HomeMy WebLinkAbout0359 ROUTE 149 - Health 359 ROUTE 149
MARSTONS MILLS
A = 079 036
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TOWN OF BARNSTABLE
SEWAGE #
-'dIL .kGl~ ASSESSOR'S MAP &LOT 0
INSTL LER'S NAME&PHONE NO. Z pl ,)-, 9i9rv"OS
SEPTIC TANK CAPACITY /000 //
LEACHING FACILITY: (type) 00 ��� ;9pq W451S (size)
i
NO.OF BEDROOMS
BUILDER OR OWNER_13Fiyl 6L,1 C110
PERMITDATE: °� S- Ul COMPLIANCE DATE:.
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility
Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachi g facility) Feet
Furnished by
t
��
No. Fee - —
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for ligpogar *pgtem Congtruction Permit
Application for a Permit to Construct( l�air( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.-1 9 1e t I if Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel �/�Pv'`/S Bee ,(jvr /a
r%Yly e . lyls l�S
Installer's Name,Address,and Tel.No. Lf%17- a f{`el Designer's Name,Address and Tel.No.
JAslc,0111 Dr- /31VA11e&5 clan cps /'a-f w-v-as
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Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soff
Nature of Repairs or Alterations(Answer w en applicable) TI-7S11411 2 —,S-aa _6�1
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Healt .
Signed ate
Application Approved by Date
Application Disapproved or the following reasons
&_
Permit No. Date Issued
- i --- TOWN OF$tARNSTABLE
SEWAGE # l' 4/3
LOCATION -
-� ASSESSOR'S MAP &LOT 0 2
VILLAGE
INSTALLER'S NAME&PHONE N0. L7
lr�D
SEPTIC TANK CAPACITY 5,X /
J CDD �Kt� ^�/ ;c/,='� (size)
LEACHING FACILITY: (type) ,
Mn nR RFnROOMS
i
BUILDER OF,OWNER
DATE:
COMPLIANCE DATE:
Separation Distance Between the:
Maximum Add usted Groundwater Table and Bottom of Leaching Facility
Feet
I an wells )dst .
Private Water Supply Well and.Leaching Facility. (If y Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility'(If any wetla
nds exist
Feet
within:300 feet of leaching''
ac/ihty)
Furnished by .
I
i
s
i
�^No. -w Fee /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
. Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
0(ppYication for ligooar *p5tem Construction Permit
i Application for a Permit to Construct( fair( )Upgrade( )Abandon( ) O Complete System O Individual Components
Location Address or Lot No. /1/Q Owner's Name,Addressand Tel.No.
Assessor's Map/Parcel !���`//� 9
011f 0
Installer's Name,Address,and Tel.No. g Designer's Name,Address and Tel.No.
�/as,!,oti CIz 1_?A001_v5 �10.5 zp4 z;,, /j po-r°os
8l �� �2 S��-c-
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
' Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title /
Size of Septic Tank Type of S.A.S.
Description of Soil e/
t U/;"
Nature of Repairs or Alterations(Answer w en applicable) �!- 11411 2 —�OD 610� l�s�c/ G11
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Healt .
Signed pate
Application Approved by r2m ate
Application Disapproved for the following reasons
j Permit No. gna/ u— ��j
Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( - " epaired ( )Upgraded( )
Abandoned( )by Q-e Y0 S
at 3S<1 �1' /'r Q `ylarSro`,S 11"Ar has been constructed in accordance
with the pro//vyie,4'sions of Title 5 and the for Disposal System Construction Permit No: Zoa�—04/3 dated Z /Z—O 1
Installer_./ r Li d-e- �F i^HGS Designer ✓OSC �lil�O,cs
The issuance of this permiV shall pot be construed as a guarantee that the syste °will fu�tio'S deny n
Date Z ! Z Inspector
1
No.------^�---------------®�� 0:500 ---Feeu0l 6 l�C� __
3
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
ligool *p6tem Conotruction Permit
Permission is hereby granted to Construct(_44-Repair( )Upgrade( )Abandon( )
System located at .3.5�9' ��'Jr /-/Z
f�.'yrST06J,S lit�Ji lls'
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construc ion must com leted within three years of the date of this 1 e
Date: ® Approved by
f
l/6i99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH .-�_,N-D .APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERI>Tr (W=OUT DESIGYED PLANSI
hereby c---uf' that the application for disposal worts
cons=ction permit signed by me dated —Ol concer dns the
property located at 1�3-y y� �, ���� meets all of the
following criteria:
d,,,�ne failed system is conner ed to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
soil is classined as CUSS I and the percolation rate is less than or equal co 5 minutes oer inch.
