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Home My WebLink About0940 ROUTE 149 - Health r940 ROUTE 149 Marstons Mills - A = 102 - 046 _ Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 940 Cotuit Rd n VU.t 1q9 Property Address Elizabeth M Pinault Owner Owner's Name information is required for every Marston Mills Ma 02648 4/22/2019 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. Inspector Information on the computer, use only the tab Arthur Bloomquist www.TitleV[nspections.com key to move your Name of Inspector cursor-do not Arthur Bloomquist LLC use the return Company Name key. 96 Lake Street rQ Company Address Plympton Ma 02367 City/Town State Zip Code r 781-585-2666 S13924 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. x Passes 2. Conditionally Passes 3. Needs Further Evaluation by the Local Approving Authority 4. Fails 4/23/2019 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 t A , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t. 940 Cotuit Rd Property Address Elizabeth M Pinault Owner Owner's Name information is required for every Marston Mills Ma 02648 4/22/2019 page. Cityr own State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: x 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: This septic system is in good working condition. 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form (, ii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e � 940 Cotuit Rd V Property Address Elizabeth M Pinault _ Owner Owner's Name information is required for every Marston Mills Ma 02648 4/22/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 r Alk Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 940 Cotuit Rd Property Address Elizabeth M Pinault Owner Owner's Name information is required for every Marston Mills Ma 02648 4/22/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 pond�ng of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official!nspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �n c / 940 Cotuit Rd V _ Property Address Elizabeth M Pinault Owner Owner's Name information is required for every Marston Mills Ma 02648 4/22/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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, Y Y g, in addition to the questions in Section CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 i T � I Commonwealth of Massachusetts p Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 940 Cotuit Rd Property Address Elizabeth M Pinault Owner Owner's Name information is required for every Marston Mills Ma 02648 4/22/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section-CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 940 Cotuit Rd Property Address Elizabeth M Pinault Owner Owner's Name information is required for every Marston Mills Ma 02648 4/22/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: This is a new septic system that was installed on 7/17/12, but the plans, design calculations and the soil log are not available at the BOH. I did receive the asbuilt. Septic design calculations are not available. Number of current residents: 1 Does residence have a garbage grinder? ® Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d attached 9 ( Y 9 (gp ))� Detail-- Sump pump? ❑ Yes ® No Last date of occupancy: current Date l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 I f Commonwealth of Massachusetts ±� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 940 Cotuit Rd Property Address Elizabeth M Pinault Owner Owner's Name information is required for every Marston Mills Ma 02648 4/22/2019 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 940 Cotuit Rd Property Address Elizabeth M Pinault Owner Owner's Name information is required