature) > YER , q No,. 1140 sTE ° -TDesigner's Signature) QVTAR\P� PLEASE RETURN TO BARNS ABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Designer Certification Form Rev 8-14-13.doc Town of Barnstable °FTHE Tp Regulatory Services h'�4 °,• Richard V. Scali, Interim Director l�BAI NS[ABLE, Public Health Division y niAss. SAT fps a`` Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Homeowner Certification Form for Alternative Systems -, Property Address: 1� RkCj--- L-Pi i Assessor's Map\Parcel: &q 113to Property Owners Name: ,NI©r e4-tl In accordance with Massachusetts DEP alternative system approval letters, the following certification information is required by the Owner of record. The Owner of record must place an "x" in the applicable box next to each line certifying the information. Yes N\A ❑ I have been provided a copy of the Title 5 I/A technology Approval letters. ' (15 page Standard Conditions letter and the specific technology letter) ❑ VI have been provided with the Owner's Manual ❑ E I have been provided with the Operation and Maintenance Manual ❑ �or Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide a Deed Notice as required by 310 CMR 15.287(l0) d the Approval ❑ For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide written notification of the Approval to any new Owner, as required by 310 CMR 15.287(5) rrl" ❑ If the design does not provide for the use of garbage grinders, the restriction is understood and accepted ❑ Whether or not covered by a warranty, I understand the requirement to repair, replace, modify or take any other action as required by the Department or the LAA, if the Department or the LAA determines the System to be failing to protect public health and safety and the ID environment, as defined in 310 CMR 15.303 1 , Lk i(� — V C I(ti agree to comply with all terms and conditions above. Property ers pri ted name Propert 0 veers Signature D to of This form must be submitted along with the septic system disposal worts permit application for all I\A systems including new construction, rep airs\upgrades, with and without aggregate (stone) and with conventional design criteria or credited design criteria. Q:\Septic\[A homeowner certitication.doc I CA 4� TRANS.NO.: CITY/TOWN: (Il/l. I A l U_S. Vim, APPLICANT: ` Me C4z." ADDRESS: I S779 (2—kcF, LIJ DESIGN FLOW: gpd REVIEWED BY: DATE: N/A OK NO GENERAL Legal boundaries denoted[310 CMR 15.220(4)(a)] Street,Lot, tax parcel number and lot number noted on plan [310 CMR 15.220(4)(u)] Locus Provided 310 CMR 15.2204(t)] Plan proper scale?(1"=40' for plot plans, 1"=20' or fewer for components) 310 CMR 15.220(4)] Easements shown 310 CMR 15.220(4)(b) System located totally on lot served[310 CMR 15.405(1)(a)for upgrades]- if not, a variance is required [310 CMR 15.412(4)] Location of impervious surfaces(driveways,parking areas etc.) [310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR x 15.220(4)(c)] Location and dimensions of system components and reserve areas. [310 CMR 15.220(4)(e)] System Calculations 310 CMR 15.220(4) daily flow septic tank capacity(required andprovided) soil absorption system(required andprovided) whether system designed for garbage grindei North arrow 310 CMR 15.220(4)(g)] Existing and ro osed contours 310 CMR 15.220(4)(g)] Location and log of deep observation holes(existing grade el. on each test) 310 CMR 15.220(4)(h) Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h)and i Location and date of percolation tests (performed at proper elevation?) [310 CMR 15.220(4)(i) Percolation test results match loading rate? 310 CMR 15.242 Certification statement by Soil Evaluator 310 CMR 15.220(4)0)] Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 115.220(4)(n)] Address /CtCj5 LAJ ; ✓�I• "l�l l �`S Sheet 1 of 1 N/A OK NO Location of every water supply,public and private, [310 CMR 15.220(4)(k)] within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply within 250 feet of the proposed system location in the case within 150 feet of the proposed system location in the case of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins located within 50 ft. [310 CMR 15.220(4)(1)] Water lines and other subsurface utilities located[310 CMR v 15.220(4)(m) if water line cross see 310 CMR 15.211 1) 1 Profile of system showing invert elevations of all system x components and the bottom of the SAS 310 CMR15.220(4)(o)] Stamp of designer 310 CMR 15.220 1 and 310 CMR 15.220(2) Stamp of Registered Land Surveyor(required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] Test Holes adequate(two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2) or as 1 approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] �C Test hole adequate to demonstrate four feet of suitable material? 