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HomeMy WebLinkAbout0116 REDBERRY LANE - Health 116 Redberry Lane Marstons Mills 4-k . F:f p A _ 047 096005 b '` ` .._ H ----_ .. ro ._......VA t } ; i I .� Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Redberry Lane Property Address Doherty 1 Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/19/2012 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, _ use only the tab 1. Inspector: ^� key to move your cursor-do not Sean M. Jones use the return Name of Inspector ` key. Capewide Enterprises `1 � Company Name s�3 153 Commercial St. Company Address Mashpee Ma. 02649 b9 ` City/Town / State Zip Code 4J r 508477-8877 SI 4522 rn Telephone Number License 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 1/19/2012 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 the4 time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection FoL: uace a Disposal System•Page 1 of 17 I ` V\T 1 Commonwealth of Massachusetts N Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Redberry Lane Property Address Doherty Owner Owner's Name information is required for Marstons Mills Ma 02648 1/19/2012 every page. 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. - Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance.indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): L1 t5ins• 1110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 a Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Redberry Lane Property Address Doherty Owner Owner's Name information is required for Marstons Mills Ma 02648 1/19/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Redberry Lane Property Address Doherty Owner Owner's Name information is required for Marstons Mills Ma 02648 1/19/2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and,the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Redberry Lane Property Address Doherty Owner Owner's Name information is required for Marstons Mills Ma 02648 1/19/2012 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Redberry Lane Property Address Doherty Owner Owner's Name information is required for Marstons Mills- Ma 02648 1/19/2012 every page. City/town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts G Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Redberry Lane Property Address Doherty Owner Owner's Name information is required for Marstons Mills Ma 02648 1/19/2012 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 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)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts u v - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M ,• 116 Redberry Lane Property Address Doherty Owner Owner's Name information is required for Marstons Mills Ma 02648 . 1/19/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Redberry Lane Property Address Doherty Owner Owner's Name information is required for Marstons Mills Ma 02648 1/19/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: system repaired 4/24/2003 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 1 feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof Septic Tank (locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 5" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Redberry Lane Property Address Doherty Owner Owner's Name information is required for Marstons Mills Ma 02648 1/19/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 3'5 Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years as maintenance. Water level was ok, tank was not leaking and was structurally sound. Outlet baffle was intact and in good condition. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Redberry Lane Property Address Doherty Owner Owner's Name information is required for Marstons Mills Ma 02648 1/19/2012 every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Redberry Lane Property Address Doherty Owner Owner's Name information is required for Marstons Mills Ma 02648 1/19/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert On 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.): Box was functioning as intended. Pump Chamber(locate on site.plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V.yy. 116 Redberry Lane Property Address Doherty Owner Owner's Name information is Marstons Mills Ma 02648 1/19/2012 required for II every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ 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.): Leaching facility was video inspected through the vent and was found to be dry with no signs of past hydraulic overloading. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �w 116 Redberry Lane Property Address Doherty Owner Owner's Name information is required for Marstons Mills Ma 02648 1/19/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Redberry Lane Property Address Doherty Owner Owners Name information is required for every Marstons Mills Ma 02648 1/19/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A- � 3 M0o -L a ,A-j lc'' 3 3-1 25 A 2 94 f3-2 33 A-3 y7fs'' 9-3 35° t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Redberry Lane Property Address Doherty Owner Owner's Name information is required for Marstons Mills Ma 02648 1/19/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 2 Estimated depth to high ground water: e°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: Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps I' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 116 Redberry Lane Property Address Doherty Owner Owner's Name information is required for Marstons Mills Ma 02648 1/19/2012 every page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE A y LOG NTION 1/61 L.Vhis SEWAGE # D 16 8 " II.LAGE C /r ASSESSOR'S MAP & LOTO�00 C 0os— INSTALLER'S NAME&PHONE NO. .rof SEPTIC TANK CAPACITY 400 LEACHING FACILITY: (type)-3 -5OU 6ol Z21,1 (size) J- X /-f NO.OF BEDROOMS_ BUILDER OR OWNERhj� PERMITDATE:5 -/S-0 3 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within.100 feet of leaching facility) Feet Furnished by ^�� :-7t4 �� v L b�jo 6 �i No. +� I 0 Fee , THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprfcatfon for Zigom' raem Construction Vermtt Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) O Complete System YAkMdividual Components Location Address or Lot No. �l G �� vY h �� Owner's Name,Address and Tel.No. Assessor's Map/Parcel O L P_6 Cr/ _00 S`_ �el V C� Installer's Name,Address d Tel.No. Designer's Name,Address and Tel.No. / y Ll Zt-- V(n Type of Building: Dwelling No.of Bedrooms Lot Size y31666 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures `// Design Flow l-/ Z/® gallons per day. Calculated daily flow 7[o y gallons. Plan Date — ��© � Number of sheets Revision Date Title Size of Septic Tank ,6,7K ano Type of S.A.S. C4a-u,1-,J 1-/ i/ Description of Soil Nature of Repairs or Alterations(Answer when applicable) S (S' X 2 �r_/ 7 '�CAdo �A-4�c�.a t ZAAt, E lr-'ac- 1 GtlO g S ° G�— /r -e44, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this J3oard 9f Hea Signed Date Application Approved by Date j Application Disapproved for the following reasons Permit No. aU d 3—I b R Date Issued No. UU 3 �„� `` Fee E` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ��• Yes lb- PUBLIC HEALTH DIVISION -TOWN OF BARNSTA. BLE._MASSACHUSETTTS 0(ppricatiort for Digpoord-*pgtem Construction Permit Application forta Permit to Construct( )Repair( Upgrade( )Abandon( ) El Complete System Individual Components Location Address or Lot No. �`�G �lv y h �� Owner's Name,Address and Tel.No. Assessor's Map/Parcel A[� O C�!