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HomeMy WebLinkAbout0040 SADDLER LANE - Health 40 Saddler Lane Marstons Mills P ----- - - - - -- - - - -- -- A = 151 044 a i` _�--._., I � i � �` i � i �--.�'--� !-- - ( -..r t',C'1S�'in tp ed►+n�S.1— i ' �5C' n5• �r e' 1 ; a ��T�i We � Li A-- - J ._ 17 j I i r 1 1 1 1 t �- I ' � � i A J ` l� , � 1 � , 1 rv�•�!s Y�S e'`�+r_psa`_r����3=� 1 1 I t r i `cue ' ztigz 0" Ai — r l ! j i f I �1E+�•� +`�z�r iMd� �Uoc ! -4 ; I 1 , 1 - � I 1 r f i r I i r i I f _ i r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f� 40 Saddler Lane M t ry Property Address Charles Cullen Owner Owner's Name '-� information is Marstons Mills ✓ Ma 02648 June-22-2018 �- required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information 67/- 3Ja4)-- on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. Excavation Company �y Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 SI 13747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority June-22-2018 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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 40 Saddler Lane Property Address Charles Cullen Owner Owner's Name information is required for every Marstons Mills Ma 02648 June-22-2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Saddler Lane Property Address Charles Cullen Owner Owner's Name information is required for every Marstons Mills Ma 02648 June-22-2018 page. City[Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 40 Saddler Lane Property Address Charles Cullen Owner Owner's Name information is required for every Marstons Mills Ma 02648 June-22-2018 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,,. 40 Saddler Lane Property Address Charles Cullen Owner Owner's Name information is required for every Marstons Mills Ma 02648 June-22-2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 40 Saddler Lane Property Address Charles Cullen Owner Owner's Name information is Marstons Mills Ma 02648 June-22-2018 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(Actual) _3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330/GPD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Saddler Lane Property Address Charles Cullen Owner Owner's Name information is 'Marstons Mills Ma 02648 June-22-2018 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of.current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2016-83,000gallons 2017- 103,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Saddler Lane Property Address Charles Cullen Owner Owner's Name information is required for every Marstons Mills Ma 02648 June-22-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- last pumped in 2016 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 40 Saddler Lane Property Address Charles Cullen Owner Owner's Name information is required for every Marstons Mills Ma 02648 June-22-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: New SAS added to existing tank in 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2'3" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1'3" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000gallons Sludge depth: 91, t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Saddler Lane Property Address Charles Cullen Owner Owner's Name information is required for every Marstons Mills Ma 02648 June-22-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27 Scum thickness 5 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Saddler Lane Property Address Charles Cullen Owner Owner's Name information is required for every Marstons Mills Ma 02648 June-22-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.' 40 Saddler Lane Property Address Charles Cullen Owner Owner's Name information is Marstons Mills Ma 02648 June-22-2018 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up. 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.): NA *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Saddler Lane Property Address Charles Cullen Owner Owner's Name information is required for every Marstons Mills Ma 02648 June-22-2018 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: (5) infiltrators 37'x10'x1' ❑ 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 was in working order at time of inspection with no sign of hydraulic failure. Leaching was Y2 full when viewed. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 40 Saddler Lane Property Address Charles Cullen Owner Owner's Name information is required for every Marstons Mills Ma 02648 June-22-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 40 Saddler Lane Property Address Charles Cullen Owner Owner's Name information is required for every Marstons Mills Ma 02648 June-22-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Rear A B Al-33' 131-21' A2.59' 0 62-41' 1 2 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 I' Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Saddler Lane Property Address Charles Cullen Owner Owner's Name information is required for every Marstons Mills Ma 02648 June-22-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No GW @ 144" 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: June 4t' 2004 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts F . Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Saddler Lane Property Address Charles Cullen Owner Owner's Name information is Marstons Mills Ma 02648 June-22-2018 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t. TOWN OF BARNSTABLE L.1CATION �� SEWAGE JLLAG ' ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY `��i�f LEACHING FACILITY: (t& 14�--� a', L—`Vr�w(size) X7 ElQ' V c� NO.OF BEDROOMS O BUILDER OR OWNER Y PERMTTDATE: COMPLIANCE DA 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 33 9 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rn 4 SADDLER LN m M 0 S E . ..