310 CMR 15.103 4)] Test Holes adequate to confirm adequate groundwater separation? 310 CMR 15.103(3) Benchmark within 50-75' of system 310 CMR 15.220(4) Materials specifications noted? [various sections of 310 CMR X 15.0001 System components not> 36" deep (unless Local Upgrade A roval or LUA requested) [310 CMR 15.405(1(b)] Address A i l k Sheet 2 of 7 i N/A OK NO SEPTIC TANK Size OK? 310 CMR 15.223 1 Inlet tee located ten inches below flow line 310 CMR 15.227(6)] Outlet tee 14" or 14" +5"per foot for increase ft depth [310 CMR 15.227(6)] Outlet tee with gas baffle or approved filter 310 CMR 15.227(4)1 Note regarding installation on stable compacted base [310 CMR 15.228(1)] Separation between inlet and outlet tees(no less than liquid depth) 310 CMR 15.227(2)] Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5))or permitted for upgrades under LUA 310 CMR 15.405(1)(k) Minimum cover 9" (Tanks buried more than 9" must have risers on all openings and on the d-box) [310 CMR 15.2228(1)and 310 CMR 15.232(3)(0] Three access covers (inlet and outlet must be 20" or greater) - middle access at least 8" (b 7/07) [310 CMR 15.228(2)] Access to within 6 " of grade -one port for systems<I 000gpd, x two fors stems>1000 gpd[310 CMR 15.228(2) All at-grade covers secured to unauthorized access? [310 CMR 15.228(2)] X. > 10 ft from building foundation 310 CMR 15.211 1)] Buoyancy calculation Required/Done 310 CMR 15.221(8)] H-20 Where appropriate? 310 CMR 15.226(3) Setbacks from resources 310 CMR 15.2111 X Multi=Com artment Tanks Required when other than single-family dwelling or flow>1000 X d 310 CMR 15.223(1)(b) First compartment 200%daily flow; Second compartment 100% daily flow 310 CMR 15.224(2) and 3) "U"pipe through or over baffle,outlet of each compartment with as baffle or approved filter 310 CMR 15.224(4)] Address � � t��� f Sheet 3 of 7 N/A OK NO BUILDING SEWER AND OTHER PIPING , Located at least ten feet from any water line? [310 CMR 15.222(2)] Disposal piping at least 18"below water line(when water and sewer cross,see 310 CMR 15.211(1) 1 ) Cleanouts required/provided? 310 CMR 15.222(8)] Thrust blocks specified in force mains?310 CMR 15.221(6)(c) X Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable [310 CMR 15.222(6) Proper pitch on all runs?(.005 within gravity-distributed trenches and beds) 310 CMR 15.251(9)and 310 CMR 15.252(2)(c)] Siphonproblem/ leachfield below pump chamber) Endca s or vent manifoldspecified? Size and orientation of discharge holes specified? (not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8)and 310 CMR 15.252(2)(h) Materials specified (310 CMR 15.251(5) specifies various pipe x types allowed) DISTRIBUTION.BOX Stable compacted base [310 CMR 15.221(2)and 310 CMR `I 15.232 2 a) �C Splash plate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 X CMR 15.323(3)(a)] Riser if deeper than 9" [310 CMR 15.232(3)(f)] Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum sum 6" 310 CMR 15.232(3)(e) Watertight cover if<2000gpd); waterproof manhole if>2000gpd 310 CMR 15.232(3)(d)] X PUMP CHAMBERS,_;, Capacity(emergency storage above working--design flow)? [310 CMR 231(2)] Proper setbacks [310 CMR 15.211 same as septic tanks)] Watertight 20-in minium access manhole at least 20" MUST BE TO GRADE [310 CMR 15.231(5)] Service components accessible (not too deep with piping, disconnects accessible) Alarm floats - alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. 