for every Marston Mills Ma 02648 4/22/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (Yes or no) (if yes, attach previous inspection records if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: The asbuilt is dated 7/17/12 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 100+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good functional condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 940 Cotuit Rd Property Address Elizabeth M Pinault Owner Owner's Name information is required for every Marston Mills Ma 02648 4/22/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) The tank should be pumped soon because of excessive solids and on a regular basis in the future. The septic tank does not have a filter. . If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 4x4x8 Sludge depth: 6 Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 8 Distance from top of scum to top of outlet tee or baffle 4 Distance from bottom of scum to bottom of outlet tee or baffle 6 How were dimensions determined? Estimated with a steel tape. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank is old, but in functional condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 940 Cotuit Rd Property Address Elizabeth M Pinault Owner Owner's Name information is required for every Marston Mills Ma 02648 4/22/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �n 940 Cotuit Rd Property Address Elizabeth M Pinault _ Owner Owner's Name information is required for every Marston Mills Ma 02648 4/22/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 inches_ 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.): The box is level and in good condition. ' 0 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 940 Cotuit Rd u Property Address Elizabeth M Pinault Owner Owner's Name information is required for every Marston Mills Ma 02648 4/22/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): There is no pump chamber on this septic system. * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: There are no signs of past problems in the tank,the d box or the pipe connecting these two components. Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® , leaching fields number, dimensions: unknown ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: - t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18. c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 940 Cotuit Rd Property Address Elizabeth M Pinault Owner Owner's Name information is required for every Marston Mills Ma 02648 4/22/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The grass is normal. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer — Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 JW Commonwealth of Massachusetts �w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 940 Cotuit Rd Property Address Elizabeth M Pinault Owner Owner's Name information is required for every Marston Mills Ma 02648 4/22/2019 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 940 Cotuit Rd v Property Address Elizabeth M Pinault Owner Owner's Name information is required for every Marston Mills Ma 02648 4/22/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t5insp.doc-rev.7/26/2018 Tiile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 i Commonwealth of Massachusetts �6: - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 940 Cotuit Rd Property Address Elizabeth M Pinault Owner Owner's Name information is required for every Marston Mills Ma 02648 4/22/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 6+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: I reviewed the file at the BOH. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: The cellar is dry. The plans are not available at the BOH. I called the installer and he does not have them. Possibly missfiled? Soil logs are not available at the BOH. Before filing this Inspection ection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 A -�( Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 940 Cotuit Rd L Property Address Elizabeth M Pinault Owner Owner's Name information is required for every Marston Mills _ Ma 02648 4/22/2019 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 am t AsBuil Page t of 1 TOWN OF BARNSTABLE VILLAGEASSES S MAP.&PARCtwt.' INSTALLERS NA:'�'lE&P i6iNi SEPT"IC T.ANII CAI'AC<I'ry _ . LEACf-9_l G FACILITY(n°pe) �(� '�aC;. (SiZe) No�OF BEDROOMS OWNER PERM it '1 F COMPLIANCE MkTF; sLp1t�4.€OEt I.� � � Gtt4$Gi'i the, - - -' Maximum�xin�um Miusid Groan l�v�t�t laktle tn't�c morn otLe�chir��Fa�it=E��;.� c9 �+� I'M t�rivase'�F rbr s FPI '01:1 d Le3ch;ne Fkil€t Of any yells exist b€. $..0 CK gt xi133'ssQ trt}(Ls� t� I1t4 t:t F, ge of�'" ar s ssi I es 3aan I ac€tity(If ais;c��ttands e�€wt within NO feet€f Je uhjng fhritit;) }eet FURtSI 5 � ICI x Y y 'l 7, cs x Ilt- +w. x �N C-O-MM WATER DEFT CUSTOMER STATEMENT ACCT NO 4,973 4/24i2019 PINAULT,ELIZABET14 M LOCATION: 940 ROUTE 149 MM LOT: L19 MAP&PARCEL: 102646 Consumption Histoiy DATE READ CONS 12/31/18 .228 144 06/30/18 .214 13 12./31/17 201 12 06/30/17 189 16 12/31(16 173 17' 06/30/16 156 19 12/31/15 137 15 06/30/15 .122 25 TOWN OF BARNSTABLE LOCATION c/�� /y`T SEWAGE VILLAGEJ`5 ASSESSOR'S MAP&PARCEL4;Z �C INSTALLER'S NAME&PHONE NO.�4,?"A 5 A ZLrr,s..I Tr q!ZQ-N 63y SEPTIC TANK CAPACITY FX/5+ LEACHING FACILITY.(type) Arg- :3x, (size) 1�/ 3?Sx 2 NO.OF BEDROOMS.2 Al OWNER PERMIT DATE: COMPLIANCE DATE: A-2-- Separation Distance etween 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' z A d sc�o to Town of Barnstable P', Department of Regulatory Services hAY �BTMLX : Public Health Division Date 2� MASS. A 200 Main Street,Hyannis MA 02601 Date / ' ! U Scheduled �- Time Fee Pd. � V Soil Suitability Assessment for Sewa a Disposal Performed By:_D G'GI `V DU6 H 130 W iZ Witnessed By: LOCATION& GENERAL INFORMATION Location Address /�� (� l/ e Owner's Name Re W ks y IMctV S opt 5 Address 2 leeU,�e l�� Assessor's Map/Parcel: L- Engineer's Name O(J�t�l!i/O NEW CONSTRUCT-ION /I REPAIR Telephone# S 0q- �[o f 0 � Land Use `"`� i J e 0 T Gl ( , Slopes(%) Surface Stones A D Distances from: Open Water Body I ft Possible Wet Area �d ft Drinking Water Well y + ft Drainage Way�C�o _ft Property Line l(D t ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) [4mK — I DRIVE ti Q1 zz� 0 0 J G O N, `rQ-2 E CD�S.43 `Parent material(geologic). ��`�� Gv��S Depth to Bedrock Vic V,( Depth to Groundwater. Standing Water in Hole: No yt e Weeping from Pit Face Estimated Seasonal High Groundwater V3 I ✓1 t DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: WWI ►tom Depth Observed standing in obs.hole: in. Depth to soil mottles: nog ® in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level s Adl•factor- Adj.Groundwater level , PERCOLATION TEST Date T1we!� A Observation Vk Hole# Time at 9" Depth of Perc 7 Time at 6" / Start Pre-soak Time @ Time(9"-6') in. 01 End Pre-soak j D" 07 ' I RateMinJlnch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) `v (Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. - Barnstable Conservation Division at least one (1) week prior to beginning. Q:\SEPTICIPERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# I Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling .(Structure,Stones,Boulders. onsistency,%Gravel) ®- t6 A Loamy 3l3 e-ne 11 ., `34-i3 Med dM to (L e ------------------ DEEP OBSERVATION HOLE LOG Hole# `Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.