�_ Property Address N ELLIS r+ Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-16 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in anya way. Please see completeness checklist at the end of the form. Important: A. General Information �- When filling out forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name "Q P.O. BOX 145 Company Address CENTERVILLE MA 02632 City/Town State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-12-16- or nature 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. t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1goff 17 17 VS Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 40 SADDLER LN Property Address ELLIS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-16 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: AT TIME OF INSPECTION SYSTEM MET ALL PASSING REQUIREMENTS. THIS REPORT DOES NOT PREDICT THE FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE. 13) 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): t5ins•3113 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official In h section Form p Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 40 SADDLER LN Property Address ELLIS Owner Owners Name information is required for MARSTONS MILLS MA 02648 9-12-16 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 SADDLER LN Property Address ELLIS Owner Owners Name information is required for MARSTONS MILLS MA 02648 9-12-16 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 SADDLER LN Property Address ELLIS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-16 Ci frown State eve page. tY to Zip Code Date of Inspection every P 9 P P B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M y 40 SADDLER LN Property Address ELLIS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-16 every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Ma ssachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 P Y rY M a 40 SADDLER LN Property Address ELLIS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-16 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1000 GALLON SEPTIC TANK,D- BOX,AND A THREE BEDROOM S.A.S CONSISTING OF 5 INFILTRATORS IN A 37X10X1 FT AREA. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: LAST 2 YRS AVERAGE GPD IS 198 GPD. SYSTEM NOT DESIGNED FOR USE WITH GARBAGE DISPOSAL. Sump pump? ❑ Yes ❑ No Last date of occupancy: CURRENTLY OCCUPIED Commercial/industrial Flow Conditions: Type of Establishment: 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 SADDLER LN Property Address ELLIS Owner Owners Name information is required for MARSTONS MILLS MA 02648 9-12-16 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: CURRENTLY OCCUPIED Date Other(describe below): General Information Pumping Records: Source of information: OWNER SAID PUMPED 2 YRS AGO Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 40 SADDLER LN Property Address ELLIS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-16 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2004 PER AS-BUILT CARD Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2.5 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON Sludge depth: MODERATE t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 40 SADDLER LN Property Address ELLIS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness MODERATE Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? WOODEN POLE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): OWNER STATED TANK WAS PUMPED 2 YRS AGO. I ALWAYS RECOMMEND PUMPING AT TIME OF TRANSFER AND EVERY 2-3 YRS THERE AFTER. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 40 SADDLER LN M prey Property Address ELLIS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 40 SADDLER LN Property Address ELLIS Owner Owners Name information is required for MARSTONS MILLS MA 02648 9-12-16 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX WAS AT LEAST 3 FT DOWN WITH NO RISER. RECOMMEND INSTALLING A RISER AT SOME POINT. BOX HAD 2 OUTLET PIPES WITH SPEED LEVELS SLIGHT SCUM LAYER IN D- BOX 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: THERE WERE NO OBSERVATION PORTS ON THE S.A.S. YOU COULD CLEARLY HEAR WATER DROPPING INTO THE INFILTRATORS FROM THE D-BOX INDICATING THERE WAS STILL USABLE SPACE BETWEEN THE PIPE INVERT AND LIQUID LEVEL. ALSO THERE WAS NO SIGNS OF FAILURE THROUGH THE VENT PIPE. THE ECACT LEVEL OF PONDING/STAINING COULD NOT BE DETERMINED BECAUSE OF LACK OF OBSERVATION PORT. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 SADDLER LN Property Address ELLIS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 infiltrators ❑ 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.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 40 SADDLER LN Property Address ELLIS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privylocate on siteplan): ( � Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 SADDLER LN Property Address ELLIS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-16 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 40 SADDLER LN Property Address ELLIS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: greater than 5 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: pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: elevation of property is much higher than a close property that I did a new septic at with no ground water encountered Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 40 SADDLER LN Property Address ELLIS Owner Owner's Name information is required for MARSTONS MILLS MA 02648 9-12-16 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I� I t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Assessing As-Built Cards Page 1 of 2 i� � -TOWN OF BARNSTABLE LOCATION SOS -�e- SEWAGE VII LA ASSESSOR'S MAP&LOT 5� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 0`�—'(5?