_OD S'' P e/VC i Installer's Name,Address d Tel.No. Designer's Name,Address and Tel.No. Old Type of Building: Dwelling No.of Bedrooms Lot Size y 3 666 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures j� Design Flow �� gallons per day. Calculated daily flow ' 7(w gallons. Plan Date - 0 ? Number of sheets Revision Date Title r -Y- Size of Septic Tank ,e k Z03ro Type of S.A.S.a'_5=! t4A-u,I J Lam/� -�� Description of Soil f L / fNature of Repairs or Alteration(Answer when applicable) S X (S l X 2 /P/liter lc,c:v, o Date last inspected: Agreement: ` The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system A-•.. in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss ed by this Board f Hea Signed Date Application Approved by 7 es Date L! l klb I Application Disapproved for the following reasons Permit No. 2U d 3- k Date Issued y�l t` /-3 ——————————————————————— -- ----------- - THE COMMONWEALTH OF MASSACHUSETTS 0 q� ,o16-oo 5 BARNSTABLE, MASSACHUSETTS Certificate of Compliance - THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( . )Repaired )- pgraded( ) Abandoned( ),b'' at Au" L ems, _ /Yl/1/1 has been constructed *n accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.2 00 3-/d dated q1/d' u 3 E Installer ,L5t-,..0a 0—, /�,r4�rr9_S Designer 6�is&/-i AW,#/, .v��� The issuance oft this pe shall not be construed as a guarantee that the system&! T,4t,,ip�as designed. Date 2 3 ill Inspector r r --------------------------------------- No. )03— /Ia tl Fee v THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 4 ligogal 6poteff"C6rt�truction 3permit -Permission is hereby granted to Construct( )Repair( u�A1 pgrade( )Abandon( ) System located at Ml0 &c�hlir t�/ L s7YY/y� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. I Provided:Construction must be completed within three years of the date of this permit. Date: ;. �'/ ,�i I Approved by k - \'S' 5/25/01 Notice: This Form Is To Be..Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION YORM I, - ✓�h ti , ,hereby certify that the engineered plan signed by me dated /ZZO 3 concerning the property located at //( L meets all of-the following criteria: -*-'-This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude.this fact or may conduct preliminary tests at the site without a health agent present. There is no increase in flow and/or change in use proposed There are no variances requested or needed. �fThe bottom of the proposed-leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: r A) Top of Ground Surface Elevation(using GIS information) zM B) G.W.Elevation +adjustment for high G.W. _ DEFERENCE BETWEEN A and B SIGNED : 91 DATE: /s�Q3 NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future with t engineered septic system Plans. q:health folder,pero&mp I ;:. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE FAILED INSPECTION Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION I r Property Address: 116 REDBERRY LANE MARSTONS MILLS MAP 047 PAR 096 OTs16 Name of Owner JOE DELUCA �f Address of Owner: SAME Ra?I rQ Date of Inspection: 8/6199 •C Name of Inspector:(Please Print)JOHN GRACI AUGA I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) 1999 TOWjyOFggRIV Company Name: n/aALTIIDEpr�tE Mailing Address: n/a Telephone Number: n/a A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: Passes The inpection is based on criteria defined In Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Eval ati n By the Local Approving Authority performing at the time of the inspection.My inspection does X Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:817/99 The System Inspector shall#ubmit copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM FAILS TITLE V INSPECTION.THE LEACH PIT IS FULL OVER THE PIPE,THE PIT HAD NO VISABLE LEACHING LEFT AND IS IN HYDRAULIC FAILURE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 116 REDBERRY LANE MARSTONS MILLS MAP 047 PAR 096 LOT 16 Owner: JOE DELUCA Date of Inspection:816199 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: n/a B. SYSTEM CONDITIONALLY PASSES: nla One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is levelled or replaced Wa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced _ obstruction is removed revised 9/2/98 Page 2 of 11 1. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 116 REDBERRY LANE MARSTONS MILLS MAP 047 PAR 096 LOT 16 Owner: JOE DELUCA Date of Inspection:8/6199 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nla- (approximation not valid). 3) OTHER nta ` revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 116 REDBERRY LANE MARSTONS MILLS MAP 047 PAR 096 LOT 16 Owner: JOE DELUCA Date of Inspection:8/6/99 D. SYSTEM FAILS: You must indicate either"Yes'or"No"to each of the following: X I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nla. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 116 REDBERRY LANE MARSTONS MILLS MAP 047 PAR 096 LOT 16 Owner: JOE DELUCA Date of Inspection:8/6/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. 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.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 116 REDBERRY LANE MARSTONS MILLS MAP 047 PAR 096 LOT 16 Owner: JOE DELUCA Date of Inspection:8/6/99 FLOW CONDITIONS RESIDENTIAL: Design flow:A4Q g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual):4 Total DESIGN flow: AK Number of current residents:fi Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NQ If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):JNLQ Water meter readings,if available(last two year's usage(gpd): n1a Sump Pump(yes or no): NQ Last date of occupancy: Wa COMMERCIAL/INDUSTRIAL Type of establishment: n1a Design flow: n&gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):M Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:Wa Last date of occupancy: rdA OTHER: (Describe) n1a Last date of occupancy: nta GENERAL INFORMATION PUMPING RECORDS and source of information: NONE System pumped as part of inspection:(yes or no):NO If yes,volume pumped W& gallons Reason for pumping: n& TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: 1992 PERMIT92-204 Sewage odors detected when arriving at the site:(yes or no) �LQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 REDBERRY LANE MARSTONS MILLS MAP 047 PAR 096 LOT 16 Owner: JOE DELUCA Date of Inspection:816/99 BUILDING SEWER: (Locate on site plan) Depth below grade: V 6" Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: V Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ nLa Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: Z Distance from top of sludge to bottom of outlet tee or baffle: 2Z 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: 1r How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING NOW AND EVERY TWO YEARS, GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: nLa Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:iVA Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: Wa Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) n1a revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 REDBERRY LANE MARSTONS MILLS MAP 047 PAR 096 LOT 16 Owner: JOE DELUCA Date of Inspection:8/6/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Wa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) Wa Dimensions: n1a Capacity: Wa gallons Design flow: nLa gallons/day Alarm present: MO Alarm level:jita- Alarm