310 CMR 15.231(6)and 8) Stable Compacted Base [310 CMR 15.221(2) Buoyancy calculations needed?Provided? [310 CMR 15.221(8)] Address 2-AC.ir. [IQ �., N. t Sheet 4 of 7 t �1 N/A OK NO SOIL ABSORPTION SYSTEMS. SAS)GENERAL Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240 1 Required separation togroundwater? [310 CMR 15.212 Aggregate specified as double washed 310 CMR 15.247 2 System Venting required/provided? (system under driveway or >36" deep) [310 CMR 15.241] Inspection ports specified and within 3"final grade? [310 CMR 15.240(13) Breakout requirements met? (No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document GALLERIES,PITS,CHAMBERS 310 CMR 15.253 Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR 15.253(6)] Each structure with one inspection manhole(if>2000 gpd must be tograde) [310 CMR 15.253(2)] x Aggregate I'minimum-4' maximum. 310 CMR 15.253(1)(b)] 2' sidewall credit maximum[310 CMR 15.25 3(1)(a)] In bed configuration, inlet every 40 s . ft. 310 CMR 15.253(6)] TRENCHES 310 OUR 15.251 : . Width 2'minimum 3'maximum[310 CMR 15.251 1 ) 100 feet- maximum length [310 CMR 15.251 1)(a)] Minimum separation 2x effective depth or width whichever eater(3x if reserve between trenches) [310 CMR 251(1)(d)] Situated along contours 310 CMR 15.251(2)] Breakout OK? 310 CMR 15.211(1)[4] and Guidance Document BED Ma .se 6bedor: m ` f eld 5000' d) minimum 2 distribution lines [310 CMR 15.252(2)(a)] Maximum separation between lines 6' 310 CM R15.252(2)(d) Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6" minimum, 12" maximum. 310 CMR 15.252(2)(g)] Separation between beds 10'minimum. 310 CMR 15.252(2)(f)] Bottom area used in calculations only 310 CMR 15.252(2)(i)] Address C-AI Sheet 5 of 7 N/A OK NO DID THE PLAN INVOLVE Pressure Dosed System ? Provided pump and piping calculations as required [310 CMR 15.220(4)(r)] Pressure dosing required on all systems>2000gpd or alternative systems under remedial approval [310 CMR 15.254(2)and UA Remedial Use Approvals] If used in gravelless system-make sure jet is directed as not to scour soil interface [Guidance Document] Inspections once per year(systems<2000 gpd)or quarterly X (>2000 d)good to note on plan 310 CMR 15.254(2)(d)] Construction in fill - Did the plan specify that the fill shall meet the specification of 310 CMR 15.255 3 ? x Impervious barrier and/or retaining wall? Guidance Document Impervious barrier installation must be supervised by designer 310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer [310 CMR 15.255 2)(a)] X Side slope not exceed 3:1 ? 310 CMR 15.255(2)] Ile Breakout requirements met? [310 CMR 15.252(2) and X Guidance Document] At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended) 310 CMR 15.255 2)(e) Gravelless System[IIA A"..roval;Letters] Check DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge X to scour soil interface Alternative"Se' tics stem''IIA A royal Letters Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? x Is the technology being properly applied and does it meet all k DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant submitted a copy of a maintenance Variances Are the variances listed on the plan? [310 CMR 15.220 4 RLS Stamp necessary on plan if a component is within five feet of property line 310 CMR 15.412(4)] New construction or increased flow proposed- [Refer to 310 CMR 15.414] /� Address I s 2 / R 19-U6 /;V+ /4 14,i S Sheet 6 of 7 i r� N/A OK NO Nitrogen Sensitive Areas Is the system in a Designated Nitrogen Sensitive Area(Zone 11 for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well ? 310CMR15.2142) Are the nitrogen loads proposed in compliance? [310 CMR k 15.216(l)] 1 t Miscellaneous Plumping to septic tank? 310 CMR 15.229 Shared System 310 CMR 15.290 Address '� 1 ��/ ' Iry M,,&j'G j Sheet 7 of 7 Town of Barnstable P it ; Department of Regulatory Services H1ttar11tK: Public Health Division Date < ' MA69 i:agg. t� 200 Main Street,Hy nnis MA 02601 • �OrFti nu.t� e / Date Scheduled r :� Time Fee Pd. � - v f y . :Soil uitahility Assessment or ►Seiya, e Ibis o, w � `,/ ,. Performed B : �Y � �,1 Y �� Witnessed By: �� ' LOCATION& GENERAL INFORMATION d `� Locadon Address Owner's Name v,�, c `p @ Address S 7 C'iEfj. Assessor's Map/Parcel: ` Engineer's Name V•v-)e j f,,N spv� 5 rZti NEW CONSTRUCTION. 6;�l'REPAIR �� Telephone ),n 7j It 3 3. , Land Use` nl�0 1 n/ Slopes(%)_ S Surface Stones cam' Distances from: Open Water Body / L LJtJ ft Possible Wet Area ;� Colo ft Drinking Water Well �/ ft Drainage Way ��Q ft Property Line �� ft Other ft SIC TCII:(Street name;?dimensions of lot,exact locations of test holes&pore tests,locate wetlands in proximity to holes) spnc_.. Pot, ),�r pu� � CAtNWP q 1��jLJ It CD i Parent material(geologic) Depth to Bedrock o� Depth to Groundwater. StandingWater in Hole: _ Weeping from Pit Face Estimated Seasonal High Groundwater s ID DETERMINATION FOR SE,ASONALTUGH WATER TABLE Method Used: Depth Observed standing in ohs.