—:A:=\6U) LEACHING FACIL rY:(tl5Pe) X�Cc LZT-�(size) c` `CLO( K NO,OF BEDROOMS_�j BUILDER OR OWNER C, PERMITDATE: COMPLIANCE DA Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility ([f any wells exist on site or within 200 fat of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by /f D l � t f http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=151044&seq=1 9/15/2016 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,, MASSACHUSETTS UL Z(ppYication for Mtpool *pztetn Cotittruction Permit -� Application for a Permit to Construct( )Repair>f Upgrade( )Abandon( ) ❑Complete System y;ndividual Components �? Location Address or Lot No. 't'LJp SA01>Ic2 (JJ' Owner's Name,Address and Tel.No. M N1 3-` 1�,a 0)000 a`C_� C;bed\• Assessor's Map/Parcel ( S 1644 5A Mc Instar's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. KDbe[ Septic S s (o�g-S?5\u S��Y Scn�►coc�c�r� \ SJCS. 0,}Q(. � S c�en'��� �t�•GSo x co��- oc Mel £•F'o. 0041j% t�_kR 0z Sat. Type of Building: Dwelling No.of Bedrooms 3 Lot Size 15,n 96 sq.ft. Garbage Grinder(11/6 Other Type of Building No. of Persons 3 Showers( ✓) Cafeteria(�) Other Fixtures vn �l� c� Design Flow 23D gallons per day. Calculated daily flow 33\$ gallons. Plan Date toS�-4 h4 Number of sheets Revision Date Title ' a�PE;c Sus\em QRQCC.60 -, Size of Septic Tank Fxt'�. 1. Boo gc A Type of S.A.S. 6'1 i��c�—/0�X a�•�Z,S Description of Soil ] \�� Nature of Repairs or Alterations(Answer when applicable) P\ark Date last inspected: Agreement: The undersigned agrees t ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisi ns of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is e y this Board of Health. Signe Date Application Approved by Date Application Disapproved for the following reaso Permit No. - ' Date Issued �^ t No. Fee , ,THE COMMONWEALTH OF MASSACHUSETTS' Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes <ll ZIppplicatton for Dtopogar bpotem Congtructiott �Q]{[V��ermtt 1 - 'f A" A" �l C. U Application for a Permit to Construct( )Repair X Upgrade( )Abandon( ) ❑Complete System Individual Components Location Address or Lot No. '0 4/Q 501D OLE IZ_ 4.n1. Owners Name,Address and Tel.No. Inc�c15'c \ Assessor's Map/Parcel 1044 M Installer's Name,Address,and Tel.No. Designer's Name Address and Tel.No. i�t�s c t 5a� ,� c ` (�y�,-5��1D j�\.�y �cn��cc.�cY .n'\�� SJCS• 0_+� . C:h-)0,) ��,t1 �'a\m�o14, M� 0253L Type of Building: I' Dwelling No.of Bedrooms Lot Size 15,C; 80 sq.ft. Garbage Grinder Other Type of Building 62CA<A No. of Persons -3 Showers( V) Cafeteria( ) +. ;a Other Fixtures k, J Design Flow gallons per day. Calculated daily flow 3 gallons. Plan Date ��' C 4 Number of sheets Revision Date Title a\5�.n) Size of Septic Tank `�� 1 , CC() a'a\ v Type of S.A.S. "y,� ,��cc c S " /C,X 7 5- r-,c Description of Soilt� r?\cam Nature of Repairs or Alterations(Answer when applicable) i Date last inspected: , Agreement: The undersigned agrees o ensure the construction and maintenance of the afore described on-site sewage disposal system ~ in accordance with the provisi ns of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is this Board of Health. Signed e y Date Application Approved by 1_ 14 �l Date Application Disapproved for the following reasor 6SZt Permit No. Date Issued 6917 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS 1 Certifirate of Colmphance THIS IS TO C . IFY, . t t n- ite S wage Disposal System Constructed( )Repaired )Upgraded( ) Aban�/one ( ) at 'tV r / .�, been constryct 1 yni accordance with the pr&ssii Ps f itle 5,�d®, e or i posai System Construction Pert i�i7Ng,.._ �I dated I Installer' ! Mor Designer J The issua'c t his pe it shall not be construed as a guarantee that the sys.e wil'l fun ctionas designed. Date /E.� Inspector kl►��1 c ` _i��••�------------------------ No.PO4�1� Fees THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migaar *pgterrt Con5trurtton Vertu Permission is hereby gra�t to o tic�( �)�Tu� Up gr e )Qr do ( ) System located at f' �i i 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:Co str cttiion must b .completed within three years of the date of this etm�i Date: ! Approved b �,✓�� . - r 1 PP Y I Town of Barnstable j"E'°w Regulatory Services s Thomas F. Geiler,Director • BARNSIgBLE, MASS. Public Health Division 05.91. ob A'ED MA'S' Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Designer: Installer: Address: .(`�, - Address: , t--I R c A IAA On ( a ��' was issued a permit to install a ate) (installer) septic system at 40 3 kk_ W_ based on a design drawn by (address) &ooz, dated (designer) I certify that the septic system referenced 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 system referenced above was installed with major changes (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. ZN OF MgSs� C CARMEN GNP. (Installer'sSignature) �� E. U SHAY �' A No. 1181 � Lo `cGISTR esigner's Signature) tr (Affix DesigirormWmp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form f Sep - 20-01 13 : 52 BARNSTABL_E HEALTH DEPT 5087906304 - S25/Oi NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOL,aTIO•N TEST AND SOIL EVALUATION EXENIPTION FORM hereby certify that the engineered plan signed by me datec concerning the property located at _ 0_-s—q,� w �.O(1sZ S- � meets all of the i^I'o4•�ng ::-,feria: . T O • ,hts failed s,V stem �s connected to a residential dwelling only. There are no -ormerzia! or business uses associated with the dwelling, -F.e soil is ciass:f•:ed as.CLASS l and the percolation rase is less than or equal fo 5 rt_�utes per inch. The applicant may use histoncal data to conclude this fsc: or may :onduc( :)rc!Irnwar; tests ac the site without a health agent present • There :s no ncrease to now and/or change in use proposed • There are n.o variances requested or needed. • The bottom of the Y proposed ro osed leaching facility will not be located less than fourteen 7 I,j fee: aoove the maximum adjusted groundwater table elevation. fAdiust the nundwvcr table using the Fdmptor method when applicable] Please complete the following: t D1 Ground Surface Elevation (using GIS information) _ �A(�2_ Fle vac:or, 40 ad;uscmcn( for h,gh G.w..3_�. .. = ..