in working order:Yes_No_: UQ Date of previous pumping: nLa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID IS OVER PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) WA revised 9/2/98 Page 8 of 11 I T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 REDBERRY LANE MARSTONS MILLS MAP 047 PAR 096 LOT 16 Owner: JOE DELUCA Date of Inspection:816199 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nla Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: ji1a leaching galleries,number: -n& leaching trenches,number,length: nla leaching fields,number,dimensions: nla overflow cesspool,number: nla Alternative system: nla Name of Technology: _nla Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING,THE LIQUID LEVEL IS OVER THE PIPE IN THE PIT AND THERE IS NO VISABLE LEA CESSPOOLS: _ (locate on site plan) Number and configuration: nla Depth-top of liquid to inlet invert: n& Depth of solids layer: nla Depth of scum layer. n& Dimensions of cesspool: nla Materials of construction: nla Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection)nla Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa PRIVY: _ (locate on site plan) Materials of construction:nla Dimensions:Wa . Depth of solids: nla Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nla revised 9/2198 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 REDBERRY LANE MARSTONS MILLS MAP 047 PAR 096 LOT 16 Owner: JOE DELUCA Date of Inspection:816/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a �qC h O (} D � n � al X-- �9 PC 37 revised 9/2/98 Page 10 of 11 � r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 REDBERRY LANE MARSTONS MILLS MAP 047 PAR 096 LOT 16 Owner: JOE DELUCA Date of Inspection:816199 NRCS Report name: nta Soil Type: nta Typical depth to groundwater: n& USGS Date website visited: nla Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 912/98 Page 11 of 11 TOWN OF BARNSTABLE LOCATION 1(� =J z�ni SEWAGE# { VILLAGE /2 ASSESSOR'S MAP & LOT — - INSTALLER'S NAME&PHONE NO. 12',5 SEPTIC TANK CAPACITY 1400 ` LEACHING FACMITY: (type) -5'0a 6W( (size) NO.OF BEDROOMS BUILDER OR OWNER r`tb+ 2 l& 1 PERMITDATE:5' -/8-CJ 3 COMPLIANCE DATE: I . Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by . s r i 6 - r I J i to LOCATION 2.6 j f6 9F.�CO� A* SEWAGE # � VILLAGE M, ASSESSOR'S MAP & LOTO U� INSTALLER'S NAME & PHONE NO. KC KZ4 SEPTIC TANK CAPACITY /, ci-t�y LEACHING FACILITY:(type) P�� (size) �crt;D NO. OF BEDROOMS --� PRIVATE WELL R PUBLIC WATER BUILDER OR OWNER L DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 2/qcg— VARIANCE GRANTED: Yes No i i (i I ���� � � �� �� .��� yro t, RECEIVED 1 K d OCT 15 2002 COMM.:O:NWEALTH OF MASSACHUSETTS TOWN OF BARNSTABLE EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI S HEALTH DEFT. 3 z DEPARTMENT OF ENVIRONMENTAL PROTECTION r a � d e FAILED INSPECTION Q.,M She" Z:7 TITLE_ 5 OFFICIAL INSPECTION;,FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACU'SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION a y ? Property Address: 116 REDBERRY LANE MARSTONS MILLS, MA 02648 Owner's.Name:. TINA DELUCA Owner's Address: 116 REDBERRY LANE MARSTONS MILLS,MA 02648 Date of Inspection: 9/27/02 Name of hispeclor: (plcuse.pl inl),I JOHN CRAC'1 Company Name: SEPTIC INSPECTIONStnt Mailing Address: P:O.,BOX 21 l9 TEATICKET, MA. 02536 CoPk Telephone Number: 508-564-6813 FAX 508-564-7270 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 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 1..340 of Title 5(310 CMR 15.000). The system: _ Passes _ Conditionally ses _ Needs Furth valuation by the Local Approving Authority X Fails Inspector's Signature: Date: 9/27/02 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspe` ion. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner-;s.ial,l submit the report to the appropriate regional ol7ice ofthe DEI'. The original should be sent to the system owner and'copies sent to,the:buyer, if applicable,and the approving authority. Notes and Comments SYSTEM FAILED TITLE V INSPECTION. LIQUID LEVEL IN LEACH PIT IS OVER PIPES. SAS NEEDS TO BE UPGRADED. 1 ****This report only describes colt(jitioois at the time of inspection anal undel' the conditions of use al Ihslt lilue. 'fhiv inspection does not address how tile.;system will perform in the future under the same or different conditions of use. Tula G Incnartinn Form (`1 4'P;Offlf 1 Page 2 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 116 REDBERRY LANE`MARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02 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 pot evaluated are indicated below. Comments: SYSTEM FAILED TITLE V INSPECTION. LIQUID LEVEL IN LEACH PIT IS OVER PIPES. SAS NEEDS TO BE UPGRADED. 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;,gr-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. n/a The septic tank is metal a4 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`.hy.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 bailable. ND explain: n/a n/a Observation of sewage backip 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 obstruetidn.is removed _ distribution box is leveled or replaced ND explain: n/a 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 I Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A :,. CERTIFICATION(continued) Property Address: 116 REDBERRY LANEiMARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02 C. Further Evaluation is Required'by the'Board of Health: Conditions exist which require furthe'r°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 manne.4 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 S 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 surfacelwater supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank'and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank'ai4id 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 n/a s ; "This system passes if the well-water,analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates flat the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is.equal to.or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be`attached to this:form. 3. Other: n/a Pa,e 4 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 116 REDBERRY LANE MARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02.:; D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool:or.privy is below high ground water elevation. X Any portion of cesspool dt;.pr%vy.is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool orlpri,vy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water,..quality analysis. IThis system passes if the well water analysis, performed at a DEP certified labora.tory,s for colifovin bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppni provided tl auho other failure criteria are triggered. A copy of the analysis must be attached to this f6rm'1 X _ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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. You must indicate either"yes"or"no".to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone 11 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 "vcs" in Section D ahove Ihe.large systein has failed. The owner or operator of any large system considered a significant threat under Section E or failed finder.Section D stall upgrade the system in accordance with 3 10 CM It 15.3U4. The system owner should contact the appropriate regional office of the Department. F, f � Page 5 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 116 REDBERRY LANE MARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02 Check if the following have been done.You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health _ X Were any of the system components pumped out in the previous two weeks X Has the system received normal flows in the previous two week period'.' X Have large volumes of water been introduced to the system recently or as part of this inspection X _ Were as built plans of the system obtained and examined?