HomeMy WebLinkAbout0033 SADDLER LANE - Health 33 Saddler Lane
Marstons Mills
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No. 53LY
UPC 12943
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Pl— , SEWAGE #
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VILLAGE /-S')�' A/Z ASSESSOR'S MAP & LOT Z�f �
INSTALLER'S NAME & PHONE NOArk6j6&
SEPTIC TANK CAPACITY G00 Q21 dq
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LEACHING FACILITY:(type) - e
NO. OF BEDROOMS PRIVATE WEL OR PUBLIC WATER
BUILDER O OWNE� 6-�'y�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
aS Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'IA, SVey`ei
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
Important: dices
When filling out 1. PropertyInformation: Al PJ
forms on the
computer,use 33 SADDLER LANE, T-B*RW-ff4BLE, MA 02668
only the tab key Property Address
to move your DONNA DONAHUE
cursor-do not
use the return Owner's Name
key. 33 SADDLER STREET
Owner's Address
f� AE �-T h4X",t;,;, MA 02668
City/Town State Zip Code
Date of Inspection: 6-11-06
Date
2. Inspector:
MR. ROBERT A. DRAKE, P.E.
Name of Inspector
KCJ ENGINEERING I _
Company Name
66 GREENVILLE DRIVE :
Company Address
FORESTDALE MA 02644�7
City/Town State = Zip Code
508-477-5048 = -_
Telephone Number
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 inspe t' he inspection
was performed based on my training and experience in the proper function and on site
sewage disposal systems. I am a DEP'approved system inspector pursua of
Title 5(310 CMR 15.000). The system: Q�_ RO A.
DR,KE
® Passes ❑ Conditionally Passes _ ils C10
No.41642 r' "
❑ Needs Further Evaluation by the Local Approving Authority
6-13-06
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
SADDLE R-MARSTONS MILLS-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
G„
A. Certification (cont.)
33 SADDLER LANE
Property Address
WEST BARNSTABLE MA 02668
City/Town State Zip Code
DONNA DONAHUE 6-11-06
Owner's Name Date of Inspection
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:
COULD NOT LOCATE D-BOX. EXCAVATED AT LOCATIONS AS SHOWN ON AS-BUILT CARDS
DATED 2/5/86 AND 9/8/94. FOUND PIPE BUT NO D-BOX. FOLLOWED PIPE AFTER BEND FOR
APPROX. 5'AND STILL COULD NOT LOCATE D-BOX. I BELIEVE THE D-BOX WAS NOT
INSTALLED.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 ears old*or the septic tank whether metal r
Y p ( o not) is
structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
SADDLE R-MARSTONS MILLS-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
33 SADDLER LANE
Property Address
WEST BARNSTABLE MA 02668
City/Town State Zip Code
DONNA DONAHUE 6-11-06
Owner's Name Date of Inspection
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):
❑ brcken pipe(s)are replaced
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND Explain:
❑ 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:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
SADDLE R-MARSTONS MILLS-T51NSP.DOC doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
,M Subsurface Sewage Disposal System Form
A. Certification (cont.)
33 SADDLER LANE
Property Address
WEST BARNSTABLE MA 02668
City/Town State Zip Code
DONNA DONAHUE 6-11-06
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (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
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, provided that no other failure criteria are triggered. A copy of the analysis must be attached
to this form.
3. Other:
SADDLE R-MARSTONS MILLS-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
33 SADDLER LANE
Property Address
WEST BARNSTABLE MA 02668
City/Town State ZipCode
DONNA DONAHUE 6-11-06
Owner's Name Date of Inspection
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 stem component due to overloaded or
Y
El ® 9 Y or s 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 Y2 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 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 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, provided that no other failure criteria are triggered. A copy of
the analysis must be attached to this form.]
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.