-.- '7 �TT-T.R,ENCF 0, ETWEEN and 8 S'G)FED -C- DATE. NOTTCE ' 33sec r.formacion, a reoair permit wil! be issued for -)edroorns N+^ ,'dd:W�nal bedrooms ;tie authorized to [he future without ,nSincerec' aplt. iV�IC l plans. --- — i ,OWN LOFARNSTABLE LOCATION �yG SEWAGE # y�l,p ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. ` SEPTIC TANK CAPACITY LEACHING FACILITY: (t& (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIAXCE DA . 6 Separation Distance Between the: water Table to the Bottom of Leaching Facility Feet Maximum Adjusted Ground 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 33� �( 9 r Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location:.. q , S"�S Lot No Owner: �t ��� Address Contractor: G Address: Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. .............................................................................. .Date month*dylyar STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: D O Appropriate index well.................................................... sCain OBWater-level range zone .............................................•....... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... 0 moot /yea STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 28) determine water-level adjustment .................•.•... ;......, ............. STEP 5 Estimate depth to high water by subtracting the water• level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ............................................ . f; Figure computation 13.—Re—Reproducible� form. . 15 t• Commonwealth of Massachusetts 9 Ilk Executive Office of Environmental Affairs Department of Environmental Protection WUllaem F.Weld Trudy Coxe Gammor seem" Arpeo Paul Cellucel Devid-B.Struhs LL Govn wr N" ✓a . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO PART A '9 CERTIFICATION 10,11 v� Property Address: t j a S ddress of Owner. Date of Inspection:, A,/�� CEO L N 1 M m u� (If different) °FAfsy� `9�?� Name of Inspector. 1- �— I Company Name,Address and Telephone Number. cR CE IFICA Af E9 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _Passes _ Conditionally Passes _ Needs FuAber Evaluation By the Local Approving Authority _ Fails Inspector's Signature: - ate: /'L" The System Inspector shall submi py of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a 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. INSPECTION SUMMARY: j Check A,B,C,or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components used to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,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 ponforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street • Boston,Massachusetts 02108 a FAX(617)SWI049 • Telephone(617)292-UN Ob Printed on Recycled Paper F � SUBSURFACE SEWAGE DISPOSAL SYSTEM INS TION FORM PART A CERTIFICATION (continued) Property Address: Owner. Date of Inspection: B)SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level o rved in the distribution box is due to broken or obstructed pipe(&) or due to a broken,settled or uneven distribution box. a system will pass inspection if(with approval of the Board of Health): broken pipe(&)are rep obstruction is re distribution box is lied or replaced The system uired pumping more than four' ' a year due to broken or obstructed pipe(s).'The system will pass inspection if(with ap al of the Board of ealth): ken pipe(s are replaced obstr�iiction ' removed Cl FURTHER EVALUATION IS REQUIRED BY E BOARD REALTH: Conditions exist which require further ev tion by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environmen . 1) SYSTEM WILL PASS UNLESS BO D OF,HEALTH DETERMINES TRAIT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is wit 50 feet of a surface water , Cesspool or privy is wi ' 50 feet of a bordering vegetated wetland or a salt marsh. Z) SYSTEM WILL FAIL S THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF` PROPRIATE) DETERMINES THAT THE YSTEM 1S FUNCTIONING IN A MANNER THAT PROTECT THE PUBEALTH AND SAFETY AND THE ENVI ONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is leas 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. S) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. Date of Inspection: DI SYSTEM FAILS: i I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of H should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component ue to an overloaded or clogged SAS cesspool. Discharge or ponding of effluent to the surface of the and or surface waters a to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet inve due overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or a 'ble volume is less than 1/2 day flow. Required pumping more than 4 times in the NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption S m, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or vy is within 100 feet of a surface ester supply or tributary to a surface water supply. Any portion of a cess 1 or privy is within a Zone I of a public well. Any portion of cesspool or privy is within 50 feet of a private water+supply well. Any po ion of a cesspool or privy is less than 100 feet but greater than\\ 50 feet from a private water supply well with no a table water quality analysis. If the well has been analyzed to be a�ceptable,attach copy of well water analysis for orm bacteria,volatile organic compounds, ammonia nitrogen and nitiate nitrogen. El E SYSTEM FAILS: 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:\ 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(1WPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Ll