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HomeMy WebLinkAbout0020 REDBERRY LANE - Health 20 Redberry Lane Marstons Mills r _ A= 047-096=010 it I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 6 - C� ti �" r Property Address Owner Owner's Name information is required for every page. City/Town State Zip Codel Date of lAspectiorf Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms I on the computer, use only the tab 1. Inspector: IV/" key to move your cursor-do not use the return Name of Inspector key. Company Name _ .p d 77/ Company dress City/Town State Zip Code r Telephone Nutfiber License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that-the -a information reported below is true, accurate and complete as of the time of the inspection. Tt4:irlspeRon was performed based on my training and experience in the proper function and rraintenance.of on stte sewage disposal systems. I am a DEP approved system inspector pursuant fo'Section 1''Q340 ofa _ Title 5(3 CMR 15.000).The system: t CID a i r~' Passes ❑ Conditionally Passes z-a i^- ❑ Needs Further Evaluation by the Local Approving Authority e, e �t M ct a) � 1� ' t1_ ``°Inspect ig a Date E-- C;; b tT 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. t5ins•11/10 T1%5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments bQ Pr�o..elprtly Address T Owner Owners Name �� information is �SM Mr f�y c required for every (� c page. Cityi I own 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) Syst Passes: ZI 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: ne or more system components as described in the"Conditional Pass"section need to be re ced or repaired. The system, upon completion of the replacement or repair, as approved by the Bo of Health,will pass. Check the box fo es", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please a ain. The septic tank is metal and r 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infil on or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replac with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection N it is stru ally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 yea d is available. ❑' Y ❑ N ❑ ND(Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address LA01 ,1 Y a bQ Owner Owner's Name information is rr .� p} e n vvi ✓� h^ r C / // required for every 1'i�l lam_ page, Cityrrown State Zip Code Date of Inspection B. Certification (cont.) stem Conditionally Passes (cont.): ❑ Observatl f sewage backup or break out or high static water level in the distribution box due to broken or ob led pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(wi roval of Board of Health): ❑ broken pipes) are replac ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ ND(Explain below): ❑ The system require mping more than 4 times a year due to broken or obstructed pipe(s)` The system will pass inspect) ' (with approval of the Board of Health): ❑ broken pipe(s)are replac ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed Y ❑ N ❑ ND (Explain below): ❑ Con exist which require further evaluation by the Board of Health in order to determine if the system is ii to protect public health, safety or the environment. 1. System will pass un oard of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is nctioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface wa ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetlan -or a salt marsh !Sire•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name _ information is required for every nnw/� /nn C Vy, ,s tz r l page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Xm will fail unless the Board of Health(and Public Water Supplier, if any) es that the system is functioning in a manner that protects the public health, d environment:e system has a septic tank and soil absorption system (SAS)and the SAS is within f urface water supply or tributary to a surface water supply. he sy m has a septic tank and SAS and the SAS is within a Zone 1 of a public water he system h a septic tank and SAS and the SAS is within 50 feet of a private water ll.m has a septic tan nd SAS and the SAS is less than 100 feet but 50 feet or more from a private water supp ell**. Method used to determine distance. **This system passes if the well water analysis, p ormed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence o mmonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure crite ' are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ E�/ 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 ❑ [y Liquid depth in cesspool is less than 6°below invert or available volume is less than day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rY 