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 , AdJ,:actor. AdJ,Groundwater level _ PERCOLATION TEST Dflia_ Time Observation Hole# Tinto at 4" Depth of Pere y Time at G" Start Pre-soak Time @ /0 10 Time(9"-6") P� End Pre-soak L !�1 ' I.Rate Min./loch Site Suitability Assessment: Site Passed y^ Site Failed: Additional Testing Needed(YIN) m - 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 a DEJ EP.OBSER`6 ATION HOLE' LOG Bole# Depth front Soil Horizon Soil Texture .Sdil Color Soil • Othe.r Surface(in.) (USDA) (Munsell) ' Mottling (Stnuchrre„Stones;Boulders. it rl olisistency.�o Gravel) ® r? 7 Lo t�'Lote 2§ / - DEL,P OBSERVATION MOLE LOG Dole# Depth from Soil Fforizon Soil Texture Soil Color Soft Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsisten % ra t) 16� DEEP OBSERVATION HOLE, LOG I101e# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%gavel) DEEP OBSERVATION HOLE LOG: Hole it Depth frorn Soil Horizon Soil Texture Soil Color soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stories;Boulders, Consistency, w 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 pervious material exist in al(areas observed throughout the area proposed for the soil absorption system? el If not, what is the depth of naturally occurring per ous material? Certification (� I cerd y that on (date)I have passed the soil evaluator examination approved by the Department of Environifiental Protection and that the above analysis-was performed by me consistent with the require in ,experti a and experience described in�10 CMR 15.017. Signature Y Date Q:\SEP'r1CWFRCPORM-DOC r� F Gommonweatth of.Massachusetts .John Grad ' ExecutNe Office of Environmental Affairs D.E.P. Title V Septic Inspector Department of P.O. Box 2119 Environmental Protection Teaticket,MA 02536 S- �k- 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO PART A RECEi1V/r(Yl_L � CERTIFICATION m AUG 4 1997 Property Address: 1679 Race Lane Lot 60 1 (re n Address of Owner: TOWN OFBARNSTABLE Date of Inspection:7131197 (If different) S HEALTH DEPT. Name of Inspector:John Gracl Christen Company Name,Address and Telephone Number: £ ti 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 in Title V Conditionally Pa es code 310 CMR 15.303.My findings are of how the system is _ Needs Fu her aluation 8 the Local Approving Authority performing at the time of the Inspection.My inspection does Y PP 9 ty not Imply any warranty or guarantee of the longevity of the _ Fails septic system and any of its components useful life. 9 Inspector's Signature: Date: 7131197 1 The System Inspector shall ubmit 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. 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 • Telephone(617)292-5500 1 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1579 Race Lane LOW Owner: christen Date of Inspection:7131197 _ 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: 1 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 cfflucllt to the surface of the yroLuld or sUIfUC@ walers dLIO to an ovorlou o.d or Lloggod cesspool. SAS is in hydraulic failure. (revised 11115195) 2 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1579 Race Lane Lot 60 Owner: Christen Date of Inspection:7131197 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 11115195) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 1579 Race Lane Lot60 Owner: Christen Date of Inspection:7131197 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. 