SADDLER-MARSTONS MILLS-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
33 SADDLER LANE
Property Address
WEST BARNSTABLE MA 02668
City/Town State Zip Code
DONNA DONAHUE 6-11-06
Owner's Name Date of Inspection
E Larg
e Systems: To be considered a large system the system must serve a facility with a
9 Y 9 Y Y Y
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either." "e es or no"to each of the following, in addition to the
9 Y Y Y 9,
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.
SADDLE R-MARSTONS MILLS-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
o�M Sye Jv .
B. Checklist
33 SADDLER LANE
Property Address
WEST BARNSTABLE MA 02668
City/Town State Zip Code
DONNA DONAHUE 6-11-06
Owner's Name Date of Inspection
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:
Z ❑ 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(3)(b)]
SADDLE R-MARSTONS MILLS-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
r` Subsurface Sewage Disposal.System Form
C. System Information
33 SADDLER LANE
Property Address
WEST BARNSTABLE MA 02668
City/Town State Zip Code
DONNA DONAHUE 6-11-06
Owner's Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes Z No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water.meter readings, if available(last 2 years usage(gpd)): °�S 31z �pd
* Sp aetivti sys�er�. - �eA�y u3� t� Zoos
Sump pump? �P ❑ Yes ® No
Last date of occupancy: PRESENT
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CM 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
SADDLER-MARSTONS MILLS-T5lNSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
33 SADDLER LANE
Property Address
WEST BARNSTABLE MA 02668
City/Town State Zip Code
DONNA DONAHUE 6-11-06
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information: OWNER'S SLIP
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: 1,000
gallons
How was quantity pumped determined? MEASURED BY CONTRACTOR
Reason for pumping: MAINTENANCE PROGRAM: 3/17/05
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
D-BOX WAS NOT LOCATED IN FIELD.
Approximate age of all components, date installed (if known)and source of information:
HOUSE BUILT IN 1986, SECOND 1,000 GALLON L.P. INSTALLED IN 1994.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
SADDLE R-MARSTONS MILLS-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
33 SADDLER LANE
Property Address
WEST BARNSTABLE MA 02668
City/Town State Zip Code
DONNA DONAHUE 6-1.1-06
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade: 3.0
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/Afeet
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEWER PIPE APPEARS TO BE IN GOOD CONDITION, NO SIGNS OF LEAKAGE, TEES ARE IN
PLACE.
Septic Tank(locate on site plan):
Depth below grade: 2.0
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
1,000 GALLON TANK INSTALLED IN 1986, ALL COMPONENTS IN GOOD WORKING
CONDITION..
If tank is metal, list age: N/A
years
Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ No
certificate)
1,000 GALLON
Dimensions:
Sludge depth: LESS THAN 1"
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness APPROX. 6"
Distance from top of scum to top of outlet tee or baffle APPROX. 3"
Distance from bottom of scum to bottom of outlet tee.or baffle APPROX. 16"
How were dimensions determined? MEASURED IN FIELD
SADDLER-MARSTONS MILLS-T51NSP.DOC.doc•11/2064 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
33 SADDLER LANE
Property Address
WEST BARNSTABLE MA 02668
City/Town State Zip Code
DONNA DONAHUE 6-11-06
Owner's Name Date of Inspection
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
ALL COMPONENTS OF THE TANK APPEAR TO BE WORKING PROPERLY.WATER LEVEL IN
TANK APPROXIMATELY 4.0'WHICH IS AT OUTLET INVERT. TEES ARE PRESENT AND
APPEAR TO BE WORKING PROPERLY. NO EVIDENCE OF LEAKAGE.
Grease Trap(locate on site plan):
Depth below grade: N/A
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.):
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):
SADDLE R-MARSTONS MILLS-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
C. System Information (cont.)
33 SADDLER LANE
Property Address
WEST BARNSTABLE MA 02668
City/Town State Zip Code
DONNA DONAHUE 6-11-06
Owner's Name Date of Inspection
Tight or Holding Tank (cont.)