9 P Y rY Property Address Owner Owner's Nam ^� information is /� required for every . l a } 6c page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No/ ❑ ,„( Required pumping more than 4 times in the last year NOT due to clogged or uuuuuu obstructed pipe(s). Number of times pumped: ❑' [� Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ d6'R' Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ EU jiff Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Ydjl�Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 2 00 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, perfonned 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. ❑ L�_J/ 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. n flow of 10,000 gpd to 15,000 gpd. For large sys you must indicate either"yes"or"no"to each of the following, in addition to the questions in Sectio Yes No ❑ ❑ the system is with) 0 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet o 'butary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sense area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public er supply well If you have answered"yes"to any question in Section E the system is conside a significant threat, or answered"yes"in Section D above the large system has failed.The owner or op r of any large system considered a significant threat under Section E or failed under Section D shall upg de the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P operty Address no'A X 4)K) I bo Owner Owners Name information is required for every 19 f +!S 7 M DO(a L page. Cityrrown 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 ❑ V 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? ❑ 1;/ Have large volumes of water been introduced to the system recently or as part of / this inspection? f--�/ ❑ 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? 1�G(,K�i a6 i _ / ❑ Were all system components, a ing the SAS, located on site? L� ❑ 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? L/ ❑ 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)] D. System Information Residential Flow Conditions: ,l Number of bedrooms(design):�v���G" _ Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): �3 0 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Property Address Owner ne s Name information is MLUOyvr l�S I required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: 02- Number of current residents: Does residence have a garbage grinder? ❑ Yes 2/"No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes VNo Laundry system inspected?&I nn e�Te�Q To ���Sy.sre� ❑ Yes 2/"No Seasonal use? C(it55_e_� �� Ar.r6 Tw, [L es ❑ No &I C_ o r�S f, fU 1'>eej11r-e'1 U�� Water meter readings, if available(last 2 years usage(gpd)): BOO o00��y. Detail: A)oT .' ffft5 6190"P•� ' 3' kGqv�,j 515i er"I /* TA ti a �� \ Sump pump? ❑ Yes EKNo Last date of occupancy: ate Type ablishment: Design flow(based o CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons s . etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form tvL Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address — Owner e s Name information is �n, ,c_t.,,,,'� CX�� '�•1 � I '1 I required for every W�.ZI(JT( O� page, City town State Zip Code Date of Inspection D. System Information (cont.) Last da ccupancy/use: Date Other(describe below): General Information Pumping Records: lq "-� -e Source of information: Was system pumped as part of the inspection? L/ Yes ❑ No If yes,volume pumped: gallons How was quantity pumped determined? �i Lu�ft� , , Zkzfe— Reason for pumping: Type of ystem: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•t ill Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 8 of W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments roperty Address Owner Owners Na e J information is _ !/�� rv, /1 /� /_(� g i� O required for every os I, r f rr V l3J 1 page. City own State Zip Code Date of Inspection D. System Information (cont.) Approximate age all.components,date installed (if known)and source of informati : /e � 3 S o . Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): O �'— Depth below grade: feet Material of constructi;/40PVC ❑cast iron ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): ^7-0 776ff� y z°�%�G�es�.��/h /Z a /J d � Septic Tank(locate on site plan): Depth below grade: / `5� feet 'Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) ' years Dimensions: � /dZ ii Sludge depth: t5ins•11110 Title 5 Offidal Inspection Form:Subsudsoe Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property A dress �nt nn ,i � Owner Owners Name Inforination is required for every M .kLLat. �//�...