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 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 11115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1579 Race Lane LotGO Owner: Christen Date of Inspection:7131197 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: 4 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: n1a 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: rda Last date of occupancy: nla OTHER: (Describe) nla Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last year. System pumped as part of inspection: (yes or no)Yes If yes,volume pumped: 1500 gallons Reason for pumping: Maintenance TYPE OF SYSTEM X Septic tankldistribution 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: 1991 Sewage odors detected when arriving at the site:(yes or no) No (revised 11115195) 5 I o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1579 Race Lane LOGO Owner: christen Date of Inspectiow 7131197 SEPTIC TANK: X (locate on site plan) Depth below grade: T Material of construction:X concreate_metal_FRP_other(explain) Dimensions: L 9'9'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: 7' 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 septic system every two years for maintenance. GREASE TRAP:_ (locate on site plan) Depth below grade: n1a Material of construction: _concrete_metal_FRP_other(explain) Dimensions: n1a Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle: n1a, 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.) Na (revised 11115195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1579 Race Lane Lot60 Owner: Chrlsten Date of Inspection:7131197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n1a Material of construction:_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.) n1a 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.) nla 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 r . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1579 Race Lane Lot 60 Owner: Christen Date of Inspection:7131197 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: n1a Type: leaching pits,number: 1,000 gallon pit leaching chambers,number:n1a leaching galleries, number: n1a leaching trenches,number,length: nla leaching fields, number, dimensions:nfa overflow cesspool, number:n1a Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The overflow is structurally sound and functioning properly.lt was 112 full at the time of the inspection. CESSPOOLS:_ (locate on site plan) Number and configuration: nfa Depth-top of liquid to inlet invert: n1a Depth of solids layer: nfa Depth of scum layer: n1a Dimensions of cesspool: n1a Materials of construction: n1a Indication of groundwater: nfa inflow(cesspool must be pumped as part of inspection) n1a Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) n1a PRIVY: (locate on site plan) Materials of construction: n1a Dimensions: n1a Depth of solids: n1a Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) nla (revised 11115195) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1579 Race Lane Lot BO Owner: Christen Date of Inspection:7131197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' IJ D o � DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts 12+Feet (revised 11115195) 9 I ///0VJU WN OF BARNSTABLE 1 � LOC-ATION IS- SEWAGE # VILLAGE k j j9 VS ASSESSOR'S AP 6: JtOT r124 s INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY /D 0 y LEACHING FACILITY:(type) ! (size) ®�U NO. OF BEDROOMS PRIVATE WE L O P BLIC W;7ER BUILDER OR OWNER �P C 1-4 DATE PERMIT ISSUED: l o� DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No a I3 R ....v r , r .. .................. r FE � 0`7 THE COMMONWEALTH OF MASSACHUSETTS � < ,. BOARD OF HEALTH 1A!:2W.0..............OF......,...:. ......... .........................- ppliration for llhipas a1 Workii Tnnitrnrtion Famit pplication is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: Pk- ..........___.... .. ..... - _ ................................................... .---. _ --.------ --- ----- ' -----Locati dd ess -T _ s C ... . .................. -.. ..� ......L 1.-..... W 7—ow Address a ...... ..... ....---.........------ ----................n__.`: ./....... ..._.._.. ... Installer Address ,,{{ y Type of Building Size Lot: ... 4bE; Sq. feet U Dwelling—No. of Bedrooms........._.�............... .Expansion Attic ( ) Garbage Grinder ( )'4 Other—T e of Building ...._.. No. of persons............................ Showers — aYP g --------------------- P ( )._.....Cafeteria ( ) dOther fixtures ------------------•-----------------•--•---•------•--..--------•--•------------------------•-----•--------- ......................................... Design Flow............15.6. ....._._.._.._._....._..gallons per person-per day. Total daily flow..........._�Z ....................gallons. WSeptic Tank—Liquid*capacity Q.gallons Length&.::� Width 1.7Ja'f- Diameter................ Depth----------- Disposal Trench—No. ........ .......... Width........ ......... Total Length....-.._........... Total leaching area........._......._.sq. ft. Seepage Pit No......I.............. Diameter.1.73...... Depth below inlet..�..:'�.._. Total leaching area.��.-...sgf- Z Other Distribution box (,/� Dosin tank ( ) `" Percolation Test Result�j Performed by.. �' ll ............................................ ate..... -.., _ ...... Test Pit No. 1....f�.......minutes per inch Depth of Test Pit.....I ......... Depth to ground water��."�. (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil... lTs ...... ....IC ! � - �Csf� .... .__. - ...........................................- x 2--- I Z l ---- 4 ---•-------------------------------•-------•------------------------•--------...------....--------•-------------------------------------------•-----------•-•-----•-•--•-----------....-------------•--- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------••------------------•-•-------------------••-------•---......-•-------------•-•---•---•-----------------------------------------------•--------•------.....-•---------------------------•------. Agreement: The undersigned agrees to install the aforedes i�bed Individual. Sewage Disposal System in accordance with the provisions of TITIL- 5 of the State Sanifl d ndersigned further agrees not to place the system in opera n until a ifi of C nce hoard of ll}ea th. Y Signe �J . .......................... Date plication Approved By--------�'Y�-•---- Date Application Disapproved for the f ollowin reasons:------•---------------------------------------------•-------.....----------...---------•-----•-•--.....--------- -•-••........................................--••-•--•--------------------•--....-------------------•-----------•---..--Date---------•-•-- Permit No. �OF..�Z------------------•--...... Issued - �' �!�...... . Date No. ........ � f�_�� - Fps.............. ...... d7 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f49 % .0..............OF............ 4� j`(` '• LA'.. Appliration for Uispaoa1 Works Tontitrur#ion Vamit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: k '= �v................_...........................�.....---••--- ---- ...._......... --•--••-----•..... -•-..... ---- .-----.....----•---•-----•-•----- Locatio Address _ eoa �� Owner Address._... .... ...__. -_.. Installer Address d Type of Buildin '� ..Sq. feet g Size Lot_�...___. Dwelling—No..of Bedrooms.....................................................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building .......... No. of � YP g -------------•----------••----•-••-------..persons------------------------_.._Showers ( ) — Cafeteria ( ) Other fixtures ---------------------- ---•-- ........................................ Design Flow..................................gallons per person,•per day. Total Oaily flow--_.......... Z................................gallons. W Septic Tank—Liquid capacity nOt2gallons Length.!.-(e" WidthAi:_J °' Diameter................ Depth(�._. 1` x Disposal Trench—No. .................... Width.................... Total Length............_...... Total leaching area----- .............Sq,. ft. t is Seepage Pit No-------............. Diameterd'.". 3�..... Depth below inlet._� `_' '..__ Total leaching Z Other Distribution box (u111" Dosing tank ( ) aPercolation Test Results Performed by.-_ '- .._ -- - .. -- - Date......" `_ .___.. n i. Test Pit No. 1......._.....minutes per inch Depth of Test Pit...... ......... Depth to ground water.'-�--_:_:�-`----- (4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .....................!;a-,- p _......--------•--------••----........-•-•-------.._........._......._.............._...-- D Description of Soil...- °? ��' ° - 1� -lam-°---� "'-....--- V ..--•-----•-------------•- •-----tom----- - ..___��c._, ±3`�; � : --% .9 1 ......................4_-....._......_.......___._..__..... W ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------------------------•--•-----------•............................-.........-.......-..--------••------------ --------------••------•---------------•--•------------•--•--......