(if they were not available note as N/A) X _ Was the facility or dwel ing inspected for signs of sewage back up? A X _ Was the site inspected for signs of break out'? X _ Were all system components, excluding the SAS, located on site X _ Were the septic tank manholes holes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum ? X Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no X Existing information. Por ekainple, a plan at the Board of Health. X _ Determined in the.feld(if any of the failure criteria 1. related to Pant C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 1 `S Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 116 REDBERRY LANE MARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02 FLOW,CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Non n.iber of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms): 440 Number of current residents: 6 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage systern.(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO: Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):-m7'X �� I i0v0 Sump pump(yes or no): NO r, ,�t li� (� Last date of occupancy: n/a V "I COMMERCIALANDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203):;Wagpd Basis of design flow(seats/persons/sgft,etc.).: n/a 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: n/a Last date of occupancy/use: n/a OTHER(describe): n/a t. GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons==How was quantity pumped determined?n/a . Reason for pumping: n/a TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _Single cesspool Overflow cesspool Privy. _Shared sysfcm (yes or no)(if ycs,ltl�cll previous inspection records, if any) _Innovative/Alternative technology.Attach.a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank Attach a copy of the'UGP.approval Other(describe): n/a Approximate age of all components, date installed(if known)and source of information: 1992 BY OWNER Were sewage odors detected when arr.ivinl;at(he site(yes or no): NO r, Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 116 REDBERRY LANE MARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints, venting, evidence of leakage, etc.): TOWN WATER SEPTIC TANK: X (locate on site plan) Depth below grade: 12" Material of construction: Xconcrete._metal_fiberglass_polyethylene other(explain)n/a if tank is metal list age: n/a 1 fs age confirmedbty a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H s 7" WX 10'l'!, Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 2" Distance from top of SCUM to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 16" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage;etc:): SEPTIC TANK AND ALL.COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan). Depth below grade: n/a Material of construction:_concrete_metal fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top ofoutlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a 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 ^` t Page 8 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 'SYSTEM INFORMATION(continued) Property Address: 116 REDBERRY LANE MARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A. Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches, etc.): n/a DISTRIBUTION BOX: X(if present anust be,opened)(locate on site plan) Depth of liquid level above outlet invert:LEVEL WITH BOTTOM OF PIPE 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.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO. Alarms in working order(yes or no).:N,O Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a 1 U Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 REDBERRY LANE MARSTONS MILLS,MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: ' n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: nla n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a , :innovative/alternative system 4 Type/name of technology: nla It Comments(note condition of soil,f§igns of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LIQUID LEVEL IN LEACH PIT IS FULL OVER PIPES.SAS NEEDS TO BE UPGRADED. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a.`;`': '. Depth—top of liquid to inlet invert:_n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a I n Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 REDBERRY LANE MARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection:. 9/27/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. ray I I� AAZO BA 211 jo i A-8 2.S )36 63 AC zil K of A'0 6D H� 0,C in Page I l of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 116 RED"BERRY LANE MARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02 N SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained fi"om system design plans on record - If checked, date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS datgbase;explain: n/a You must describe how you'established the high ground water elevation: HAND AUGER- 12+ FT. i FEE ._ /'� THE COMMONWEALTH OF MASSACHUSETTS !!� Ate MEI, BOARD OF HEALTH moors .w ...OF.... /Z'`✓s...T -13.1 ' _ = 1 i��u�ttl �rrk� C�.a���rttr�itt�t rrmi� Application is hereby made for a Permit to Construct ( V1_'0r.Repair ( ) an Individual Sewage Disposal System at: Loc tion-Address or Lot .....................4 _ ....4-_. -..L -2..�`�`�4: ''L -n! Owner Addres W Installer Address Type of Building Size Lot... ....,;,t...............Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder'�"j-' Other—T e a Other—Type of Building _lr%__�________Gt._!"'�.... No, of persons____ ___________________ Showers'l`'-j'-= Cafeter'� Otherfixtures ------- ------------------------•-----------••--------___-•---••--------------------------•----------_........._...•--......_•••---- Design Flow........................ ...gallons per person per day. Total daily flow_.._._______��_�_.©___........_.gallons.�� 0oa i_�a" Septic Tank—Liquid capacity_ ._..-____gallons Length____ _____ ___ Width__ ______ __._ Diameter................ Depth_..A_.__..� x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. ___._ iameter_____._9!...... De th below inlet_.3.e..47..... Total leaching area.Z.4_.__ � Seepage Pit No......_._-I. ._ � p . g �.sq. ft. Z Other Distribution box ( V Dosing tame-� _ aPercolation Test Results Performed by.___�:__1�.9... 1 �... h'or__, .__FLF ate___._.1__o�-.t�''__�_8_�. Test Pit No. 1__�_Z_.minutes per inch, Depth of Vest Pit----�._�.7r.Q___. Depth to ground water..__!. ____'" 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.._ __ ,__ . RS ..-----------------•-�---•- :........ U .s�'_ ..y.r s -WeDDescription of Soil............. ..... --- -_---------------•---------------------------. ............. -•------------------ -----•••-----•••• ----•----......._.._......_.__ ...•------••---- __ g W VNature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------------•---------------••-•---•---------------------------------------....--=-------------•-------------------------------------...