� 1, l��.D u '�a. Z�! page. ay/Tom State Zip Code Date of inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle G Distance from bottom of scum to bottom of outlet tee or baffle p How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence f leakage, etc.): e Sego /22 /�c�LcT,�J2� 7e e.;o�Tt/Pe— 0 �oe" 5 4ul t 6—ea-4-0 4— js &K, % /t O tTCT u-ee- _ Dep elow grade: feet Material of cons ton: [I concrete El me ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum-to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pro arty Address Owner Owner's Name information is required for every r page. Cityfrown State Zip Code Date of Inspection D. Syste Information (cont.) j Comments(on p 'ng recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related tlet invert, evidence of leakage, etc.): Tight or Heading Tank(tank FAust be pumped at NFAs of iRepeetieA) (leGate 9R sots -... Depth below grade: Mate ' I of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: El Yes ❑ No Alarm level.' rm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pro rty Address t Owner owners Name information is L required for every JLI S v I r J W m 0 l � 5 !l page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Pumps in ing order: El Yes ❑ No Alarms in working order: El Yes ❑ No Comments(note condition of pump cha condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): / If SAS not located, explain why: o4196dk> t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 12 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ro ity Address n 41 ,41 &� Owner Owners Name information is a5 ( required for every ��f� � � / page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Type: leachingits number: P ljti"A' u S:S Gar CL✓/1� eP�'h. ❑ leaching chambers number: ❑ 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.): Co 'Inse. -5w-j N a SiG,-j ao AP01Ae- Number an I uration Depth—top of liquid to inle Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Offidal Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pro Address Owner Owners Name information Is required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Com is(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Materials of co ction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic fa level of ponding, condition of vegetation, etc.): 4 t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Pape 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pr6pe rty Address Owner ner's Name information is 1 r required for every page. Cityfrown State Zi ode Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate wher public water supply enters the building. Check one of the boxes below. and-sketch in the area below ❑ drawing attached separately • GUf1T-� !=aZ6. 6 o t5ins•11/10 Title 5 Of al Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Forth Not for Voluntary Assessments Property Address 11 l U Owner (0,wn�e/r's�ANameinformation is required for every Llh page. unyt I own State Zip Code Date of Inspection D. System Information (cont.) Site am: heck Slope Surface water [Check cellar [Shallow wells / 7 Estimated depth to high ground water: t 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspecdon Forth:Subsurface Sewage Disposal System•Page 16 of 17 44 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name information is � a required for every o I I U J I I ' ,�/�J,J ��I page. Cityfrown State Zip Code Date of Inspection E. 711-1spection ort Completeness Checklist Summary:A, B, C, D,or E checked C1�Inspection Summary D(System Failure Criteria Applicable to All Systems)completed Y stem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t t5ins•11110 Title 5 Offiaal Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 Table 3-2 Do's and Don'ts of Private Septic System Management DO... DONT... Do have the on-site system inspected and pumped by Do not use the toilet or sink as a trash can by a licensed professional approximately every 3 to 5 dumping non-biodegradable material(cigarette butts, years. Failure to pump out the septic tank can cause diapers,feminine products,etc.)or grease down the system failure. If the tank fills up with an excess of sink or toilet. Non-biodegradable material can clog solids,the wastewater will not have enough time to the pipes,while grease can thicken and clog the. settle in the tank.These excess solids will then pass on pipes. Store cooking oils,fats, and grease in a can to the leach field,where they will dog the drain lines for disposal in the garbage. and soil. Do know the location of the on-site system and drain Do not put paint thinner,polyurethane,anti-freeze, field, and keep a record of all inspections, pumping, pesticides,some dyes,disinfectants,water repairs, contract