% vel - 12 Loam n CDY 3l �ohw t2-3C LOOM di lD 4/6 Y% C „, �0n4 lD Y F- !914 L-065 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. C sistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, onsi ten Grayeb � 1 Flood Insurance Rate Man: / - Above 500 year flood boundary No— Yes .V__ Within 500 year boundary No Z Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? t�e 5 -- If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consisten the requiretrainin ,expertise and experience described in 310 CMR 15.017. / �cH of Mgss�cy Date S�Z // I �° DAVID Signature o D. " COUGHANOWR 0 Q:WEPT1MERCF0RM.D0C E VAL13 f No. 0 c?, Z1i3 e Fee THE COMMONWEALTH�D- F MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppYication for Misposar 6pstrm Construction 3dermit Application for a Permit to Construct( ) Repair(J)/Upgr e( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. CG/U �f )!�� Owner's Name,Address,and Tel.No. i2cy'/I y Assessor's Map/Parcel �. �y� Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. uslGs it- �j�Z.tZ� IN C IeC� Type of Building: Dwelling No.of Bedrooms Lot Size /2/00 sq.ft. Garbage Grinder( ) Other Type of Building k 17 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 2;t-O gpd Design flow provided 3 sS;2. gpd Plan Date - I?-�. /2 Number of sheets 2 Revision Date Title Size of Septic Tank txi t f-,ter` Type of S.A.S. 41-r ?g G #C Description of Soil Nature of Repairs or Alterations(Answer when applicable) JP151-kd N e".-� 51 , S Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date 7 / --2— Application Approved by Date Application Disapproved b Date for the following reasons Permit No. 0012 -ZZ-3 Date Issued /3/�►2 .. ` r (5 No. O{Z �,�-�,J ��- 4 3 Fee ( �0 c THE COMMONWEALTKOF W ASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN'6 BARNSTABLE, MASSACHUSETTS Yes 2ppYication for Disposal *pstrm Construction i3ermit Application for a Permit to Construct( ) Repair(VY/Upgr e( ) Abandon( ) '❑Complete System ❑Individual Components Location Address or Lot No.f vo k- L!5 ►n Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 16,QL -6 y Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. ��1 .._A 13�dwa rNc Socb-'ico-v5cr 77-reA Type of Building: Dwelling No.of Bedrooms Lot Size /2/(Zr)sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 2 2 C� gpd Design flow provided '3 S'S , 2,, gpd Plan Date /., i�_ Number of shoets 2 Revision Date Title Size of Septic Tank f,,, ` ,n,C Type of S.A.S. Description of Soil „A ,,Nature of Repairs or Alterations(Answer when applicable)�„/S�� f/ ,�r,A, 4�� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date 7 Application Approved by e ---- Date Application Disapproved b Date for the following reasons Permit No. 7012 — 23 Date Issued 7 ---------------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by at 42 i/i,Jc has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.ZO Z - ZZ3 dated -7(1 3 kj Installer , 6.J,/� Designer �,9 #bedrooms ��,�,�� Approved design flow 2 2 n gpd The issuance of this permit shall not be c�nstrued as a guarantee that the system �c�i . Date af� // Inspector ------------------------------------------------------------------------------------------ -------------------------------------------- No. /(9 IZ — 7Z-3 Fee,$/Q U3 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) k System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. ,d Date Approved`[ �n i� PP Y - i Town ofBarnstable Regulatory Services • u►aKeresia • Thomas F. Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Tvne. (.7( 2,0 I Z Designer: ��iy+`�( C®w �r�ao.,�v� �S f� Instailer: �(v IA- Ay- Address: 4-3 1 i\i aNt4f Cff►' Address: On /'2 G S ��_ZXNTA'ewaS issued a permit to install a (d e) (inst er) septic system at qW Caiui f R-e{ k415AO5 W 1�5 based on a design drawn by (address) �W yid Co��ti q Mo Cvr I Z dated Nay Zq, '012. �- (designer) I certifythat the septic stem reference p y d above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic stem referenced above was instal � (' P y led with major cha..oees ;i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. SN OF Mgss�O DAVID 4gfistaller's—Signature) o D. COUGHAWWR No. 1093 S �G,ST0L SqN 1 P� (Designer's Signature) (Affix Desi p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DMSION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOUi SOIL TEST LOG "Ptr, * 13542 D E S M W CA L C UJ L/n1 T M N S DATE OF TEST: MAY 29. 2012 DESIGN FLOW: 2 BEDROOMS X 110 GPD = 220 GPD SOIL EVALUATOR: DAVID D. COUGHANOWR. LSE-461 WITNESSED BY: DONALD DESMARAIS. HEALTH DEPS. SEPTIC TANK: 220 GPD X 2 DAYS = 440 GALLONS USE EXISTING 1000 GALLON SEPTIC TANK IF IN NO GROUNDWATER DWA E IN RE ENCOUNTERED SOILS SOUND STRUCTURAL CONDITION. IF NOT. INSTALL TEST PIT 1 NEW 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DISTRIBUTION BOX: USE 3 OUTLET D-BOX. (FEET) IINCFES) H3MM TEXTURE (MUNSELL) KTIMM 91.90 SOIL ABSORBTION SYSTEM: 0-10 A LOAMY SAND 10 YR 3/3 NONE FRIABLE INSTALL 20 ADS ARC 36 BIODIFFUSERS 89 07 10-34 B LOAMY SAND 10 YR 4/6 NONE FRIABLE 20 UNITS x 5.0 ft / UNIT = 100 L.F. 134-1381 C I MEDIUM SAND 10 YR 5/4 1 NONE I LOOSE 100.0 L.F. x 4.80 S.F./L.F = 480.0 S.F. 80.40 480.0 S.F x .74 G.P.D. / S.F. = 355.2 GPD USE 20 ARC 36 BIODIFFUSERS AS CONFIGURED BELOW NO - Vt = 355.2 GPD ) 220 GPD REQUIRED TEST PIT 22 MIN/INCH INTC SOILS ER ENCOUNTERED REFER TO DEP APPROVAL LETTER TRANSMITTAL # W000052 FOR CERTIFICATION OF ADANCED ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DRAINAGE SYSTEMS BIODIFFUSER SYSTEMS. (FEET) DICFES) F 3EM TEXTURE (MUNSELL) MUrn-M 92.00 0-12 A LOAMY SAND 10 YR 3/3 NONE FRIABLE y 12 �'��'��'®� �O^-6 El SAND 10 YR 4/6 NONE FRIABLE NOT 139.00 USE SHOREY PRECAST H-10 RATED TO 35-138 C MEDIUM SAND 10 YR 5/4 NONE LOOSE j 3 INLET 5 OUTLET DISTRIBUTION BOX SCALE 80.50 WITH SPLASH BAFFLE OR EQUIVALENT. DISTRIBUTION BOX TO BE PLACED ON A STABLE COMPACTED BASE ONTO WHICH 6 in OF STONE HAVE BEEN PLACED TO 1000 (GALLON SEPTIC TANK REDUCE SETTLING. LINES EXITING D-BOX TM RUN LEVEL FOR 2 FEET DIMENSIONS AND DETAIL NO T TO BEFORE PITCHING DOWNUSE EXISTING UNIT SCALE TO LEACHING FACILITY.INSTALL RISER TO WITHI O6 In OF FINAL GRADE SEPTIC TANK IS TO BE PUMPED DRY 6 to MINIMUM SUMPAT TIME OF INSTALLATION AND IS TO ►2 rn MINIMUM 6oa BE EXAMINED FOR STRUCTURAL INTERIOR DIMENSION INTEGRITY. INSTALL NEW PVC OUTLET TEE EQUIPPED WITH A GAS BAFFLE. I In LEACHING GA L L ER Y TAPER CONSTRUCTION DETAIL USE ADS ARC 36 BIODIFFUSERS II C GRAVEL FREE INSTALLATION - USE DEP C APPROVED INSTALLATION PROCEDURES. 0 � 0 ++ INSPECTION PORT 20.0 ft L0 INSTALL O TWO AND SHOW ON w �0 AS BUIL T 8 ft-6 !(IL CARD ul �n A c� v INLET OUTLET COVER COVER —� �3 IN DROP FLOW LINE FROM = ---► 20 UNITS TOTAL - 5.0 ft PER UNIT BUILDING 10 In Iq In D- BOX 48 In CROSS SECTION VIEW LIQUID GAS LEVEL BAFFLE RESTORE VEGETATIVE COVER _ BACKFILL WITH CLEAN PERC SAND TO TOP OF CHAMBERS SEPARATION OF INLET AND OUTLET TEES SHALL BE NO LESS THAN LIQUID DEPTH CROSS SECTION VIEW EXIS TING 2.875' SUITABLE MATERIAL EFFECTIVE WIDTH = 5 x 2.875' USE 5 ROWS OF 4-ARC-36 ADS BIODIFFUSER UNITS-NO STONE NOTES " 1) INSTALLER TO OBTAIN DISPOSAL'' WORKS PERMIT BEFORE',STARTING WORK. SEWAGE DISPOSAL SYSTEM PLAN 21 ALL MASSACHUSETTS TITLES SEP IC CODE 310 CMINIMUM R1REOUIREMENTS PAGE 2 OF 2 3) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND`UTILITIES BEFORE'EXCAVATING FOR SYSTEM. WILLIAM A. REILLY III 5) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK. 61 SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT 940 ROUTE 149 PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. MARSTONS MILLS. MA 7) SEPTIC TANKS SHALL BE.INSTALL'EO LEVEL AND TRUE TO GRADE ON A LEVEL STABLE-BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED'STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING. MAY 29. 