-------- Agreement: The undersigned agrees to install the aforedes 'ibed Individual Sewage Disposal System in accordance with the provisions of TITIZa 5 of the State Sanitary de! e undersigned further agrees not to place the system in operat :n until a rtifica of C!tpl•ance has b issued q-t oard of l lth. � -•. rSigned --- ------------•--------------------------------••-- ...............---------------- -r` A licat ion�Approved By.... <. ....... ..,.!`f ... l �!!t-----.. . , Date ' Application Disapproved for the followin Date easons:.._._ ---------------------•--................-----.....-------•------.....----...------.......--•-•------....-------------••--•----•---•-•---•-----•---•--•-•----•-----------------------------............. Date Permit No.....9?n.P,�......----•--•-------.._.. Issued- AD . �..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... .E�, :�1 .............0F.......1.-� •r.�q�. �.(`�. r ...................... Tntifiratr of Tontplittnrt THIS IS TO._C-ERTIFY�That ;the Individual Sewage Disposal System constructed ( ) or Repaired ( ) ---�•-y-•--•--....--•--••--------••-•------------•-------•----------------------------•-------------•----......--•-------.....------•------•---••. f Installer 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..`r-�.'_""--I .......... dated_....-- .:�.�-��r�.rJ -.---._•---. THE ISSUANCE OF THIS CERTIFICATE SHALL POT BE CONS UED AS A GUARA EE THAT THE SYSTEM WILL FUNCTIONS Wqi/ TISFACTORY. DATE.....-----•--•..................... ................. Inspector----------- ... THE COMMONWEALTH OF MASSACHUSETTS t BOARD OF ,HEALTH HEALTH .l ., OF No.. ( . .......... .. FEE...:-: ''�,--....... i o orkii Tonstrudion Prrutit 1! ,t (r J rl%tC.r��l,r r z� , .. Permission Is hereby granted =- --------------------•-•--•---•------------- ........................................................................ to Constru t ( ) or Repair ( ) a ndlvldual Sewage Disposal System at No.......Cr?-' ..'. _ Street as shown on the application for Disposal Works Construction Permit No.:"-?fZ.:J_16-i Dated....LK Board of Health DATE.............)...... .................................................... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS MARSTONS MILLS LEGEND - -- ]--1- PROPOSED CONTOUR 98 PROPOSED SPOT GRADE FocE �cE �aNE —— g —— EXISTING CONTOUR °F + 96.52 EXISTING SPOT GRADE W— EXISTING WATER SERVICE \ m� SITE !9 TEST PIT 76 ' 78 g ' 80 BENCH MARK 82 PAINT SPOT ON DECK CORNER ' LOCUS MAP Ek ELEVATION 77.20 /;' 84 LOCUS INFORMATION �jz/ /' i ,' �� _ P RCELE D: MAP167 047 PAR. 136 / O �= SEPTIC SYSTEM 20 ft REPAIR PLAN LOCATED AT: // D T� 1579 RACE LANE ,10 f �(/�� �C 86 MARSTONS MILLS, MA op-0/vc PREPARED FOR �oN JOHN & JEANNE �\ MOREAU ` SEPTEMBER 3, 2014 LOT 60 ` v _ OF AS AREA = 24485 �f ASSR MAP298 PCL1 2co DAR\` / sq�yG �� Cj c M a- O 114� Kai IST ' i F NIT0 EXIST. 1 ,000 GAL MEYER 8c SONS INC. SEPTIC TANK CV P. O. Box 981 78-- --- - ,- E. SANDWICH , MA 02537 PLAN I -- PH. (508)360-3311 SO'_ , ' U EXIST. LEACH PIT J fax (774)413-9468 SCALE: 1 in = 20 ft 82 meyerand son sinc0gmail.com 20 40 4 < o (SEE NOTE 1 O) F---- ; 8 i {1�4t t SHEET 1 OF 2 J#1684 NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL:73,89 SEPTIC TANK PROPOSED D-BO PROPOSED S.A.S. FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. X T.O.F. EL.=84.88 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER OUTLET AND SET TO 6" OF FINISH GRADE SET TO 6" OF GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G. GENERAL NOTES: F.G. EL.=78.0t F.G. EL.=77.7t F.G. EL: 76.5t F.G. EL: 76.75(MAX.) I. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL ... /_ L BOARD OF HEALTH AND THE DESIGN ENGINEER. i 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 9" MIN COVER/ OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE 36" MAX COVER L = 30' L = 10'(MAX) INSTALL TWO INSPECTION PORTS (MIN.) LOCAL RULES AND REGULATIONS. 0 S=l% (MIN.) EL 75.7 0 S=l% (MIN.) 0 S=l% (MIN.) 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. 10" " 14- 6 11.3" TO �� �F M,4 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING INV.=74.65 INVERT Q� `S�'� FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 48"LIQUID yak L'y ENGINEER BEFORE CONSTRUCTION CONTINUES. LEVEL INV.=74.40 INV.