8/1-Iere are no wetlands within 100 feet of the proposed septic sysem
mere are no private wets within lJ0 fert of the oroposed septic srsem
(There is no increase in flow and/or change in use oroposed
There are no variances requested or needed,
i ne boaotn of the proposed leaching facliry will not be located less than dve Eee:above the
ma.'dmum adjusted—oundwaEcr table elevation. (Adjust the groundwater table using the Frimptor
me;hcd when applicable]
• If the S.A.S. will be located wick 250 feet of anv vegetated wetlands, the bartom of the proposed
leac:ung facility xill net be lccated !ess than Gurtetl(I fee;above the maximum adiused
Q*oundwater table e!evaaort
Please complete the Following:
A) Too of Ground Sur-tact F!e•iation(using CIS iruortnacion) L�
r
B) G.W. Elevation _the AA C. ;igh G.W. Adjuament
D T-FER.E`i CL B ETVEEN a.and d
SIG-ED :��/l ��i D T—c.
(Sketch proposed plan of system on back-J.
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000 (9 ,/ 4�
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TOWN OF BARNSTABLE
LOCATION �-5(7a ) �,( (` 1 SEWAG
,!40
VILLAGE ` ASSESSOR'S MAP &
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
pec
o A�
G
0
1 181
'b 3
q104
Y �
.� "ems S �000 /
COMMONWEALTH OF MASACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 359 RT. 149 MARSTONS MILLS, MA 02648 01 0A �� 3
Name of Owner KEN PAULEY
Address of Owner: 369 RT.149 MARSTONS MILLS,MA 02648
Date of Inspection: 6/10100
Name of Inspector: JOHN GRACI
I am a DEP approved system inspector pursuant to Secdon 15.340 of Tide 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636
Telephone Number: 608-664-6813 FAX 608-664-7270
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The Inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes
_ Conditionally Passes
_ Needs Further Evaluati the Local Approving Authority
Fails
Inspector's Signature: Date:6/10/00
The System Inspector shall sub it a 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 inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My
Inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS FOR PROPER MAINTENANCE.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 359 RT. 149 MARSTONS MILLS, MA 02648
Name of Owner KEN PAULEY
Date of Inspection: 6110100
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
X 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.
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.
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.
n/A 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
I1Ld 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 9/2198 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 359 RT. 149 MARSTONS MILLS, MA 02648
Owner
Name of O er KEN PAULEY
Date of Inspection: 6110100
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 16.303(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 Wit(approximation not valid).
3) OTHER
n/a
revised 9/2/98 Page 3 of 11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 359 RT. 149 MARSTONS MILLS, MA 02648
Name of Owner KEN PAULEY
Date of Inspection: 6/10/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
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 Il.
- 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 compounds,
ammonia nitrogen and nitrate nitrogen.
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 9/2198 Page 4 of 11
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 359 RT. 149 MARSTONS MILLS, MA 02648
Name of Owner: KEN PAULEY
Date of Inspection: 6110/00
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)j
X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems.
i
revised 9/2198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 359 RT. 149 MARSTONS MILLS, MA 02648
Name of Owner KEN PAULEY
Date of Inspection: 5/10/00
FLOW CONDITIONS
RESIDENTIAL
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):
Total DESIGN flow: 330 gpd
Number of current residents:1
Garbage grinder(yes or no):NO
Laundry(separate 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 two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: n/a
COM M ERG IAL/INDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow: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:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of Inspection:(yes or no):NO
If yes,volume pumped n/a gallons
Reason for pumping:n/a
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/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
THE SYSTEM IS 7 YEARS OLD.
Sewage odors detected wheni arriVing at the site:(yo gr ng) N9
revised 9/2198 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 369 RT. 149 MARSTONS MILLS, MA 02648
Name of Owner KEN PAULEY
Date of Inspection: 6/10/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 18"
Material of construction: _ cast iron X 40 Pvc _ other(explain)
Distance from private water supply well or suction line: n/a
Diameter: 4"
Comments: (condition of joints,venting,evidence of leakage,etc.)
THE SYSTEM HAS TOWN WATER.
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 12"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 1000G L 8'6"H 5'7"W 4'10
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 33"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 24"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
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.)