Dimensions: N/A
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.):
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
COULD NOT LOCATE IN FIELD. I BELIEVE IT DOES NOT EXIST.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
SADDLE R-MARSTONS MILLS-T51NSP.DOC.doc•.11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
,Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal.System Form
C. System Information (cont.)
33 SADDLER LANE
Property Address
WEST BARNSTABLE MA 02668
City/Town State Zip Code
DONNA DONAHUE 6-11-06
Owner's Name Date of Inspection
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:
LOCATED ACCORDING TO AS-BUILT DRAWING.
Type:
® leaching pits number: 1-1,000 GALLON
❑ leaching chambers number:
❑ leaching galleries' number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
LEACHING AREA IS LOCATED IN A GRASS AREA. NO SIGNS OF PONDING OR HYDRAULIC
FAILURE, NO ODERS DETECTED.
SADDLER-MARSTONS MILLS-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
33 SADDLER LANE
Property Address
WEST BARNSTABLE MA 02668
City/Town State Zip Code
DONNA DONAHUE 6-11-06
Owner's Name Date of Inspection
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
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
N/A
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
SADDLE R-MARSTONS MILLS-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
33 SADDLER LANE
Property Address
WEST BARNSTABLE MA 02668
City/Town State Zip Code
DONNA DONAHUE 6-11-06
Owner's Name Date of Inspection
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.
IZ LAO
Pt
t
2 O O
A (�
`( 1/7 �qy
SADDLER-MARSTONS MILLS-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Not for Voluntary Assessments
y` Subsurface Sewage Disposal System Form
�M
C. System Information (cont.)
33 SADDLER LANE
Property Address
WEST BARNSTABLE MA 02668
City/Town State Zip Code
DONNA DONAHUE 6-11-06
Owner's Name Date of Inspection
Site Exam:
Slope 3°/a ±
Surface water (vo N 6
Check cellar
Shallow wells c/y G
Estimated depth to ground water: f 2-(3
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:
ACCESSED 1992 GW CONTOUR MAPS
You must describe how you established the high ground water elevation:
1992 GW CONTOUR MAPS: GROUNDWATER ELEV.: IS APPROX. AT ELEV. 39.0' NGVD.
BARNSTABLE'S GIS MAPS INDICATED GROUND ELEVATION IS APPROX. AT ELEV. 143' NGVD.
SADDLER-MARSTONS MILLS-T51NSP.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
I_
LOCATION ► SEWAGE PERMtT NO.
vILLACE n/- � � ® 005
it
Imo, INSTA LlER'S NAME' i ADDRESS`
_ S U 1 L D E R OR OWNER ;
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
- TOWN OF BARNSTABLE
LOCATION, � SEWAGE
VILLAGE II-S km A/mAl ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE N0 Ar
SEPTIC TANK CAPACITY GEC
LEACHING FACILITY:(type)
NO,OF BEDROOMS PRIVATE WEL OR PUBLIC WATER
BUILDER O Q WNE �
DATE.PERMIT ISSUED:
DATE . COMPLIANCE ISSUED: h/
VARIANCE GRANTED: Yes No
f ji .l= v i
a /
hf eW ,
q 17/gv
LI) CAT IONS S SEWAGE PERMIT NO.
V.) LLAGE
A16,
, INSTALLER'S NAME, ADDRESS
B U I L D E R OR OWN R
_ E �
e�e� So\how s
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
�..O� ��o ' � `a..
�..
�,�
�.
,,
i�� �y's
� ,�
® � 11
No....�S.�q6+ FEs.... r�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................OF...._..k fl ►�1: �"s9T Z1. ...................
Appliratiun for Diupuual Works Toutitrudiun ramit
Application is hereby.made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: .
D�.....__i SA'��L� L �57 rJ�1�413L
........ .. _ .._..:....1.. (�,......rtr.... ..: -... .�'-- ....._... . ...........................•.........
Location-Add res or Lot No.
......................... ..............-------•-•=-----------•--........_.....---....................�.
...--
wner-
a ................¢ —r.�-- --- ..... .........--------------------- ....-=•- --_---------..._......------......��____ `if°s�r_ ...���...