or engineering work for future softeners,and other strong chemicals into the references. Keep a sketch of it handy for service visits. system.These can cause major upsets in the septic tank by killing the biological part of the on-site system and polluting the groundwater. Small amounts of standard household cleaners, drain cleansers,detergents,etc.will be diluted in the tank and should cause no damage to the system. Do grow grass or small plants(not trees or shrubs) Do not use a garbage grinder or disposal,which above the on-site system to hold the drain field In feeds into the on-site tank. If there is one, severely place.Water conservation through creative limit Its use.Adding food wastes or other solids landscaping is a great way to control excess runoff. reduces the system's capacity and increases the need to pump the on-site tank. If a grinder is used, the system must be pumped more often. Do install water-conserving devices in faucets, Do not plant trees within 30 feet of the system or showerheads and toilets to reduce the volume of water park/drive over any part of the system.Tree roots will running into the on-site system. Repair dripping faucets dog pipes,and heavy vehicles may cause the drain and leaking toilets, run washing machines and field to collapse. dishwashers only when full, and avoid long showers. Do divert roof drains and surface water from driveways Do not allow anyone to repair,pr pump the system and hillsides away from the on-site system. Keep sump without first checking that they are licensed system pumps and house footing drains away from the on-site professionals. system as well. Do take leftover hazardous chemicals to an approved Do not perform excessive laundry loads with a hazardous waste collection center for disposal. Use washing machine. Doing load after load does not bleach, disinfectants,and drain and toilet bowl cleaners allow the on-site tank time to adequately treat wastes sparingly and in accordance with product labels. and overwhelms the entire on-site system with excess wastewater.This could flood the drain field without allowing sufficient recovery time. Consult with an on-site tank professional to determine the gallon capacity and number of-loads per day that can safely o into the system. Do use only on-site system additives that have been Do not use chemical solvents to dean the plumbing allowed for usage in Massachusetts by MA DEP, or on-site system."Miracle"chemicals will kill Additives that are allowed for use In Massachusetts microorganisms that consume harmful wastes. have been determined not to produce a harmful effect These products can also cause groundwater to the individual system or its components or to the contamination environment at large, hnp:/M*w.mass.govldep+water/resouromrnpgLAde.doc 3-17 Jury.2005 TOWN OF BARNSTABLE LOC.ATION1?,ecll,?Crr\l zm � SEWAGE #_aL!r i VILLAGE & �_sc __. ASS1;$SC)It.'S MAP 1� LOT INSTALLER'S NAME 1ST PHONE NO. /Z`i`G(�e �r���7r _C'G 'nc. 7 SEPTIC TANK CAPACITY A00 LEACHING FACILITY:(type)P c Cc s 1 (size) /06 0 NO. OE BEDROOMS /—PRIVATE WELLOR PUBLIC WATER BUILDER OR OWNER-7 7 Cam,�/a �, DATE PERMIT ISSUED: DATE COMPLIANCE ISSIJED_� /- / - r _- VARIANCE GRANTED: Yes No _ ��� `�a i �� �3ya w � ; - �� .� C � ,� A No. ...Z€3 ( Fsic.........r�................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ v.. `'°'/......OF....1�r �ZAJsi---..... .................... Appliratinn for Biupnuttl Workii Tonut.riir#iun "amit Application is hereby made for a Permit to Construct ( Pror Repair ( ) an Individual Sewage Disposal System at: 2 1 J L' e f- �-�t /V?a r-s r� ....�-`o-�'-----•.................................••-•---•--... ..........--------- ..............----.....-®.....s..��./1.�.....................--•-•...---- Locatio Address or Lo Z......�.... I ._ �. h.a a--------------��� ....5 4.. .. 1� at.. .. s_T .. ........ ...... ._..... NL. Add w r �/� DwC= c. G_ Q ram. ...................................................... .............................................................. Installer Address �(�/� � Type of Building Size Lot...b_ ..__,�............. q. feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder--(---)-- P4 Other—Type of Building ---l__-Z�.. No. of persons...._�................. Showers t--T_— Cafeteriart----�r Q' Other fixtures .. Design Flow...................`_�...�•..........._gallons per person per day. Total daily flow............................................w . 1q o� �,e .. a .� WSeptic Tank—Liquid capacity ._.....dgallons Length.c�.._._ _._ Width__../_.. Diameter................ Depth_�._.o. x Disposal Trench—No- -------------------- Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No.....I.............. Diameter.......