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFULL 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 of outlet 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:
(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.)
n/a
revised 9/2/88 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 359 RT. 149 MARSTONS MILLS, MA 02648
Name of Owner KEN PAULEY
Date of Inspection: 5/10/00
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or 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 gallonstday
Alarm present: NO
Alarm level:WA Alarm in working order:NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
n/a
PUMP CHAMBER: _
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
revised 9/2198 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 359 RT. 149 MARSTONS MILLS, MA 02648
Name of Owner KEN PAULEY
Date of Inspection: 6/10100
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:
n/a
Type:
leaching pits,number:(1)1000 GAL 6 X 6
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (nla)n/a
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (n/a)n/a
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.THE PIT WAS EMPTY AT THE TIME OF
THE INSPECTION.
CESSPOOLS: _
(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: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nla
PRIVY:
t(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
revised 9/2/98 Page 9 of 11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 359 RT. 149 MARSTONS MILLS, MA 02648
Name of Owner KEN PAULEY
Date of Inspection: 5/10/00
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)
AA 6s
O
PA
�� 7
3S
revised 9/2198 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 359 RT. 149 MARSTONS MILLS, MA 02648
P Y
Name of Owner KEN PAULEY
Date of Inspection: 6/10100
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n/a
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-12+FEET
revised 9/2198 Page 11 of 11
i
. ,.. o7l? - 036
C�
No.--7 3_.-:3.1..Gj
F>�$.........1 ....
THE COMMONWEALTH OF MASSACHUSETTS
9 $� BOAR® OF HEALTH
Appliration for Disposal Works Toniiuur#iun Urrmit
Application is hereby made for a Permit to Construct (K ) or Repair ( ) an Individual Sewage Disposal
System at:
Y fl� Q
/ I. tion-Address or Lot No.
6/o P ........................ �C 15n!!n ........... ...........------.
W Owner Address
a •--•.......................•.....•-•---•-•---------••--...........-•----...-------••-•--•-----•--• -----•....------------------•.........----.....--••-........-----•••--....-----•--...----------•--
Installer Address
U Type of Building 3 Size Lot__40e _PA. ..Sq. feet
Dwelling..—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
`•4 e� Other—T yp of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
� Other fixtures
W Design Flow..................................gallons per person per day. Total daily flow............!t�U.9?.................gallons.
WSeptic Tank—Liquid capacitye`*'?!?®gallons Length Y Widths� ?"_ Diameter................ Depth.`?_.'."
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.__.................sq. ft.
Seepage Pit No.......®----------- Diameterz'�'.`'�_ Depth below inlet.F............... Total leaching area.Z<......sq. ft.
Z Other Distribution box (K Dosing tank
aPercolation Test Results Performed .................... Date..s&.ter.._
Test Pit No. 1.....?........minutes per inch Depth of Test Depth to ground water.... '®- .--_-__.
Li, Test Pit No. 2..... ......minutes per inch Depth of Test Pit___Ar- B`._.. Depth to ground
,J.water.__�/'�---.____.
�i � ._...:�•.'2 f�..... dam.f ti.�.._. cJ�Dr46?p/....................*ta......... ...........l
0 Description of Soil.............. V.............................. ,r_c,�..--•--------------------------------24! ! �,1�.
V �'®es /fj/i�6� t!;l�Rse.. ��'" ----------•-......-----•..........................�••....••—••-••-
x .................................................................................................
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 iIT?:F� 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has is ed by the board of health.
Signed.... .....--•--_6 -- •-•••-•. --•-•-----•-•--•--••-••---------- ............ _...
Date
Application Approved By.......... . . 6--�--
Date
Application Disapproved for the following reasons:------•--------------------•-----------------------•----------------------------------------------------.....---
--- ----------•-----•---------....------....----•---------•----•------•-•----•-------------- --•-----•---------------•----•-------••-------•-•--------••---
Permit No........_� Date
... .........Q
Date
No....�. ..._...t... FI+s........L :J....: .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
35,
,r
Applirtatiun for Disposal Works Tontrurtiun Errant
Application is hereby made for a Permit to Construct (; ) or Repair ( ) an Individual Sewage Disposal
System at:
£! I f, — /. A-V � a y 4.
..................... ........... ...... ...................................... .........
__ ......_........../......................
Location-Address or Lot No.
Owner Address
W _ _
Installer Address
d Type of Building Size Lot'..... ..............:._Sq. feet
Dwelling No. of Bedrooms................`.`..........._....._..._...Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures -----------------------------------------••••.
W Design Flow......:..:...:_.--`s �_....•-......•-_-gallons per person per day. Total daily flow .....f.L'-...._.-------._..gallons.
WSeptic Tank—Liquid capacity.....'t.'.gallons Length:...` ...... Width.'_.'!:.::.. Diameter................ Depth.:............
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...... ............ Diameter!��!...r?.... Depth below inlet.................... Total leaching area....._.�.......sq. ft.
z Other Distribution box (< ) Dosing tank
'-' Percolation Test Results Performed by -._ ......... /
a Date = ==' ...............= =...