Installer Add ess
Type of Building Size Lot---1_r5,3 1.P....._Sq. feet
., Dwelling—No. of Bedrooms............:...Z-----------------•--.:.Expansion Attic ( ) Garbage Grinder
Other—Type of BuildingNo, of persons............................ Showers — Cafeteria
a' Other fixtures ----•---------------•--:._......_ ...... '
Q
Design Flow.......... =---...gallons per per-serr�Pe day. Total daily flow..,. ��.........................gal
W , I ', t lonso$
WSeptic Tank—Liquid capacrty_): allons Length..c�._.Ls..... Width:_ Diameter............ s?.... Depth.....
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No........I........... Diameter.....1.21 Depth below inlet.....A........... Total leaching area_26:10:sq. ft.
Z Other Distribution box ( Dosing tank ( )
Percolation Test Results Performed by.....9 F ........................ Date....... ...........
minutes per inch Depth of Test pit.... .. Depth to ground water...-.Q..W ?. �
a Test Pit No. 1._....�3_-...._. P P: eP
f% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
....................•-•-----•------....--•-••-•---••---•--•--........---••--•--•--•-----••--•--•-....---••--•••--••••----_.:...
O Description of Soil........Q.`-�.--k_.......L!2A_11y-- 6"— 30" 5 c9,1��C9!? r........................-3 0�,_ .........
1 !f
....................••-----•. -
'U .mil�...TR, S,i ..._C?_ _].L ,+....G.J?Av 1-_.c_.._ r_.�L.0..(..1_._l-.IJ C ------------------•-
W ----------------------•----•--------...---------•---•---------•--••--•--•--•••.....--•--•-------------•---------•---•---•----......--...--•......--------------.._......._...._....---.._....._.........
UNature of Repairs or.Alterations—Answer when applicable...............................................................................................
.......................................................••-----...........-•-•---....---.....----------•----------•--------.._.............-----••--•--•---...........---._......•--.............
Agreement:
The, undersigned agrees to install the aforedescribed Individual age Disposal System in accordance with
the provisions of.:ITLZ 5 of the State Sanitary Code I'he unders- u her agrees not to place the system in
operation until a Certificate of Compliance has been is e o h th.
Signed..... ........ ............................... .. .
�` j � ate
APPlicatlon Approv By....._. .....�---_._... .. •-•.......................•. 1C�- g...._&
Date
Application Disapproved forte folloiuing reasons:.................................................................................................................
.................................................. ---•--------------.................._..-•--•-•-••-------------....•-------...-------•-----------....---------....---••----- ....__•--•-_-•---
r Date
r�
Permit �- Issued........................................................
Date
No....:?�. ..:. FEs.............C�............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
>J...............OF....'.. z r4 r�.N.S ' l`TL
Applutttion for Dhiposttl Marks C9onitrurtion Permit
Application is hereby made for a Permit to Construct (( � or Repair ( ) an Individual Sewage Disposal
System at
........:�:.O._�__��_...�A-�D L f:� .L A. � �'`4�5 7..................................S 1....................................................
Location Address or Lot No.
.........1; l3 •_-, y L L -l��t l --•-•-• -•------_-•... •--•••--- ..... ........ . --- ...._.._...... .......
wrier a, ......
f� t
Wc. .............................................:.. ................................... ..._..7 ..._r.. .. ....
a
Installer / Address
Type of Building J Size Lot... ram¢?�f J ......Sq. feet
U Dwelling—No. of Bedrooms.................. ............. ..Expansion Attic ( ) Garbage Grinder
04 Other—Type of Building ........._.................. No.__of�person---' ................... Showers ( ) — Cafeteria ( )
Q Other fixtures --------------- ••-••kApJ-Z�zS`.v.*....... .......•.............
•--•..._..------------
.... .......... ...........