=73.50 D R N�M G 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. GAS BAFFLE PROPOSED 4 ROWS OF 4 UNITS AT 6.25'/UNIT = 25.0'/ROW R ,V D-80X INV.=73.90 y 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF INV.=74.10 NO. 1140 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF DB-5 SOIL ABSORPTION SYSTEM (PROFILE) HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. l� EXISTING 1.000 GALLON SEPTIC TANK H 0 O 7. DWELLING IS SERVICED BY MUNICIPAL WATER SUPPLY. • �£�� � 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED RESTORE VEGETATIVE COVER sANITAR�aa TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. EXIST. SEWER OUTLET BACKFILL WITH CLEAN PERC SAND �L 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE TO TOP OF CHAMBERS LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO STARTING WORK. 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION PIPE INVERTS PRIOR TO CONSTRUCTION BREAKOUT=TOP ELEV.=73.89 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY 2) D-BOX SHALL BE SET LEVEL AND TRUE TO INV. ELEV.= 73.50 AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY GRADE ON A MECHANICALLY COMPACTED SIX BOTTOM ELEV.= 72.56 EXISTING SUITABLE 13. NO KNOWN PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING INCH CRUSHED STONE BASE, AS SPECIFIED IN 2 83' MATERIAL 14. ALL PIPING TO BE 4" SCH 40 0 1/8-/FT (UNLESS SPEC. ) 310 CMR 15.221(2) 5' MIN. ABOVE BOTTOM OF 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW 3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK FOR THE USE OF A GARBAGE GRINDER. T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 4 x 2.83' = 11.32'WITH 1500 GALLON SEPTIC TANK IF FAILED, (7.72' PROVIDED) 16. NO WETLANDS WITHIN 150 FT. OF PROPOSED LEACHING USE 4 ROWS OF 4-HIGH CAPACITY DAMAGED, OR UNDERSIZED. BOTTOM OF TESTHOLE: EL:64.84 = INFILTRATOR OF UNITS-CA STONE 4) INSTALL INLET & OUTLET TEES W/ GAS BAFFLE AS REQUIRED SEPTIC SYSTEM PROFILE TYPICAL SECTION N.T.S. Krs 75" �{ SOIL LOGS DESIGN CRITERIA NUMBER OF BEDROOMS: 3 BEDROOM DESIGN DATE: AUGUST 21, 2014 DESIGN FLOW: RESIDENTIAL: 3 BEDROOMS ® 110 GPD/BR = 330 GPD SOIL EVALUATOR: DARREN M MEYER, R.S., CSE 1614 DESIGN PERCOLATION RATE: <2 MIN/IN SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) WITNESS: DONNA MIORANDI, BARNSTABLE HEALTH GARBAGE GRINDER: NO (not designed for garbage grinder) DISTRIBUTION BOX: USE DB-5 (H20) Elev. TP- 1 Depth Elev. TP-2 Depth • 75.34 A 0" 76.11 A 0" SEPTIC TANK: 330 gpd x 200% = 660 gpd USE EXIST. 1,000G SEPTIC TANK LOAMY SAND LOAMY SAND 16" IOYR 4/1 10YR 4/1 74.76 7" 75.53 7" LEACHING AREA REQUIRED: (330)/.74 = 445.94 S.F. B SANDY LOAM B SANDY LOAM 10YR 5/8 10YR 5/8 PRIMARY S.A.S. 73.18 C 26" 73.78 C 28" 11" USE 4 ROWS OF 4 - HI-CAP INFILTRATOR H-20 UNITS-NO STONE SECTION INVERT MEDIUM MEDIUM HEIGHT END CAP SAND BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.73 SF/LF OF CHAMBER) 2.5YY 7/3 2.557/3 INFILTRATOR - HI CAPACITY (H20) CHAMBER (CHAMBER) 16 UNITS x 6.25 LF x 4.73 SF/LF = 473.00 SF PERC TEST ® 71.s PROPOSED SEPTIC SYSTEM UPGRADE PLAN TOTAL AREA = 473.00 SF DESIGN FLOW PROVIDED: 0.74GPD/SF(473.00SF) = 350 GPD > 330 GPD req'd 64.84 126" 65.61 126" 1579 RACE LANE, MARSTONS MILLS, MA PERC RATE <2 MIN/IN. ("C2" HORIZON) PERC RATE <2 MIN/IN. ("C2" HORIZON) Prepared for: Moreau/Re d Rooter Exc. NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED p System Design and Site Plan by: SCALE DRAWN DATE Meyer&Sons,Inc. N.T.S. DMM 09/03/14 • I, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 PO BOX981 CHECKED SHEET NO. to conduct soil evaluations and that the above analysis has been performed by me consistent with the EASTSANDWICH,AM 02537 requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Eval. Exam in October, 1999. 508-362-2922 DMM 2 Of 2 1' Y GENERAL _NO TEC ,-1 1 444 ' C3 N � 4+' .n/�f - - _ 7L- —J' � ,-:-... ..- 2. t"/TCH /-t.�.� &t/VE'+S �ftNf U/l9 F`0o E tJTHER 13�/SE 5P 'CIF't �\ Ii' t/11 T F SY S �.� >1 .�. A.(.�C. f'/P�.S 3"C1�N H ST'�'r�f �/A/,•0 � A L�fc .SG'H�"1�,C/4,F. 4 PVC. _. / .��ny ..{y�fyam� �s./� �sq.`w./�n.{a+�y/a}e��y{t{t/T</1'II /�l��JrY.-�^y�o ✓ jISYtSr/I i'ilV6dC /VVN�L.V� n j� (� � AA+� SE 7_/�i A/1t/� �_. P �.EACH No PtTs HA�k �E s�o emoC C C� CD CSC i t x AYH .Cl�,4P/NG5 THEN o N yam' �pj/p�,�r�+- �g J / h;�+/ ! 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