1 Test Pit No. I...............minutes per inch Depth of Test Pit.X_...._f�....... Depth to ground water-.-._.'.:--a.-.---- .
riI Test Pit No. 2.....K.......minutes per inch Depth of Test Pit../Ki' .. Depth to ground water---e�ll ..........
r r -1'x'r i< <.. . 1 3 ..�„!-----------------•----`=•--•-------C-2f...... /?a54f.�_Suhset f
.....................rt..........................- -
D Description of Soil ``..............................................' ` " ----=--�- .---
'�
x ---•----••_--•••_•......•_••-------... � - s �.
(� --•--•---•••--••--•...••---•-•----•••---....Q— �y.�rr--�>ii/.ii-_rld.. -----------_•••-•--••••..............•-•_ .........................•... ....... ......-
W /. .r +P 1+ z-t- C ti 4F Ar�
............._....._........-----........-•----------.._.----........._•---_-_-__................... .....-_...j...-__.i:..t: ---.._._..__-__.....----..............................................
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-------•-----------------------------------•--------------------------------•-•••---•----------•-••••--••••....•••••••---•--••••-••--•-•-_-•----•-••--•••••--•--_---••••-_••--•••-••-••---••-.......••--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has rn is ued by the board of health.
Cl Signed v =. �. '�f ` �- - -3--•--
Date
Application Approved By------... : :rt� ��-- -------------------•------------•-----• J.� Date --��
Date '--J
Application Disapproved for the following reasons:................................................................................................................
---------•--••-•••••--•••--•--•-•-------•--••--•--•-••-•-•-••-----•••••-•--•----•-•...-------•---•-•-------•-•---••---•••-----•-••----...----•••-••--_-_-----_-•---------•--_--••-••••••-_•-•..........
3 Date
PermitNo........ ........................................ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............O F.......�o�= d!?Z'�rYdi?�C i''S ...........................................
Tnrtifirate of TuntpliFanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-•••--••-------•---•••--•.....-•---•.....--••----•---....--••--•....................•--•------•••--•-••---•------•--•----•--------•------••-•-------••............--•••-----------.....----..._....
f1 Installer
atL: ... !` l .. . - ----------------------------------------------------------------------0----------
has been installed in accordance with the provisions of 1 p fta 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......... -1 � -1*1_......... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...................... -----........ Inspector------------ —
COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r
............ ..............OF.....G r. i' .>. t�,, z?�1!1 C.!.Z�-----•...................................
.
...................
Disposal Works Tontrnrtion rrutit
Permissionis hereby granted-------- ----------------------------------------•••---•••••••--••---••••--••••_••---•••_•-•••••••_•_•-••••-•--•••...0........--••-•---_--••-
to Construct (>,' ) or Repair ( ) an Individual Sewage Disposal System
. ..' ...9............... 1t '7-------------------------------------------------------------------------
at No. . Street �� •;_ ��
as shown on the application for Disposal Works Construction Permit No,1 -.._=�. _-_ Dated..........................................
............................. --- _.�l--
�i Board of Health
DATE.......... J-----------------------------------•----
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
TOWN OF BARNSTABLE
LOCA,nON tot � ' 7 SEWAGE # 93-37 _
VILLAGE fe r.Z0Af �/�/� ASSESSOR'S MAP & LOT AS
INSTALLER'S NAME & PHONE NO. J�240,
SEPTIC TANK CAPACITYlmz
LEACHING FACILITY:(type) / -t (size)
NO. OF BEDROOMS 3 PRIVATE WELL OR UBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: 6 / 3
VARIANCE GRANTED: Yes No
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2. ALL PIPES IN THE S Y,S TEEM MUST 8E CAST IRON
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A, r r�US T : No rxf=xEa
3. THE 8/Jtl�ir'lJ of-- HF. N L
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_ 4. ANY GHANG7S IN THIS PLAN MUST BE APPROVED
�, 1,11TNES SED 6Y:
APO of HEAL TH ANO CA G ISI�f�O�
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PRECAST CONCRETE . . MATERIALS L S AND INSTALLATION L L A TION SH L L
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..BARNS. F�F7!J. CAP H��AL TF .• r f ,r' l
Ca�+ L IA��CEI TH Trr fE STATE--YE SAKI rARY _ _ _ —
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OA TE' JAN.19,._1993
PULES AND PE �A TIO�^fS �� � Z
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s ���✓ s� �,�,f DA IL Y FL ON 330 G,�L .
2''� 000 GAL .
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