------•-----._.--------•--•••-••••-•---••......_...---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITIS . 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the b and of health. Signed. = ! _...._...et..................................... /at;e Application Approved By.............. . .--------•-••---•••---•-•-•-- Date Application Disapproved for the following reasons:----•---------•------------•--•--•-•---------------------------•--------._....--------•-•••••--......--•._ ... Z P ®y Date l PermitNo.......... •-a •-••--7 .................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................ .. .OF..1 /2..`.......................................................... C� Tatifutt#r of T amplittttrr TL(IS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) t f 1 11 3 f�.--, r^ 11 by...................•- -- �: ... -------•-•••---•_.... ---.................._._._._..... --.................. ._.__.............--------- Instal er at.......................................... ........................................... -= - - ..� .: ,- ........... ... .........._...._._ .has been installed in accordance with the provisions of TIT o e5State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated.............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON GUARANTEE THAT THE SYSTEM WILL FUNCTION TISF CTORY. DATE.. ....... .¢. --...... Inspector.......... ._. _.. --_...---........................ THE COMMONWEALTH OF MASSACHUSETTS .' BOARD OF. HEALTH 7S7— No......................... Fzz................ ' Roposal Works f austrttr#iutt f rrttti# ° Permission is ereby .granted.......! ... ...-----•............................. to Constru ( or Repair ( ) j_dual Sewage.Dis sal System at No..................................... ------------==4 �` % z,-� ''' = •-• _ k} Street c/ S as shown on the ap 1ica Ion for Disposal.Works Constructio / e t No.................. . ed.a.. c Board of H alth ' DATE.... .......................... FORM 1255 A. SULKIN. INC., BOSTON RECEIVED OCT 15 2002 COMMONWEALTH OF MASSACHUSETTS TOWN OF BARNSTABLE EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAII S HEALTH DEPT. DEPARTMENT OF ENVIRONMENTAL PROTECTION Vff z , e FAILED INSPECTION Q�M SyOv %Z:7 U, ti TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE. SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 116 REDBERRY LANE MARSTONS MILLS, MA 02648 Owner's Name:. TINA DELUCA, , ,.• ��l <<b Owner's Address: 116 REDBERRY LANE MARSTONS MILLS, MA 02648 Date of Inspection: 9/27/02 Mimic of hisltcclor: (I►lemse.In ini),�; .N/1IN (OZAC'I Company Name: SEPTIC INSIIECI'IONSjnI ► Mailing Address: P:O. BOX-2119 TEATICKET, MA. 02536 COP? Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT 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: t 4 _ Passes _ Conditionally ses _ Needs Furth valuation by the Local Approving Authority X Fails Inspectors Signature: !1 Date: 9/27/02 The system inspector shall submit' copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspe'c►on. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner'sbiall submit the report to the appropriate regional ollice ofthe DEP. The original should be sent to the system owner and copies sent to•the:buyer, if applicable,and the approving authority. I " . Notes and Comments SYSTEM FAILED TITLE V INSPECTION. LIQUID LEVEL IN LEACH PIT IS OVER PIPES. SAS NEEDS TO BE UPGRADED. ""'1'llis report only describes con,ditiolis at the time of inspection and under the conditions of use al Ihsil lilur. 'I'llk inspection does not address how tile.system will perform in the future under the same or different conditions of use. Title 5 Inulortion I7nr111 61150'onn 1 Page 2 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 116 REDBER'RY LAN MARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02 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: SYSTEM FAILED TITLE V INSPECTION. LIQUID LEVEL IN LEACH PIT' IS OVER PIPES. SAS NEEDS TO BE UPGRADED. 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 rep Iacemen ,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. n/a The septic tank is metal and bver 20 yeacs`o1Id* 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 year0olt1`is available. ND explain: n/a n/a Observation of sewage backup or break oiit'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 obstructio'n is removed distribution.box is leveled or replaced ND explain: n/a n/a The system required ptnnping-more thanA times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the 136rd of Health): _broken pipe(s)are replaced ,._obstruction is removed ND explain: n/a I Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 116 REDBERIZY LANEiMARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02 C. Further Evaluation is Required'by the'Board of Health: Conditions exist which require furthei"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' ithin 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh j 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 I of a public water supply. _ The system has a septic tank'and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to de`terniine distance n/a **This system passes if the well`water;analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds�i"ndicates tl'at the well is free from pollution fi-om that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must b'e'attached to this:.form. t ! : 3. Other: n/a �W r 1 `j �1 I Pace 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACKSEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 116 REDI3ERRY LANE MARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02f; D. System Failure Criteria applicable.to all systems: You must indicate"yes"or"no'.'°to each of the following for alLinspections: Yes No X _ Backup of sewage into facility'or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of.eftluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspoo'i or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool o'rjpri,vy is",within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water,quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,`for coliforin bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppni;provided that`no other failure criteria are triggered. A copy of the analysis must be attached to this'forin X _ (Yes/No)The system,fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system°fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure.' E. Large Systems: � To be considered a large systeni�the'systean,must serve a facility with a design now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"too to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet"ql'a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—I WPA)or a mapped Zone 11 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 "ves" in Section D above the.larl,e'systcin has Failed. The owner or operator of any large system considered a significant threat under Section E or failed Lind r Section U shall upgrade the system in accordance with 310 CMR 15.304. '1 he system owner should contact the appropriate regional office of the Department. ` a L , Page 5 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM a. PART B CHECKLIST Property Address: 116 REDBERRY LANE MARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Pr t J Yes No X _ Pumping information was provided by the owner, occupant, or Board of Health ".'