2012 ETE-3611 LEGEND BENCH MARK EXISTING C LEACH� PIT IS TO BE PUMPED AND EXISTING TOP OF CONCRETE REMOVED. REMOVE ALL ASSOCIATED STONE 1000 GAL BULKHEAD CORNER* .i-.AhID�CONTAMINATED SOILS AND REPLACE WITH SEPTIC TANK ELEVATION 92,4 0 CLEAN MEDIUM SAND PER TITLE 5. EXISTING <9ARNSTAI6LLE G;M DATUM Dl�� # VE • LEACH PIT LAKESME D-BOX 0 TEST® EDGE OF PAVEMENT _ PIT TREE <R $ �A UTILITY \ aXr� POLE 82.50 IF EXISTING MINIMAL / 0 CONTOUR GRADING 0 , 40 PROPOSED -40 0 J /� � PAVED \ � 3 DRIVEWAY O C 10ARAGEI �p SLAB I 1 C=i1 111 o FNDN , �1 \ Wo P � � 92 col N o , Q Z O TP-1 N V V \ UU1J �e 12 Ft O 1 92 1 \ e I 16.3 � I n I , AREA e 92100 a� I LASSR MAP 102 PCL 46 708.43 ft PROPOSED S PLAN A13SORPTIONOIL STSTEM SCALE: I 1n = 20 f'f 20 FL x 14.375 Ft GARBAGE GRINDER - SEE DETAIL ON REVERSE IS NOT ALLOWED 0 20 40 WITH THIS DESIGN. THIS PLAN IS INTENDED SOLELY FOR INSTALLATION OF THE SEPTIC SYSTEM 0 10 20 DEPICTED ON IT. FOR ANY OTHER CHANGES TO THE PROPERTY INCLUDING PLACEMENT OF ADDITIONS. SHEDS.FENCES OR SWIMMING POOLS.OWNER SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. F L So W p R 00 F 0 (L E TOP OF FOUNDATION RAISE COVERS TO WITHIN EL =93.32 In OF FINAL GRADE 92.0 �D—BOX 3 INSPECTION =r! MAX PORT USE 'EXISTING 1000 GALLO - = - = ARC-36 ��p�� t�� 89.09 6 in �88.60 - _ = _ = UNITS SEE DETAIL ON BACK EXISTING STONE O E 88.50 SOIL ABSORPTION 4J EXISTING 88.? SYSTEM -SEE DETAIL m ON BACK EXISTING 19 F� 4-11 Ff- B�gj MOTTLINGNO OOBSERVED 7 BELOW RACE LANE NOT 1, OF So %TNOFMd 0'rF SEWAGE DISPOSAL SC o`er DAVIO tiG o�� DAVID �Py� �'G c's' SYSTEM PLAN LOCUS L^�FS�Of p D. �� o� D. EST. -TO SERVE EXISTING DWELLING Vf 0 COUGHANOWR COUGHANOWR � W I L L I A M A. V NO. 1093 REILLY III J �� '1 S T E��O �O�SIC E N SRO OQ. �G 1995 �� OWNERISI OF RECORD N 1� '�''' 9'41VITA Pa � �vAL�P� 014m 940 ROUTE 149 m LAKESIDE �' MARSTONS MILLS. MA mi MILLS TONS C(7L: 43 TRIANGLE CIRCLE PROPERTY ADDRESS Mw-/ 2R, 'Z 0 l 2 SANDWICH MA 02563 FOR SURVEYOR'S CERTIFICAtION REFER TO-PLOT PLAN SHOWING LOCATION DATE. MAY 29. 2012 LOCUS MAP BUM IIS RILS ONA FILE4W TIHITHE BARNSTABLLE BUILDING DEPAT/2/975 SIGNED AND STAMPED BY MENT. 1506 3 6 4-0 8 9 4 Pc 1/2 ..wer ETE-3611 I.00 T10N SEWo.GE PERMIT UO. IW5T LE , 5 IJ E ADDRESS 1 III D E l3U D R l� E S A R S DtJ►TE PER"VT 155UED DATE COMPLI W aCE e '�.�' �� t ® _��► •�° r R'� ° ` Q tX� � i� No d...: .. �aa •." 7,11 low 0� (-P Fi n...1144:��......... THE COMMONWEALTH OF MASSACHUSETTS BOARD H EA T .......T,��. --......OF........... . .. -------------------- , ppliration for %ipmal Workii Tate rurtion Prrutit Applicaon is hereby giade for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: - F, . .. .......... ................................................/9 Location-Address or Lot No. �. :.. P.. r_. --•------••--••--------- -•--- IU .C, o 6 ............... er Address #ofuilding .n` ...-----•-••-•-------- -- oa---------•-------------- Installer Address Type Size Lot.-_.__.1----.-_._/......Sq. feet Dwelling—No. of Bedrooms.............9t...........................Expansion Attic ( ) Garbage Grinder ( ) 4 p., Other—Type of Building .44� 4.fZ&y''No. of persons........... ............... Showers ( ) — Cafeteria ( ) Q' Other fixtures ................................. W Design Flow............................................gallons per person per day. Total daily flow........PZ.on_.........................gallons. W Septic Tank—Liquid capacity/ 4 gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width----------_ of ex:gth.., Total leaching area....................sq. ft. 3 Seepage Pit No............. ------ Diameter_6X�-"-- �--- -- _..... Total leaching area....:.............sq. ft. Z Other Distribution box ( ) Dosing tank ( - PC r �- 31/arO/ l V, Percolation Test Results Performed by---•••------------•---------------------•--------•--••--------•----...... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.,................... Depth to ground water........................ J W .......�..... .......................' -'. . ..... _.._.. _..._..p. ........ O Description of Soil--- P 1 `.._. _..-d�' -----• - ---------- a U ..................•......_..... t/ (� •----------- W ..........................................................r.....-•----------------------............................. .....-----•---•-•--..._....------------------------..................._...... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ i. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Date Application Approved By...... � ` -- , � -w Date Application Disapproved for the following reasons:--------------------------------------------••-•------------------------------------•.-•-- --•--------------•- ..........-•---•-----------------------•--•-....-----.........-----------------•-----•-----•----.....-------........._.......-•-••••-------------------------------------------------------....---..._.. v 2�,7 Date PermitNo. - Issued--- ................................................... Date No .F� _ . THE COMMONWEALTH OF MASSAC.HUSETTS � . BOARD F HE ... OF....... ......................... Applirafinn for Diopmal Worko Tonstrur#i.on Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal . S stem at ...................................... ..................................................... ............................................. ............................. 'Locatio ddress or� t N07 ............... ._... ....... -. ... --•--------------•--------....----•--•----�Z............................................... ......:.................................. .... ner Address W ... ..... ............................................. ...........••-••••...__.........._................._.......__ Installer Address j/�d ............. d Type of ui,ding .' Size Lot....... Sq. feet ............... U Dwelling—No. of BedroomsWW40;V�_________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of BuildingNo. of F,,Np'a'nsion Attic Sho Cafeteria Q' Othett. i, ures ------------------------------- - W Design Flow______________________________4/3! __gallons per person per day. rTotal daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length ______________ Wi i. / netep�_ ....... Depth................ Disposal Trench—Nol ________________ Wi6tl'lB"---- o _ �________ tali' ec'`hmg area....................sq. ft. x Seepage,Pit No............ Diameter-------------------- e i et____________________ Total leaching area..................sq. ft. Z Other Distribution.l)ox ( ) Dosing tank- - ) Percolation Test:Results Performed bY-------------- --- ----•-••---•••--•-•-•--•....... Date........................................ Test Pit No. 1______ lttfinu s per inch ? f . P rI1e tar ro nd water________________________ d 4 l �PsP. , P g .}� Test Pit No. 2__ ____________min( inch De of Test ..:___.___. D to grdiZn water........................ , P4 .. - - .--•-------•................................. t . Description of Soil' ..... - k .............................................. --------------•-----•---•---••....__..._._.... • = ._ ;.w ._..._. ...............................---......................................................................................