O Opener. Date of Inapect�2 ­7—Q 7 Check if the following have been done: pumping information was requested of the owner, occupant,and Board of Health. '-'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. A built plans have been obtained and examined. Note if they are not available with N/A. L, a facility or dwelling was inspected for signs of sewage back-up. vKe system does not receive non-sanitary or industrial waste flow v_ a site was inspected for signs of breakout. c/pll system components,excluding the Soil Absorption System,have been located on the site. _A A//e septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,,rmterial of construction,dimensions, depth of liquid,depth of sludge,depth of scum. _/Thhee sise and location of the Soil Absorption System on the site has been determined based on existing information or :The pp . ted by non-intrusive methods. facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 r Y _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �� ��-c +v �✓a'v'�� Owner. Date of Ins pecti j FLOW CONDITIONS RESIDENTIAL• Design flow: one Number of bedrooms: Number of current residents:_ Garbage grinder(yes or laundry connected to system(yes or no): CIP-4 Seasonal use(yea or no): U Water meter readings, if available:_ Last date of occupancy: COMMERCIAL/INDUSTRIA.0 Type of establishment: Dssign flow:___pllona/day G e trap p ea or no)_ Industrial Waste Holding Ta c nt: (yes or no)_ Non-sanitary waste discharged to the Title es or no)_ Water meter readings, if available: Last date of occupancy: i OTHER(Describe) Lest date of cy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)&O If yes,volume pumped: gallons Reason for pumping: TYPF OF SYSTEM optic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yea or no) (if yes,attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components,date installed(if]mown)and source of information: r Sewage odors detected when arriving at the site: (yea or no) (revised 11/03/95) 6 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address qC) S' m-jK2/t/ Owner. Date of Inspection: SEPTIC TANK: (- (locate on site plan) N Depth below grade: V Material of construction:�crete_metal_FRP_other(esplain) Dimensions: f5- Sludge depth: , Af Distance from top of Sludge to bottom of outlet tee or a baffler Scum thickness:__ iC Distance from top of scum to top of outlet tee or bafile:_,,4� Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition o inlet and outlet or baffles,depth of liquid level in relation outl invert,stru integrit , evid n of leakage,etc.) GREASE TRAP:_ (locate on site plan) Depth below grade. Material of construction: _ to_metal_FRP_other(ezplain) Dimensions: Scum thicimess: Distance from top of scum to top of outlet tee or Distance from bottom of scum to botto outlet tee or baffle: Comments: (reoomme n for pumping, condition of inlet and outlet tees or baffles,depth of d level in relation to outlet invert,structural integrity, ce of leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Ins n: M- TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee,condition'of alarm and float switches,etc.) DISTRIBUTION BOX: C% (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level an distribution is equal evi ce of solids over,eviden of akage into out o box,etcJ y"y' PUMP CHAMBER (locate on site plan) Pumps in working order(yes or no Comments: (note condition of ber,condition of pumps and appurtenanoes,.1 7777 (revised 11/03/95) 7 ` i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. — `� Date of Inspection: .1'�— y.. SOIL ABSORPTION SYSTEM (SAS):_,_/ (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: leaching Pits, number:_ leaching chambers,number:_ leaching galleries,number: leaching trenches,number,length: leaching fields,number, dimensions: overflow cesspool, number: Comm e ts: (n condition of soil,�s' of h ulic failure, level of ponding, co lion of ve tatioa,etc.) U CESSPOOLS:_ (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(cesspool:rust be pumped as part of ins ion) Comments: (note condition of soil,signs of ulic failure, level of ding,condition of vegetation,etc.) Y PRIVY:_ (locate on site p I Material oonatruction: Dimensions: Depth o lids: camnts. (note condition of soil,signs of hydraulic failure,level of ponding,condition of etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: tm S J 7�,� Owner: Dale of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' e - e 3 7 DEPTH TO GROUNDWATER cs— Depth to groundwater._&-f—feet method of determination or approximation: lr�vi�ed t/15/951 9 CO CAT ION SEWAGE PERMIT NO. ~�ILLAGE C A ` =11A ++ INSTALLER'S NAME a ADDRESS WsL �e o R UILDER OR OWNER DATE PERMIT ISSUED ZS g� DATE COMPLIANCE ISSUED Sbl/ i? aj uc�5 e Lo Ar.. ry�p` y (o 170 a ' No. .�.......1� FEB.......................... THE_ COMMONWEALTH OF MASSACHUSETTS BOARD `OF HEALTH opoOhh.l JF . . ............0 F..... Appluttfion for Disposal arks Tonotrudion rrrmit Application is hereby.made for a Permit to Construct (Vlo'or Repair ( ) an -Individual Sewage Disposal System at --.-Location-Address or Lot No. ...............[.. -- ---..................---•--......-•---•........... . (!rJ..:../ ........... ........ ............. 5..!.1...........' Address Installer Address Type of Building Size Lot.15.jDeD .....Sq. feed' ., Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type e of Building .. No. of persons............................ Showers W YP g...-•.....:........•-•--•-- P ( ) — Cafeteria ( ) `, 44 Other fixtures ... ............................... Design Flow........... ..!Q.....:.............. lions per per da Total daily flow...........55.0 W gn . ..gallons P Y Y ....... ......gallons. W Septic Tank—Liquid capacitytDQQ.gallons Length.!&.-.G_.. WidthA.'