. . X Were any of the system components pumped out in the previous two weeks X _ Has the system received nornial flows in the previous two week period ';' X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back LIP? X Was the site inspected-for signs of break out:' X _ Were all system components,excluding the SAS, located on site X _ Were the septic tank niarlholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum '? X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance ol'subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no X _ Existing information. For exairiile, a plan at the Board of Health. X _ 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(3)(bfl 1 • ` i f iL Pa-e6ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 116 REDBERRY LANE MARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02 FLO'N,CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN Flow based on 310 CMR 15.203 (for,example: 110 gpd x#of bedrooms): 440 Number of current residents: 6 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system (yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):-fir �� C�tooC) Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type ofestablishment: n/a Design flow(based on 310 CMR 15.203):,n/agpd Basis of design Flow(seat s/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title S system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a K GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the,inspection(yes or no): NO If yes, volume pumped: n/agallons How was.quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank, distribution box, s6il"absorption system _Single cesspool Overllow cesspool Pi ivy _Shared system(yes or no)(if ycs, itl;icld pt evious inspection records, if ally) _ Innovative/Alternative technology.,A,ttach a copy of the current operation and maintenance contract(to be obtained li system owner) _'fight tank Attach a copy Of tile'DEP approval Other(describe): n/a Approximate age of all components,'date ietstalled (if known)and source of information: 11102 BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO A Page 7 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 116 REDBERRV LANE,MARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02 BUILDING SEWER(locate on site plan)_ Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance fi-om private water supply well or suction line: n/a Comments(on condition of joints, venting, evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete,_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a 't°sage confirmed bt, a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" Ha5,.;7" W1.41'10't Sludge depth: 2" Distance fi-om top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 2" Distance from top of scum to top o� outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 16" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan), Depth below grade: n/a Material of construction:_concrete_metal_�iberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottoni of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inle,t,and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage_etc.)f h n/a It . F 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ''SYSTEM INFORMATION(continued) Property Address: 116 REDBERRY LANE MARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02 TIGHT or HOLDING TANK: (tank Hoist be pumped at time of inspection)(locate on site plan) Depth below grade: n/a }`( Material of construction: _concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a ; Capacity: n/a gallons I ; Design Flow: n/a gallons/day Alarm present(yes or no): N/A. Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alanni and float switches, etc.): n/a e , DISTRIBUTION BOX: X(ii'presen('must b'elopened)(locate on site plan) Depth of liquid level above outlet invert. LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and.dis,trib^ation'to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): . D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate oil site plan)' Pumps in working order(yes or no): NO Alarms in working order(yes or no).:N,O t Comments(note condition of pump chamber,;condition of pumps and appurtenances, etc.): n/a I 1 a • u Page 9 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 REDBERRY LANE MARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02 SOIL ABSORPTION SYSTEM�(SAS): X (locate on site plan,excavation not required) If'SAS not located explain why: Wit Type 1000 GAL 6' X 6' leaching pits, number: 1 11/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a 11/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a s innovative/alternative system t Type/name of technology: n/a . E l; Continents(note condition of soil,fsigns of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LIQUID LEVEL IN LEACH PIT IS FULL OVER PIPES. SAS NEEDS TO BE UPGRADED. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: li/a'i Depth—top of liquid to inlet invert:,n/a . Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no):NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a ° Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of Hydraulic failure, level of ponding,condition of vegetation, etc.): n/a L C' � i f Page 10 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 REDBERRY LANE MARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposEd system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. B AAzo Bn29 ° A-025 136 -:5 M) 14Vb 6D q(� Ifl Page I I of I I 1 d OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 REIJBERRY LANE MARSTONS MILLS, MA 02648 Owner: TINA DELUCA Date of Inspection: 9/27/02 4 SITE EXAM i. _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained fi-om system design plans on record- If checked, date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database,-explain: n/a 1 You must describe how you`established file high ground water elevation: HAND AUGER- 12+ FT. } 7 l(j TOWN OF BARNSTABLE LOCATION � I /6 /W41--ce0 ' A* SEWAGE # -1� VILLAGE M. iw.<<S ASSESSOR'S MAP & LOTO INSTALLER'S NAME & PHONE NO. KC Ooojsg— SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL R PUBLIC WATER BUILDER OR OWNER L< DATE PERMIT ISSUED: — , b ho/3(5 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r � . � 6: 1��'C� � .�f 1 �� �� y,� ��i . � �� '. A ;::: ` -� �'''— J` .. .... g, TH / E COMMONWEALTH OF MASSACHUSETTS A+OVEo BOARD OF HEALTH L 1 Wpolial Murky Tomitrurtion ramit Application is hereby made for a Permit to Construct ( Vj'or.Repair ( ) an Individual Sewage Disposal System at: y L. o T / TDB -r/Z/Z Y G .... --....__.................................................•--.--•-•---.-•.. ................ Loc tion-Address or Lot • �T d L� c�-_ . ..........................................�..5" . %Zf vLPhi Owner Addres W .............. ...---... „Installer Address Type of Building Size Lot... ._..,�_________------ Sq. feet Dwelling—No. of Bedrooms............ ................................Expansion Attic Garbage Grinder'1`—j'� Other—T e of Building A No. of persons...."o..................... Showers — Cafeter' Q' Other fixtures ...................................................... W Design Flow........................% ......gallons per person per da . Total daily flow............ .......-.....gallons.�� IxSeptic Tank—Liquid capacity.0a0gallons Lengthf_...G.'-r t'._ Width. !4 0."Diameter________________ Depth..• __"...47 x Disposal Trench—No. -------------------- Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..........I------_-eiameter......1.2........ Depth below inlet_.3.e.•7..... Total leaching area..Z:4s.sq. ft. Z Other Distribution box ( ► Dosing tawet'-� _ Percolation Test Results Performed by..... -Y....q t_.Vest .�... h'� •_. ate...... . _ 7. a Test Pit No. 1__4t..73-_.minutes per inch Depth of Vest Pit....1..5.Q.... Depth to ground water.._.., ©_...'� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..- .. .._ x �'tO� s 0 Description of Soil...........Z,r. �_S�_........ Q Q.j/!�5 e °� --••--•-----------------------------•-•---••---•-•--------•--- -•--•............... •......._..-____..............._--•--- 4 1.. W ••--••----•------------------•----••--•--••-•••••-•-----------•-•-•-•••-•-••••-• ••-•-•-••••--•••-----..........---............................................ ..................................... UNature of Repairs or Alterations—Answer when applicable............................................................................................... ----••-•------••------------•--••---•------•-------••---•--•-•---•-••-•-----•----•-•------=-----------------------------------------•--•------------•-------.......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of AITLi: 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the bard of health. Signed. --------• /, ate Application Approved By-•-•-••••_. _.. ...... .............................. -•--------- Date Application Disapproved for the following reasons_______________________________________________________________________________________________________________Date PermitNo...........F !ta7s�--------•------------ Issued....................................................... l Date FEE THE COMMONWEALTH OF MASSACHUSETTS vBl-O,VA R DP O F HEALTH ............. .. \....... ..... .........................../.................................. for Disposal Works Tonstrurtion Wrinit Application is hereby made for a Permit to Construct �r Repair an Individual Sewage Disposal System at: 7— __S Location- dress -N-- ............................ Owner Address ................................................................................................... ................................................................................................... Installer Address Type of Building Size feet U, 13 --r- 0­4 Dwelline—No. of Bedrooms......... --------1*...................Expansion Attic t Garbage Grinder �4 P'4 C 11 —J-- Cafeteria P4 Other—Type of Building ............ No. of persons.... Showers <P4 Other fixtures ................................................................................................... ......................... Design Flow.........................��.;.........gallons per person per day. Total daily flow............. ............................gallons. Septic Tank.-7-Liquid capacity............gallons Length................ Width..._...-..__...... . 9 Diameter.............._. Depth.. Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...................sq. Seepage Pit No._......... _........ Diameter......'.?:_....... Depth below inlet..-'a:..:::...... Total leaching area...2 14 ...............sq. ft. Other Distribution box Dosing"I tank-(--3— Percolation Test Results Performed by........................ ................__-.7......�fDate......... ....... 0 ............ _1 Test Pit No. I...4�%...L.minutes per inch Depth of 'Test Pit....1.-5 Depth to ground water............. ..... ..... . Test Pit No. 2................minutes per inch Depth of Test Pit............._.._... Depth to ground water........................ P4 ................................................................................... ....... 0 Description of Soil............. d I U/-�-) , _:y'? C <:) CA V',-:,- I? %�( _-) ................. ................................................................................................................................. q '�"' ��A '/ e I ----------*--**---------------------- ------------------------f---i....................................................................................................................... ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of'JI TIS 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beeR issued by the board of health. Signed../y...N. .................... ....................... Date to e6 Application Approved By.............. Da t e Application Disapproved for the following reasons:........................................................................................................... ..................................................................................................................................................................................................... 7'� '�_2's Date PermitNo...................................................--- issued.................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................................ ..................................................................................... (Irrtifirate of Toutpliaurr T4IS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( <or Repaired by------- ........... .......................................................................................................................... Installer. at._..._.. I ...................................... -----I?................................. ........................................................................ I - has been installed in accordance with the provisions of TIT120'g5 9f;T)ler;',,State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated...............r­.............................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON GUARANTEE THAT THE SYSTEM WILL FUNCTIONTI.SFAkCTORY. Inspector............ .. ....... . ... ....... ................................... DATE.................................... ... ............ 7 GUARANTEE___ _7 -.514-J4 ..... ... . .... ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................OF........:77:......................................................................... ' S No......................... Fzz....................... Disposal Works Tonstrudiatt Permit ' - —' Permission is hereby granted.. .......................Q 'kv- _f ­"- C­ � . " ........................................... ..................................................... to Construct ( �or Repair an-Individual Sewage Disposal System_ atNo.......4=... --3 — / _.,2__ e—:- ',�-L-- k�f_ / c �/ -, ,-/ ..........:!�w.......................................I............................................. ................:........................................ Street as shown on the appli cation for Disposal Works Constructio er it No....................Pted.q............. V­/ ...... ... . ................ .......... ..................... Board of H alth Jr DATE........_.... . .......................................... FORM 1255 A. WSULKIN, INC., BOSTON L BENCH MARK : TEST HOLE RESULTS DATE : ,�Q/Ql�t WITNESSED BY J �Fizfz>1 I C7 }fG, i2. r4<?tz -I- 7— J _ TEST HOLE " �'o,a TEST HOLE sUa,�So� . w•/ nz A c s 2 .4 o r= C Lf .L .4�. 0#=7 2 'w ? •`� � o� C lay to D 2 7 vim- I l © �/Z /✓a UWATERGROUND WATER Ap ,�, GRO ND Parma r \ ENCOUNTERED ENCOUNTERED f� y �t r �' (-\�"`\ Q + !f'a� � DWEL�'c � \ `� � � — MANHOLES AND COVER TO BE BUILT TO ELEV. TOP OF WITHIN 12�� OF FINISHED GRADE \ c3oX v 2e. tf �i alp FOUNDATION o FIN ISHED GRADE 3 �. MIN. 2 /o. SLOPE 4" DIA. r, 4'tDIA. PIPE FIRS 12MIf;. „ PIPE „'�i„v. w N FT. `' :� _' MIN . 