Design Flow..........1_1_.Q..........................gallons per per-sow er day. Total d ily flow..._.=�_z.!_..;r_._........____.._gallons.t�
Septic Tank—Liquid capacity �ll.ons Length_...:_f?_..._ Width___._ .� Diameter.........:..... Depth..._.��.......
x Disposal Trench-No. ...................... Width ... ............ Total Length......__...._:.... Total leaching area....................sq. ft.
3 Seepage Pit No........I............ Diameter. �. :__._._. Depth below inlet.___.4.. ._... Total leaching area.ZhA!4.sq. ft.
Z. Other Distribution box (�) Dosing tank ( )
Percolation Test Results Performed .........................P .i................. Date_......(0.': :. ........._.
Test Pit No. 1..... ._....minutes'per inch Depth of Test Pit_ .-�.. .4_:_. Depth to ground water.._
44 Test Pit No. 2..........,J....minutes per. inch. Depth of Test Pit.................... Depth,Aojground water........................
P4 .. ........................................................
• -_-•_• -- ••--_. ....... ---
O Description of Soil (2 6'1 1 QAn.. 6" 2.011 S U `�G` 1 L____ -3 O''-- 1 ��{'' Sf►N f�
......................•••••..........-••--•-•-_•-...
U ...........j� _1 Tt2saC _..._ ._.; _3. t•:t..��a. .r..__. ;.:._. a(�1_��__L-1 �'Q�
W . ........... ........ --------------------------------
U when applicable ._._____:____________________________________ _._...._._.
Nature of Repairs or Alterations`Answer
.......................................•--..._..._....-•-•-•---•----•---._.......---._......---.....__._.......:-----------------•----------•------.._...------.._......----......._••................_.
Agreement
The, undersigned agrees to install the..,aforedescribed Individual age Disposal System in accordance with
the provisions of TITLZ 5 of the State. Sanitary Code7qrhe unders` u her agrees not to place the system in �{
operation until a Certificate of Compliance has been issu a `o h Ith. `
r'f Signed..... r .•_-•-• -•---....---•.._.....••....._..! .. ....��.
ae
ApplicationApprove... _...1. ...........:.. •--•-•-•-•-........................... ................................
Date
Application Disapproved for t e following reasons:
--------------- ..
k
............................•--•....•-•••-....-••••-----•-••-•--•-•••-•-•-•••--•-•.................__..._...-••---•---•-•------•-•--•-•----••--•••-•-•......•-_......_.. ....-•-----
T # a --.._....Date
PermitNo...........6..... .................... Issued........................................................
Date
.------ -n ....• .1 ................. ...9J 3s ........ .......................
......................,
THE COMMONWEALTH OF MASSACHUSETTS
BOAR F HEALTH
)
................
(Inrtif irate. of f omplittUrr
THIS TO TIFY, Th In iv' Sewage Disposal System constructed epaired
r
by......... r-j. ...:.... ..... .. .._..._.... ...........................-
/ � ^'�...............................(
at......... . ._. n `..,_.. __. ,.. I ( ........... . ......
�.. �_.._.......•-•_.. . .. ..
has been installed in accordance with the provisions of TIT 5-of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.........� ................ter __. dated---..._�.�l e ..
- .. .....................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
�SYSTEM
WILL
W 'FUNCTION
SATISFACTORY.
DATE: .......... ...� ............ . ..........•---•---.......... Inspector.�
. ..
-
............. w- - ----------«........s....a z........ .. .a
THE COMMONWEAL OF MASSACHUSETTS M
_ BOAR F HEALTH
�� sL
�. ........................:.......:.........OF...:. _........_.���;f_`lL_......_.._....
NO......Q.............l..6H"- FEF........................
r
i t ttl urk o ttr ' n unt y
�7 _ �' i
Permission is�her granted-, --- •• -•-•---•�-_--•-- -------------•------
t� Construct ( Repa' ( ) ai> d'vid 1 e a e Dispo S tem r
1n1 at No............ .�r----•------- fr �`... -
Street v / /
as shown on the application for Disposal Works Construction Permit No........... ______,Dated±'_'_..... !' .