•--•---•--•-••-•----------•--------•-•---------•------•-•-••-•-•--•------•-••-- UNature of Repairs or Alterations—Answer when applicable...................................................._........................................... -------------------------------------------------------- Agreement The undersigned agrees to 'install the aforedescribed .Individual Sewagei Dis�sal System in accordance with the provisions of Article XI of;the State Sanitary„Code—'The undersigned further a1 rees not to place the system,in operation until a Certificate of Compliance ha board of h9alth. L Si d ___ _______ __ ......................_ ____�___ T �rE Late.............. - Application Approved By..... _.. "' `> 1__ .... ___. _. _ _ �3.'..._____. ,r j+r Dat Application Disapproved for the following reasons:___ _______ - e n$ 1 _ xt f , - ••... = s �t jo- tfi Date Permit No........ Issue ...-•--•------_... _-_•--•---•-•----••----•-------- t - , : ' � �'� ate .. �.4 `THE COMMONWEALTH.OF MASSACHUSETTS BOARD F HEALTH$' a'`r 1 TH S 0�C/ RT the Individual Selit, isposal System constructed ( ) or Repaired ( ) by �' ..____... ... .._.. = •-----.:...: ........................... r - ; nstalle' , `� �/ � `s h ___ -••• --•--•� ____ __ _________________________.................................................... r j has been installed in accordance with the provisions of Articleo. he. State •Sanitary Code`as described in the application for Disposal Works Construction Permit No.. _ __._ ______________. -dated____-__......................................... ` THE ISSUANCE OF THIS CERTIFICATE'SHALL NOT BE CONSTRUED. AS A G ARANTEE THAT THE : 4n �` SYSTEM WILL FUNCTIONSATI'Sr-ACT0Sj DATE............... sIn --------•..............••----- ?ector , ----------- THE COMMONWEALTH OF MASSACHli1SETTS BOARD OF HEALTH N - 1 o FEE ... ......... Permission eby granted......= --••-- •-- •_.... - ......................= •-----._.::_: .... .. --- to Constr or Repa ) an_Livid a,..a'Disposa r atNo. r - � '-� " ......-`.----'----- � ............................................. Street as shown on the application for Disposal Works Construction P No.. f pated........................... ' Board'of Health DATE-� -•_____.._----•- ....,............................................ .. FORM 1255 HOBBS. & WARREN, INC.. PUBLISHERS % - .j are.«a r CHARLES N. SAVERY , INCORPORATED l r •, t 712 MAIN ST. HYANNIS , MASS. PL17T PLAN SHOWING PROPOSED BUILDING MARS70NS MILLS BAR N S T ,A, 13 L E MASS. i FOR } w` ' RAL. P H B. M A S O N 5CALE. : i" = 20' MARCH 14) 1915 i r _ r l08. 52 Io' x � FUTURE PIT 1000 GAL. EACHING Ph l I �! 10 1 ILA 2r.'-O" 1' 0 0 GARAGE I O N N BqX nl 26�- O'• I � /'� 30' 000 GAL. i BZW Y SEPTIC .TANK 42'-o 0 i 0 i 0 PROPosEo `p 2 BEDROOM ' co I N DWELLt NG ci T oW�_�,t)RT E2 - ---- - S E p1\/ L 0 T 19 I ) z loot S . F. L, • N S. 08' I -70. �� ,A OF Af,ISSgC 149 3��N OF Af4 Ro B s c 13 Py U T ERT �y� �. O �O ROBERT c , o 13UNIKIS S P. BUNIKIS �2= No.22152 7 v l S I \l4 t'ISlkR ID / i �� S U Rye`+ �vsa N275011 . e_ ' t CHARLES N. SAVERY , INCORPORATED" 712 MAIN ST. HYANNIS , MASS. PLOT PLAN 5HOW ► NG PROP05ED BUILDING MARS70NS ► ILLS BARN STAB L E- MASS. FOR RAL P H B. M A S 0 N SCALD. : I" = 20' MARCH 14) 1915 I r _ Io8. 52 ►o' I -7� D -� FUTURE ` — LEAC JII NG PIT rn 1000 GAL. LEACHING PIT I 0 0 ((( z GARAGE f Is �-T 1 0 N N 130 1P N 30' Z6- o" (0 11 •o•• / 000 GAL, BZWY SEPTIC TANK � ' � z'o• I I'-o'. �� 30 � 4Z'-o' - 0 I - 0 PR0P05E.D 0 Q m Z BEDROOM N co D W E L L. I >,I G ci I � ' ToVJ VJATEP- _ ----- - SER\/ ► GE.- _ 30 L 0 T 1 9 Lp N 9 " S R / I I '7 I OF �4Sf - , 1 4 ✓ ��`H pF�!/S T � O U -� RoaER yN o ROSE P. v'1 �o uU+vlrus ti P. o 13UNIKIS No.22162 0 1V0 SURIA Ta.S.JJ. N° 75011