2 LAYER OF _�.,,�,,,,,• MIN. PITCH 2 LEVE _ i = „ �^- CnrQ �BrQ.� MIN. PITCH, im'.v� NN ? "C 3 �. ' I% Y��2 EASTONE P /N. I 4%F T. oOO ry INV R ' swap INVE ' d ,•� I INVERT +. GALLON ,VZ G - +7i.� SEPTIC TANK ", ..� DIST, �r-,p<y ;,' w ,• Q $ per �/4- Ii� DiA. _ _ } FOOTING TO BE , P�LACE"D ;Y INVERT - =- ' = — INVERT BOX �' p3�J � © ' • WASHED STONE ON •A_Al I N I M UM OF 18",0F 0 r INVERT � � �p � p � ALL AROU'ND — FL A C E ON VIRGIN 0R COMPACTED �% - .) FIRM BASE �-- •�{` -- �—,J,3 ; �' aJa.: /.Z N == 0 MIN•) BOTTOM AT ELEV, `� SAND .- T"' �" _ O GARBAGE ( 2 0' MI N.) 3 3 ELEV.�� GRIN DER PR O F I L E OF GROUND WATER TABLE S %J� SANITARY DISPOSAL SYSTEM ( NOT TO SCALE ) D E S I G N D ATA • CONSTRUCTION OF SANITARY DISPOSAL `* BEDROOMS SYSTEM SHALL CONFORM TO THE MASS. DESIGN FLOW 33o GAL./DAY ENVIRONMENTAL CODE TITLE Z LEACH RATE :5, 2- MIN./INCH • (REVISED 7- I-77 ) AND THE TOWN HEALTH DEPARTMENT REGULATIONS REQUIRED LEACHING CAPACITY : ,I27qff- (To vV.v • SEPTIC TANK, DISTRIBUTION BOX AND LEACH - PROPOSED �3 GAL/DAY ING UNIT TO BE OF REINFORCED CONCRETE : 2,S' 3.,.5' 77-1T-) �- `� MIN. CONCRETE STRENGTH = 3000PS.1. REQUIRED SEPTIC TANK /000 GAL. MIN. STEEL STRENGTH = 20,000 PS. I. / MIN. DESIGN LOADING : H#10 PROPOSED SEPTIC TANK : /000GAL. • 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 PLAN ISITE SHOWING PROPOSED CONSTRUCTION ZONING DATA LEGEND LOCATION ���� .ST.L�.� L �" (/�' Arzs7--©A✓s �l• �. FOR : LEEEL— SOLLOWS DEV. CORP. DATE : ' ZONE : _ __ — _ /Z TEST HOLE LOCATION F : LOT / 6 AS SHOWN ON REVISIONS : _ o �,� REFERENCE REQUIRED AREA _ _ `� 3-� � G � `S EXISTING SPOT ELEVATION 17.6 0���_ c CR REQUIRED FRONTAGE _ /,5'O EXISTING CONTOUR — 16 PLAN 2/ ROS )N VV, W/1c..Gvx ;Z.L•� � . REQUIRED FRONT SETBACK : PROPOSED CONTOUR 16 . 27483 ii 1� i4T'�� 8�2e6/87 A o �� SCALE REQUIRED SIDE SETBACK : � PROPOSED WATER SERVICE ----W----- FSro� �E����� REQUIRED REAR SETBACK �" PROPOSED GAS SERVICE G PROPOSED ELEC. a TELE E ekT � / CRAIG R . SHORT , p. E . �Z-.DG7 PRO FESS10NAL CIVIL EN G I N E E R BU ( L D I NG INSPECTOR APPROVAL DATE 131 OLD ROUTE 132 HYANN IS , MA. 02601 FILE NO. 66000 ( TELE. (617 ) 562 - 9411 ) SHEET / OF W _ - : uesign - Laicuia�tions SITE PLAN c ,A ,. Number o- Bedrooms. 4. �:� � IT �. BENCH MARK c ZI�NER or CONCRETE /! U�arba e Grinder: '`•'`ES /TO BE REMOVED, GRINDER NOT ALLOWED t�>d`I_:r THIS DESIGN) Leaching Ca acity Required: 440 Gal.i Deaf R�;�; ul_ wEAD EI.E�r.-1 c�o.oe�` A�su¢aEr ; #s _.o: W E ...AN E ° 8 R Leaching Area Required:l: 40 l r � �;., ` 0. '�° � RR Proposed Leaching Structure: 1 -33.5'L X 13'��� X 2'D � each n Tr<,nch f G,aN ,"•F! { f 9aG @o E Lecchin Area Provided: 621 .5 Sa.Ft. }l {r 'a p°�• Proposed Leachin .. Capacity: -460 d .`f `�40 ' ; d. req'd �;` � v,t Ali concrete driveway r "l � _. f! CIOA� \ sLOCUS P G7 p{•. \ i Of is J 274 ,2+ NO SCALE - VV @ \l s f oG'a /°c f• °° G��f•Ofip�s %K �. \ / G AA^c TES #i /pcp F 10 /��6.61' X �,• tic,.:'r° x �16 LOT 16 AREA = 43,666 SQ.FT. X 99,70' SHED DECK �h 1-33.5'L X 13'W X 2.0' D r�`�' leaching trench using 1 3 H-10 500 gal. chambers with 4' of stone on sides & end s. x'ss<s�r �.✓ � X s5.ss' f i.75' y �. <,t...73' 3••7�' iAA9.P:�:C-. S F#R;iH':.F.i•: 'aboveground pool (to be removed) OV i ``•'"`�.,� �'"�-.,,� 4 ... ``�� ._...._.,.-'�Fy ` % 95.9�' � � •Se Y:� to PERK TEST SOIL EVALUATION �`` -� � � ) Bc �0;/ 13 Date of Perc. Test & Soil Eval.: October 9, 1987 `~ O(t,� STEEL ENioc€ PRECAST eiieR ;E Test Performed By. CRAIG SHORT, P.E. # PLAN VIEW PERK NO.: P6695 PERK RATE: LESS THAN 2 MPI RFD A:) I 5�4 9FRR `'�.•� X 95,88, �� 5, Test Hole :DEPTH SOILS ELEV. CONSTRUCTION NOTES i € 0 1. Contractor is responsible for Digsafe notification `''�� . �w� " ��........� ....... .......T........ 34„ j loom a sub and protectirn of allrndergrai�nd utilities and pipes. ~� /traces of dc V 2, The septic tank and distribution box shall be set �. 24" level on 6s, of 3/4 —` 1 f 2' Stone. ; . Bac;kfill should be rlcon 3onj or- gravel witri no ^� � � � 3 H-10 500 gal. chambers pocketr do) stories over 3" in size. x 96.8 END—SECTION to 48* '` `S `` `�`` wear side only GENERAL NOTE 4. This ystern is ubjec:t to inspection during €nstollaLlon by Glen E. Harrington, R.S. H-10 1500 GALLON CHAMBER S. Thy contractor shall install thir system; in accordance 1. ADDRESS: 1 16 REDBERRY LANE `` `` " P i�d3il1 Title V of the Massachusetts Environmental Cade 2 �,SS:ESSORS NL M13ER: 04709600a , �, `~ `� NOT TO SCALE mad.—as sun • .� r 'd ,• ac growl sand the Regulations of the Town of Brewster.star. ,,. C}E;1EIrCf�ER S LOT: LOT 6 �. •.. S 6. Provide a Aerne Precast 10, 5—hole D—Box end 4-. TOPOGRAPHIC INI=ORM�,TIi N WAS COMPLIED FORM AN � tv" .......... ......................... USE ACME PRECAST OR EQUAL _., i 3 H--10 00 al. chamber. or equal. ON THE GROUND INSTRUMENT SURVEY, Q € NO GROUNDWATER ENCOUNTERED ` the °� PROPOSED SEPTIC SYSTEM UPGRADE 7. No vehicle or heavy machinery shall drive over 5. TQWN WATER IS PROVIDED TO SITE �� Si.RI �? PSI:JII�lC PROPERTIES. �. � � �` l septic system unless noted as H-2(: septic carnpcnents. 6. REFERENCE. PLAN: L.C.C. NO. 42083A, PLAN NO. 4.2053A2 `� C,� �,�OFMq�s� 7'. NO, WETLANDS ARE LOCATED WITHIN `•GO FILET Oi•� AS. PREPARED FOR 8. Install gas baffle or equal on septic tank outlet tee end, 6, NO POTABLE WELLS ARE LOCATED WITHIN 150 FEET GE SAS. LEGEND o 9. A1I existing inverts and site conditions sholl be vcrif ee by contractor. ' E a TINA M. DELUCA 10. Existing leach ;pit to be purnped and backfNed. H RI ON 1. Existing garbage grinder to be rem loved by licensed plumber. /!l �''i Ixls-lr3 l E,���r { PIT 'TO BE', AT i f , PIrMPE, & BAMPILLED A O �`� 116 REDBERRY LANE GIS1 P� i ~....._...+ P r ...e sgN/T ARC EXISTING 10-0f? GAIL BARNSTABLE (MARSTONS MILLS), MA w 10' rnir., from--. *NOTE: ALL PIPES ARE TO BE 4" DIA. SCHEDULE 40 P.V.C. �� t�' I I-10 SEPTIC TA 4< l l n,;lss to sstic tank *NOTE: INSTALL GAS BAFFLE OR EQUAL ON SEPTIC TANK OUTLET TEE. l •c tank covt3r3 rr�:sit e DENOTES EXISTING PREPARED BY: ` with€n C,' srf t3 ;a ed gr de Finished grace everytemTMc sloe away X 104.46 F Existing House 5 HOLE SPOT GRADE i rtrv.�3oz.31' EXiS71. v €97. tiLsY. Existing Grade Elev.=97't GLEN E. H A R R I N GTO N R.S. 95 EXIS r'ir�G UN' 31 i; full �.` " 36'------------------------ min.. 9 L E D A ROSE LANE �.+. Level for V Min. 2"—t/8"-1/2" , DEEM TEST >oLE 1000 GAL. s=.ot washed atone TTo Peastone Elev.=52.17 cellar TO: SEPTIC TANK i M A O MARSTONS MILLS, 648 H-10 = 67' PER-CO; -N TEST TEL: 508-428-3862 v C rn wl 01. g t u Y4•MIN. GASmix l f n FAX: 508-428-3862 OR EQUAL ind 33.5 ranch lev.= 9 .70' , o'i = A prox. Iocatic�n R. JR LEACH TRENCH s.r ,� water , ... .... . . ... .. ...... I x I Ilo ' " c}F 3f4"-1112" S t}v F c a• a II sting ----------------- € r` yBottonn of T.H. #1 elev.=87.0' F. :-prox. location SCALE: 1 "=20' DRAWN BY: GEH APRIL 8, 2003 SYSTEM PROFILE °' ...........""' :; e• sFf4•..tt/ sTor: ox :�t`r gasservice FILE: DELUCA SHEET 1 OF 1 _ Not to sc.,Ae C DATUM: ASSUMED �_. • : x F _ 12- 5 r { r i () } _ . ...:_._ ..- ._. ... _ �.y..te.��.•� a,...' g. , g 1 f4 S it � 1 j I , , 4 ........ i � .. .... ..... ,rv., .._.. .: , .,.-ate. r .. �e-�. w. -�%..m^:•�....::-«v.:r�a s . ... II J _ _ Ua - rN_ T_ _..,_..:_.. - . .. -- TW T j APPROVED BY: DRAWN BY SCALE: L f,�t�sr� u' �- REVISED . ., DRAWING NUMBER . II , .._-.... „. --- - - r ' t _ . --- ---- �_ - t - N i f • `-__. _ ...... ............ _. i t i 1 f .......... y