��'.._....... Depth below inlet..... ........... Total leaching area._2.:q_Lsq. ft. Z Other Distribution box ( ✓j Dosing tanj:4 5 �� Percolation Test Results Performed b �". !-cam........................... .... .... Date._.....f_a `4a Test Pit No. 1......�.._. Z-minutes per inch Depth of est Pit..1. __G__�Depth to ground water--___/ f'— fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to a ---- grounw ater........................ ._.... � - -- ------- ---•---. .of Soil---------_-��_-?� � S--C------ •- -----..._._..-•----------------•--...........---•----.. x tJ --------------------------------------------------------- ------------------- --------------- -----...... •--------- --.------- •--------------------------- ......_._.....------------- ----------------------- w ----•••----•----------••-------------------•--...----------•-•-•----•---•--...-----•-•-•--------•---•--•-•----------------•••••.....----•--•--•-•....----------------------•--•---------•--•------------ UNature of Repairs or Alterations—Answer when applicable.................................................................................._............. -------------------•-•- •---•..•-- ........... ----------------------------------------------------------------------------------------------------------------------------------------------- Agreement: -•----•--------•---•-------•--•---••----------•----------------------.----.----------------------------------------------•-----•-- Agreement: �. c ` The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLU 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. --•---•----=--------- .......................................................... D Application Approved BY- r=--- ---.------- ...-�-L�-�� ----�--- --.. ate Application Disapproved for the following reasons________________________________________________________________________________________________________________ .............................•--.......---............--•-•-•----.............----•-------•--•------..............-----•---•-----•-•------------......------•---•--•------------------........_..._..._.. Date Permit No.. -•--•-.........g(-•-------------- Issued............... f. -------•- D THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Movaiial Works Tonstrur#Uan Frrlltif Application is hereby made for a Permit to Construct ( kr or Repair ( ) an Individual Sewage Disposal System at: -Locatio4-Address •�- or LoL. . ..t ' `�—'?_... :.. --•r r• -- ' '—= ....................... . .....................T_..._..-.`''..,... _ ��„..eA:........ Owner Addr� Installer Address Type of Building Size Lot... feet U Dwelling—No. of Bedrooms............. .............................Expansion Attic r(� )---- Garbage Grinder-(—) p`4 Other—Type of Building ...... No. of persons....................... Showers-r)-- Cafeteria•-()�- a Other fixtures . d . . ----------------------- Design .......... W Flow............................................gallons per person per day. Total daily flow................---...Z:7.................gallons. WSeptic Tank—Liquid capacityl��ggallons Length.8:'...�.. Width.'-(.� Diameter................ Depth.!A..... .. x Disposal Trench—No--------------------- Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No.....I............... Diameter......-@........ Depth below inlet................ Total leaching area.. !22...sq. ft. Z Other Distribution box ( ✓f Dosing tapjr.4� � Percolation Test Results Performed by.....�1 .Y". !!.. ,5..................`................... Date....... a If Test Pit No. I.....'f�____.Z%.minutes per inch Depth of Test Pit._1_:=?... .... Depth to ground water....Z. .c'.......... - G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ D Description of Soil.......... C c).c(, r.�.� -5ci ,..z "( .• --•....................................•----............---- U ------------ --------------------- ---------- ••...... -...... ------------------.-_............. -------------------- -...------•------- --.............-.------------------ W ----••-----------------------------------------------------------------------------------------------------------------................................................................................ UNature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------- ...... Agreement: .��.• C,4 '� The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. _ D _ Application Approved B .. .. - , „ J ��r�, Date Application Disapproved for the following reasons:........................................................................................................... •--•------•-•.........................