.4d. Diameter.. Depth.S. . -4 x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. ` • 3 Seepage,Pit No...OUSt.. Diameter.......�1....... Depth below inlet-._..�a1........Total leaching area=.O..26q. ft. Z Other Distribution box ( ) Dosing-�to ( ). Percolation Test Results Performed b .......t.5-1 �� +L ... t......... Date...�t r�t� ......... a Y c:•N._.� Test Pit No. L.... minutes per inch Depth of Test Pit...14.'�...:-- Depth to ground water...)U.0UF_:-.. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground'water........................ a .._ . .... --•......... ......................................... 0 Description of Soil.......t04�...... .R.'�...4 Oa4� �'.s�1113SQ14- y��•` y....-•................. • x jq:uE.L ....LJ ✓ 'r4 ...D "......................•-•=- •--•--•--.............._...........•.... ... w ...................•-.-•••-................-•-•-•••••••.......--•---•--••••----••-•-••--••--•---•......••----••-•••-•----......--•----•-•••......-...........- ..........._.............. tjj Nature of Repairs or Alterations—Answer when applicable......;......................................................................................... -•-•............................•-------.............----•-•------------•----......................---._....---......................................•................................................ Agreement: The. undersigned. agrees to install the aforedescribed Individ al Sewage Disposal System in accordance with the provisions of.�ITL; 5 of the State Sanitary e—"The un sig d rther agrees not to place the system in operation untila Certificate of Compliance has be i b a ealth. �l Si ned ��.......�.� . Date Application,Approved By. ._ ..... ..... : Date Application Disapproved for the following reasons:---......--•-•--•..............................................................................:.............. ...........................................................................•-••--••-•----•-•----•--•--.•----------•----•-•••--..........----•-..._......--•---...........-••-•--••---..........._...._ Date Permit No..... �-� .. .0 2 Issued.-•-•................................_.................. ............. ..._...._ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF....�u�..'A: *. :. !A_.V�)i ...------•--•-----......... ,gyp# iration for Mgposal Workii Tonstrurtion Prrmit Application is hereby made for a Permit to Construct (1,1�r Repair ( ) an Individual Sewage Disposal System at .l-IVU -15P �1W,if �Ak?Q:FEZ �_O- -J"r- , i,,1�T %. -L'C .S- -4�-�............... ..... -- . ..... _^• -.- .Location Address ----or.Lot No. .... --. .�s'�'s.• 1�/ ... ............................ Owner / �^ � Address W t J .... ..�... = .............1 ...........---.....--------•-•-------.... Installer Address Type of Building Size L1'-5_1`) .......-a ot.. • , --- Sq. feet± Dwelling—No. of Bedrooms...............` ......................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type T e of Building No. of persons............................ Showers a YP g ..----------••-•--•---•----• P ( ) — Cafeteria 04 Other fixtures ...................................1-• Q ....... .... ........•............ ........ .....---•----- ........... Design Flow........... � %.......................gallons per person per day. Total daily flow..........._�5-0................gallons. . n �t 1 �t Septic Tank—Liquid capacity! ?P.O.gallons Length...-G'.._ Width: •._1-Q.- Diameter:............... Depth.5. ..- . W Disposal Trench—No..................... Width.................... Total Length................. Total leaching area....................sq. ft. x 3 Seepage Pit No.... )NAen.. Diameter........5 i........ Depth below nlet.......-..-..:Total leaching areas -sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.....y� �. .1 � �,� ...f_. :......... Date._. is �f��......... _, minutes per inch Depth of Test Pit...�.AM."... Depth to ground water....0..K�E.... a Test Pit No. 1._' p p 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ........:.............•--....................-----••------•--.............-----....---------•--.............................................................. D Description of Soil......52 1`. Ze 1� G0��y) 9 6U5.5_CJ/C... t �� �g `c r ���......................... ......._. x Cep 4.R� ./.<. jj t. ' "�' ... .. i/GT .......... •.. :..... j �, r UNature of Repairs or Alterations—Answer when applicable............................................................................................... ..........................................................•--•••......-•---==--•-........_......•----•--•--•---••--••••••------•--------.......•-------.:.................----•.........:............ Agreement The, undersigned agrees 'to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE' 5 of the State Sanitary Cole-`fhe and r)sig 5d further agrees not to place the system in operation until a Certificate of Compl bncc has bee sue 1 b 'the oa f ealth. _ � . /G� S r J Signed... .L..4.1......... : J Date e1 f Application Approved By..... ":E 1.__ ...- _ ........................... } ,.� _......... r^�...� �...�.. ._._.... .............. -- -........_ Date . Application Disapproved for the following reasons: -----------------------------------------------------------------------------------------•--.--------- ........................................••--••----•-•----------.............-_........---•- -•----........----------•-------------•-----......------..........--••------------...............----.....Date Permit No..... _ t ...1. :_ Issued............................... Due r ............. .......... THE.COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Y� ` ' oF. y.: .................................... Trrtif iratr of Tomlif ttnrr THIS IS TO•_CE T FY, That tbp Individual3ewage Disposal System constructed ( C-r Repaired ( ) by..........................................................................