-
.:,,,�,�,., r, I _ V� oar -,of 16alth 0 �'
fi
""..DATE _...--------� --------------••--------- ----•--------•---........_
I-
SECTION -'SEWAGE
. r
SEPTIC TANK— 3 —"D"BOX — -LEACH
TO P��JF F�D'N� n
11 Z (MSL)* _.-2..OFi/a To,
4i"
WASHED STONE _ /�►Y�`
Clad, l _ �.. -�a-� . � � •
C p0
IN• OUT
LSG�1Q G IN-
OUT INS - - ��`, ,. 1: �rpidllr�.11�►��
- TANKC
ELEV. ELEV. ELEV. :.,..E' I 67.FiT e5P►c�I'lr.� 7�✓",,�p
1
ELEV. ELEV. S
1
OF 3A IW"
1 WASHED STONE
TEST HOLE LOG .4'
.TEST BY �:�I��a-�1g d , GO�LL-O{..I,
WITNESS _
TEST DATE I BEDROOM HOUSE (tj' #t ,
DESIGN �� \ ; �S g LVT 7
T.H.- • 1 s T.H. +' 2
ELEV.II E3.4 ELEV. NO
3 DISPOSER DISPOSER 90 {
1.31, q PERC RATE MIN/IN. ' ►
P� I FLOW RATE \ p (GAL./DAY yip �O �`
n SEPTIC TANK _
s 13
s c q.� � .
3 ®'
s.9
E EPTI NK�-SIZE
�--
R QDS CTA S
LEACH FACILITY
5i AvEL SIDE WAL 12sr4 = r.�0� S_.2,z a ._33�f .�/D. -� ti
5�' /
e�l� IJS BOTTOM C2 Z C 3 . O�QZ) !� G/D.
TOTAL G/1� p
(4,�•n 12.E / � � � �,,� /� ��
USE: I ACHING
121
WATER ENCOUNTERED _..
`mot'
NOTES:' (UNLESS OTHERWISE NOTED)
L DATUM(MSU�TAKEN FROM S1S*t�VJ t(�___QUADRANGLE MAP
2.MUNICIPAL WATER %!�2 ----AVAILABLE
3.PIPE PITCH:W'PER FOOT ��t� �� * to
r / ~
4.DESIGN LOADING FOR ALL PRE-CAST UNITS:AASHO- - /� -44
5.MIN.GROUND COVER'OVER ALL SEWAGE FACILITIES:(1)FT. �q AR NE m`r�y m '�
6:PIPE JOINTS SHALL BE MADE WATERTIGHT ° O ALA
7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. D (2�
STATE ENVIRONMENTAL CODE TITLES CIVIC 6' (Q I _ 1 ^ /S� PLAN
8. T�-�.a P�.a..J Fo�G 72t�7tYxb ►�oZ�C c +�`t �...a0 �+ U , 9 8 10 16 � 1 /.�_N. O,.�qS f LOCUS:
�-.taT VbE U58D PaZ '�IZG7C.L„f L.yCT• '�S�-�.�-+...►G. — ���i' � G�:� .!g J,� /ta�
q, Au. i 9�-2al-rcz Lr, M kT;Ki_AL_ �riaEF r.��- 1 AC2 _ -
nA'n. -- AIR
'. _ REG. L ENGI R
132,-+0 TD t�ti MOVEO A1J0 KG-�'LL4GGD _ REF:
i `^ 1a� L. OW s
1� 1'-' G.EAI� GOAKSE To M c)l d Nf hQ0h FO-K- l� -- down cape engineering �-� P EPARED FOR. L�5—�
CIVIL ENGINEERS s/
t$
LANDSURVEYORS '�Ql1�tQ. II BOARD OF HEALTH RE G. __ YOR•
SCALE �
CONTOURS (EXISTING)------------- APPROVED GATE � MA Yam.. .
$� RIOlitl
(PROPOSED)-O-O-O-O- DATE