•-......................---...............--------------------..._.-•----.................----•---------------..........------......._....................._...._ Date Permit No. ' -�` ....._.......... ........�" ........---___ Issued...............4Q. D THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ....''..`'"' .. .....OF.....�.q..r`.':!....................................................... f9rr#if irate of fauntpliann THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (__T'or Repaired ( ) by........`'` ` ._ /?.. .......C...... - -- •--•---------•--•--•--•...................................................•---......-•---•..........-~._...._ # Installer at. ' � ` c . .... ....`........ .. ` ::............ .. '' 2... ................................................ has been installed in accordance with the provision of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit Xa�......2,t;`%j......... dated.--..... 1.. ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................•---....................----................--•.........--..---- Inspector....................................................................--.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No"E5.._....2. � !..< �..:.......OF......� -:. .%...` .................................................... Fss........... ....... ]Risp,asal 19orks Tnnshurtiun f erntit Permission us eby granted..__.`-`- ?..�.........�.- = -- ._........- == e ........____ to Construct ( or Repair ) an Individual Sewage Disposal System �: at No. --tr.......................................... es....� s�� .........:.....��............................... Street ,.. as shown on the application for Disposal Works ConstrWfii xl-Per NT......G..-........ Dated.....:.. 1���..� ............ Board of Health DATE . ................................ FORM 125$.. A. M. SULKIN. -LNG., BOSTON BENCH MARK : TEST HOLE RESULTS P 670Q DATE : I WITNESSED BY j—'e /Z /Z y Z G rZ,,,4 / rn / ' «a / gal 7" 0 TEST HOLE i Z-,G-. 47. © TEST HOLE' r► �►-•- ® �� GROUND WATER GROUND WATER ENCOUNTERED ENCOUNTEREID L ELEV. TOP OF MANHOLES AND COVER TO BE BUI LT TO � �'/�' pia. �', Z.�i' , :; toFOUNDATION WITHIN 12�� OF FINISHED GRADE Q QFINISHED .GRADE MIN. 2% SLOPE R -27 .:,,�� b _ a __. , • _. 4 D i A. PIPE FIRS 12'MI /L. MIN. PITCH V.. FT. �2' LEVE f OF D pric rrE- , MIN 1,21IILP E A ST O NNI E 130A SF,F,�K� `j 0O •' MIN. PITCH is.v�n,i �4-' 4 �8 �2 �} _ I/ T ZS 4 _ F °• • /000 - Q• . Y INVERT .�;-.� G A L L O V I N4 Z G.,sc+vHP INVERT ..4 0 .�• .� _i " �« ''cr -" ---- EFT 1 C 'i A N 'r: I S . Q ^�. d t : D 1 A. FOOTING TO BE PLACED INVERT' D 44,00 Q Co c� v © • 4"9 STONE - , .. ►." INVERT. -- =- _ _ _, - _ BOX . q w WASHEDS ON � ON A MINIMUM OF 16 OF INVERT ,, ;© t © �• = , PLACE ON a � ALL AROUND VIRGIN OR COMPACTED „ FIRM SASE ,E-- �A3 . � a l{� Q"� y BOTTOM AT ELEV.-3?•O0 F-� Q -".--'-�"I SAND '- 0 M I N.) rMl C � , ,�- - - 0 GARB, GE 1114 '' ; .�,• ( 2 0 MIN.) �� ` G R I N [ E R J 8► ,� L e> T ,8 07 ' ow T: ELEV. PR 0 F I L E OF GROUND WATER TABLE 4B ,,�Qw+✓ SANITARY DISPOSAL SYSTEM ( NOT TO SCALE ) DESIGN DATA I / • CONSTRUCTION F 3 0 SANITARY DISPOSAL BEDROOMS SYSTEM SHALL CONFORM TO THE MASS. DESIGN W ENVIRONMENTAL CODE TITLE FLOW o GAL./DAY (REVISED 7- 1-77 ) AND THE TOWN LEACH RATE z MIN.�INCH HEALTH DEPARTMENT REGULATIONS REQUIRED LEACHING CAPACITY : 427qlf- SEPTIC TANK, DISTRIBUTION BOX AND LEACH - PROPOSED 427 GAVDAY ING UNIT TO BE OF REINFORCED CONCRETE : Z, � G '8,� f- LpTY MIN. CONCRETE STRENGTH = 3000PS.1. REQUIRED SEPTIC TANK : /000 GAL. MIN. STEEL STRENGTH 20,000 PS. 1. MIN. DESIGN LOADING : MI > PROPOSED SEPTIC TANK : i000' GAL. • DRIVEWAYS NOT TO BE LOCATED OVER SYSTEM UNLESS H2O DESIGN LOADING IS USED • ALL PIPES AND FITTINGS TO BE WATERTIGHT / AND TO BE OF CAST IRON OR APPROVED P.V.C. HEALTH AGENT APPROVAL DATE � SITE PLAN SHOWING PROPOSED CON STRUCTIONI ZONING DATA L E G E N D L O C A T 10 N �3,o9 RIV .6 7 ',oe::�.3 2— (I;V AR.S T©n/5 / , L.[ s) � ,� FOR LEDIEL- SOLLOWS DEV. CORP. DATE ZON E � _ _ _ TEST HOLE LOCATION � , EFERENCE • LOT 2 / AS SHOWN ON REVLSIONS � REQUIRED AREA * _ — _ �{-3, ,5GOs� EXISTING SPOT ELEVATION 17.6 R E Q U I R E D FRONTAGE :— — �� EXISTING CONTOUR — 16 � �ZH of IZ O //�/ 1/►,r. 1 /,C 4�{ , ► S REQUIRED FRONT SETBACK : 3� D•��". gl'�' 4' e PROPOSED CONTOUR —C6}------ SCALE : � ��_ ©, REQUIRED SIDE SETBACK � PROPOSED WATER SERVICE W No. REQUIRED REAR SETBACK : �' PROPOSED GAS SERVICE G PROPOSED ELEC. 81 TELE E a T -51Za% ' RAIG R . SHORT , P. E . PRO FESS10NAL CIVIL EN G 1 N E E R BU I L D I NG INSPECTOR APPROVAL DATE 131 OLD ROUTE I32 , HYANN IS , MA. 02601 FILE NO. ( TELE. (617 ) 362 - 9411 ) SHEET 1 OF / I I