• ..... !.(o ............ ........... at`= ............ :�t)� _.....---•,.../__�/i-••............... V. "... . ................... has been installed in accordance with:the provisions of ThLE -5 of.The State Sanitary Code as described_in the application for Disposal Works Construction Permit No..... �._.y�f-'_.�. dated_......-..................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THATTHE SYSTEM WILL FUNCTION SATISFACTORY. DATE.:............. � ._.....�-•---------.............------•--.......... Inspector... t� .. .... mow.c.s.w •a..a.r a a_ .-a a a w�.�.r._ys�.s .• .. n,a ww•n .................... ......L........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH tNo... � ........... ,�?.,. OF..........6�...j. r.. . FEE...--.�---•-•--.... e Disposal Yorks Tonptrudion Permit Permission is hereby granted......VJ.1...Z-----r•` p-.\. f_.. -mil T�-----••-••-•-•..............`.. . to Constr c (�) or,,Repair ( ) an Indvdtdual Sewa ge Disposal System at No..... ..h ?') __`'.---•�-=f- --- ----- J!. ---- -6 .............. .ry /f i; I , Street .� e c �; •• as shown on the application for Disposal Works Construction Permit No.�' .r7 n r Dated..................................... Board of Health DATE..............I-)...... ~f� ----------------------•- .......... H SECTION — SEWAGE ° L D ISEPTIC TAN 5 �..D..BOX LEACH �- � TOP OF,FDN ..2"OF II&TO I/i•• - x*R(nnSL)• WASHED STONE ...e Kh 4•t.'•.1�'1�iri' ftli-+...'il SJ'�'/`� It I � � O •.` ir IN• ( w OUT• IN. OUT IN • SE Ic i!T20 TANK ELEV. ELEV. ELEV. - ELEV 61 t ELEV. ELEV. $1 ti of V4.:..1,�.._ ELEV: WASHED STON {' , �� ';Y+ . `) 1 i r0, 3 3 Z 'foM__or r .. i Y TEST HOLE LOG I' # TESTBY R. �Fo��ba.nl; .� C.ol�Ia,h CB,(o.I-I TEST DATE ra rR 65 wITNEss 3 BEDROOM HOUSE. 5 DESIGN �q6 n T.H. r.1 T.H. # 2 ` 15.5 O = ELEV E •,t LEV I C NO `! L.00.w+ ER DI OS 8 3 DISPOSER DISPOSER PERC RATE MIN/IN. 5 ,1 as so \ 143,5 p FLOW RATE (GAL./DAY) 334 ..SEPTIC TANK 33C3 (000 4 \ REQ'DSEPTIC TANK SIZE cf LEACH FACILITYi-- a SIDE WALL"[r1ffx 150.72_ (2Z2) 23 'Z G/D. v BOTTQNI '�LBl�,�Z—:�•2L1 (}.92)"".. �16.2e G/D. •// Il-l- �33 0 TOTAL Zoo.9 t 6 � a 385,3� l „ Ca0 'SSA. o• - s USE: OIJ�i LEACHING I�il \ �, \� �•� 1 �'© WATER ENCOUNTERED G p� D V P NOTES: (UNLESS OTHERWISE NOTED) ��l;TP.�AGKG✓ 75g0 ©��� ��.,����� IZEb�C�"Cloll,. OFF 1 1.DATUM tMSV TAKEN FROM r..tl_�W .QUADRANGLE MAP ����T I 3�I T 2.'MUI'.ICIPAL WATER �-------J4VAILABLE �'�OF1 1 p'� I �j� �-7,� 3.PIPE PITCH:W••PER FOOT t`' �x �'• I I�-IO i 4.DESIGN LOADING FOR ALL PRECAST UNITS:AASHO- -44 .� � ' �'�--p..� � .��I — 71 S.M(N.GROUND COVER OVER ALL SEWAGE FACILITIES:(1)FT. RRAIE 6.PIPE JOINTS SHALL BE MADE WATERTIGHT ZE JALA �+� 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. �7i1 G LAN STATE ENVIRONMENTAL CODE TITLE S —c*C-IC A—aa OF �4 RS LOCUS: H.tOT �E t}�ED �C.�_ '�CLo.�--.ZT`C L...ti-ia= bTla�n...►G� Off. ,IS ��N ,r' ti ice.3 �u - ARN � REG.PR E/ INEERI E •� N. F-�u�1Z�_rL A Iv`_ L OJ �� EF: l.> I c a A�eerin ®O�IIa ��� � 8 � PREPARED FOR• `�. CIVIL ENGINEERS TER - R. Zvi SEt� Icy �. 8S .S & • LAND SURVEYORS - �- / � � '�g BOARD OF HEALTH �� RE R �` Q S� (EXISTING)------------- an SCALE ( -4 I�� CONTOURS (PROPOSED)-0-O-O�- APPROVED DATE �� �T��Y-�� MA ` .�. DATE SECTION - SEWAGE 40 LD SEPTIC TAN 5 � "D"` ' BOXY LEACH 11� % / TOP OF.FDN � SL)/► ..Z..OF VETO 3b" WASHED STONE '- IN• OUT• 1. = J/�/� N• OUT• IN• .. � � .. `1 t 1000G E IC �� k �qA 1 t To 'TANK .. ELEV. ELEV. ELEV. ELEV t%pl 11 ELEV. ELEV. OF V0 r 1d 3> �• 1uNO�' WASHED STON " 1 TEST HOLE LOG t' TEST BY �: oa�bq �. GC?1�1IG14'! LB.©.� •J ��..- `p � � 6 85 WITNESS TEST ORT� DESIGN BEDROOM HOUSE. -,t46 n �T:N: r.1 T.H. 2 d -aL ELEV.CI 55 ELEV. NO P DISPOSER DISPOSER ERC RATE MIN/IN. as5so � �143.5' FLOW RATE (GAL./DAY) 33O Y� t5o SEPTIC.TANK 33C3 (1.:�= 9 REQ'D SEPTIC TANK SIZE 1000 r-Av 2I, / LEACH FACILITY I: �-- a SIDE WALL—ir18 6 =Ir70.7Z- (2; i) '55D.I G/D. ?/ "\- BOTTOM '1r�8/S2�Z , 5p.2A I .92) 4G.2P G/D. / I li- /,33 0 \ TOTAL 2:00 '5 g� � '585,S4 4 t�O t� L' J ��5�,., �moo, -� USE: 01.I1%i LEACHING W f�W.VIA G' —l=.=WATER ENCOUNTERED LIlsT d>:vE P Fob� NOTES': (UNLESS OTHERWISE NOTED) �T��C�� OF" 1 4� 1.DATUM(MSL);TAKEN FROM lyil lY]L41[L� QUADRANGLE MAP 1 �l 2.'MUNICIPAL WATER 1 - AVAILABLE x QF 1 Ga)1p ��I - �,�I 3.PIPE PITCH:w"PER FOOT 'J 1 O ? 4.DESIGN LOADING FOR ALL PRECAST UNITS:AASHO- n -44 �F Q E 5-MIN.GROUND COVER OVER ALL SEWAGE FACILITIES:(1)FT. ARNE H. 6;PIPE JOINTS SHALL BE MADE WATERTIGHT o Cvl,LA 7•CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. y V L 441 PLAN E. A/�1 STATE ENVIRONMENTAL CODE TITLE 5 SITE f�LI' N 8 Tv.� pLA�J f=o� pk� tti�o�tX 4.-��`C n._,a �+-+o.�`� by OF RS LOCUS: LoT' 3�4� S•�a�l�c_Z l—�L�� - �-Jo-c- �E USED �aL �Crvk.�,�`f �.�.tC; �r�.�n._►v (),�, ,/� ���` �M A9 _ ARNE R EG.PR E INEER '� H. ✓ ^� ff/ 0i EF: Q®WII C��� �I��'I���I��Ig� ° 8 PREPARED FOR:op CIVIL ENGINEERS LAND SURVEYORS ——— �•E V I SE b ((� /t .: CjS .�j'(o►g�0 BOARD OF HEALTH RE R - (EXISTING)------------- SCALE CONTOUR$ (PROPOSED)-O-O-O-O- APPROVED DATE �Ta` � MA GATE S;> -Z-�S 1' 2000' +/ . . VENT PIPE(o Least 24 inches tau) SECTION A A Schedule 40 PVC w Charcoal Odor Filter AiL OUTLET PIPES FW N THE 10' min. from SCHEDULE 40 P.V.C. / PROFILE YI if OF ADDITION TO LEACHING SYSTEM IArSTRIeUTM BOX SHALL BE - [house *NOTE. ALL PIPES ARE TO 4 SC � t2 CONCRETE C04ER Existing Foundation to septic tank SET LEVELFOR AT LEAST z FT S TOP OF FOUNDATION _ ELEV. 100.00 (Assumed) Septic tank corers must be 3- of 1/8" - 1/2- Washed Psostone FR 6 within 6 M. of finished grade _ over SAS -96.00 3J4• to 1`t/2 ' Washed Crushed Ston 3_ K OUTLET , -' • 2 l'IC£ Grade over Septic Tank - 98.50 Ora" over D-Box 96.00 ,r _ KNOCKOUTS /- 4•PVC(CAPPED)INSPECTION PORT To BE / II wsTAuLW AND To BE Nn w 8"OF GRADE - 5.5 f Y NET S 0.02 3 HOLE H-10 _ "3' Moxlmum ower Top Load - 19w. -94.25 •_ ` \/ EXISTING S-0-01 or Greater dST. Box Top of SAS-Ekw. -93.75 �asT.r E td 8 1,000 CAL a 18 S- 0.01"per foot . ,5 - 4' - SCH. 40 Tee/ t.>s' °iQ vc 3a EM FROM EXIST, FOUNIIATION Iw (6 SEPTIC tTAW PVC TEE 1' 5 Units a 6.25' 30 PLAN SE:CTION CROSS-SECTION �s a / I o. rn CONCRETE Fuu: fOtNtDA O > A TO REDUCE d aa% o 0.83' (10 inches) 3' 31.25' 3' �Q' SIT a,rtQoja� wATEtt vaoaTY M -W--^ 37.25' 3 HOLE H-10 DISTRIBUTION BOX t` SYSTEM PROFILE w o eox � ' 'o of Effective Length NOT TO SCALE. r Not to Scale - -S ; SOIL ABSORPTION SYSTEM (SAS) LOCUS U M A P 0 3.58' 3.58' I c , Provided INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE ❑'BRIEN GENERAL NOTES 6 In.of 3/4•-1 1/2• - e Effective Vldth compacted .tone - � (OR EQUIVALENT) Not to Scale 1. Contractor is responsible for Digsafe notification m NOTE.- OVERALL HEIGHT OF INFILTRATOR IS 16' /EFFECTIVE HEIGHT IS 10" and protection Of all Underground utilities and pipes. Bottom of Test Hde t Ear-es.OD 2. The septic tank and distribution box shalt be set I level on 6 ,of 3/4"-1 1/2 stone. 3. Backfill should be clean sand or gravel with no stones over 3" in size. O p ! 4. This system is subject to inspection during installation ,•, �, by Carmen E. Shay Environmental Services, Inc, I n! / 5. The contractor shall install`this system in accordance with Title V of the Massachusetts state code, the approved plan PERCOLATION TEST , - --- 5 00� -' ? / and Laval Regulations. 10 5 i I / 6. If, during-installation the contractor encounters any Date of Percolation Test: JUNE 2, 2004 05" W �� I soil conditions or site conditions that are different Test Performed By. CARMEN E. SHAY, R.S., C.S.E. 58 s 78d 10B---_ - ______ ,�r i �� from those shown on the. soil log or in our design Results Witnessed By. WAIVER ( per BARNSTABLE B.O.H.) r ROBERTS SEPTIC SERVICES LOTS 3 & #46 �� � > O installation must halt & immediate notification be Percolation Rate: Less Than 5 MPI ® 60" # made to Carmen E. Shay - Environmental Services, Inc. f5,080 Square Feet / 7. No vehicle or heavy machinery shall drive over the 106___ _ /�� �/' j / septic system unless noted as H-20 septic components. I " ------- 8. Install Tuf-rite gas baffles or equals on all outlet tee ends. ' n Lines shall be 4" diameter Schedule 40 NSF PVC pipes. f Test Hole � '� ',.' / 9. All Distribution I No. 1 104-__ ' --' �.' 10.-Alt soled piping, tees Ec fittings shall be 4" diameter j DEPTH SOILS ELEV. �``'--------- - -'�' Schedule 40 NSF PVC pipes ,with water tight joints. 0 9&00 10,2 _ _ � too / / 11. Municipal Water is Connected to ALL OF The Residence and Abutting j _ _ _ 100Sand ____ ___ T.25 -Jr..� Properties Within 150 Feet. Loamy � , 10 YR a/z - O-_6- A, s7.25 .,,-.•�� -' . -.., _ •:.,••ti, / THE PROPERTY LINES ARE APPROXIMATE AND COMPILED FROM THE SURVEY PLAN GENERATED BY Sandy =t' e• �• i'rt DOWN CAPE ENGINEERING of YARMOUTH, MA f ' " 4Y i'}- / ENTITLED " CERTIFIED PLOT PLAN OF Jj40 SADDLER LANE Loam 4+s c;S•w 1 ,.. _..' " Tr 10 YR 5/6 98- c.r Co 4 PV - ------.___D-Box Vent W. BARNSTABLE, MA", DATED JANUARY 1, 1986 8"-'`24" e. 96.00 _-- died / AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN Lsut Leach Pit CO IT SHOULD BE USED FOR NO PURPOSE OTHER THAN { 2.5 Y 6/6 ��\ I THE SEPTIC SYSTEM INSTALLATION. I 34-_ 60- C 3.00 TEST HOLE #1 `. Med - a ELEV.= 98.00 f EXISTING LEACH PIT TO 8E PUMPED OUT AND EXIST.Sand 1000 gal. / -� REMOVED TO FACILITATE INSTALLATION OF NEW SAS. 25 Y 7/4 Septic Tank LOT #25 IBO-- 144 .00 NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE DECK / FROM THE EXISTING LEACH PIT TO BE DISPOSED � OF AS PER BOARD OF HEALTH SPECIFICATIONS. MARK PROJECT BENCH _MA __ o _ TOP OF FOUNDATION N0 WETLANDS' ARE PRESENT WITHIN 200 OF THE PROPERTY ELEV. = 100.00 (Assumed) # Perc #, LEGEND Depth to Perc: 60" to 78" EXTSTINC Q Perc Rate- Less Than 5 MPI 3 ByDRO0�1( Observed ESHWT- None Observed ADJUSTED H2O Elev. None A0USE ---1 104X, 1 DENOTES PROPOSED LOT #47 It. ;I �J C� SPOT GRADE g6 .I� N DENOTES EXISTING I .\ 1 �+ X 104.46 � 1 � - SPOT GRADE , ASPHALT CO 1t DRIVEWAY '� PL PROPERTY LINE � �i71 PROPOSED CONTOUR 9767 -------- - - - - - - 1 / ` 97 EXISTING CONTOUR �c�; it DEEP TEST HOLE & 2-1 a' aAN. AccEss MANHOLES g�� � CD � - PERCOLATION TEST LOCATION Cb •---. 6 FOOT STOCKADE FENCE 10 ASSESSORS MAP 151 PARCEL 044 THE ACCESS COVERS FOR THE SEPTIC TANK. ' INLET T DISTRIBUTION BOX AND LEACHING COMPONENT OUT SET DEEPER THAN 6 INCHES BELOW FINISHED GRADE SHALL BE RAISED TO VATHIN 6' OF PLOT PLAN FINISHED GRADE `� -i ��� , '1 _ 34 OF PROPOSED SEPTIC SYSTEM UPGRADE 1 13. , INSTALL TUF-TITE GAS BAFFLES OR EQUALS --� �• T�•-r•- 1 .G. - - / STEEL REINFORCED PRECAST CONCRETE 9 r K 509.92 '•/ / - �.- � �_,-' PREPARED FOR PLAN VIEW -_' MS . DEBORAH CIBELLI 3-24" REMOVABLE COVERS-� / 9 0-- _. L_- V6, AT I � l t 4. LAC \NAYS #40 SADDLER LANE -e.: .3'men•clearance tr ae-ET �_-----""__'--- --- 1 / Y 'j RIGH� °` Y MET B- mM.T- 2• min. hwt t rnin o autlet S h 5° °° WEST BARNSTABLE, MA t0-men-� idTe� OUTLET t 5' -r Design Calculations s -r E 5 r 4'-0- min. �N OF)RA ." PREPARED BY: Number of Bedrooms: 3 Equivalent to 330 Gal./Day (330 Gal./DoyLn.' per Title V) � ro.se. :• uaw,ld depth. ... 0 20 40 50 os = ' , Garbage Grinder: No ! E.a CARNEY ,S`HA �' Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V . :,,.,,t,• �, .y:-91., . - _..- i Septic Tank 3 x 330 Gol./Doy- 660 USE EXIST. 1,000 GAL ptic Tank. ENVIRONMENTAL SERVICES, INC. s_o 4' -t0' SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch >, $f Bottom Area: 0.74 gal/sq. ft. x ,370 sq. ft. 273.8 gallons SCALE: 1 "=20' 9 o P.O. BOX 627 CROSS SECTION END-SECTION Sidewoll Area: 0.74 gal./sq. ft. x 78 sq. ft. m 58 gallons ISTE EAST :FALMOUTH, MA 02536 P Ing: = 331.80 gallons AmTARk�'N TEL/FAX 508-548-0796 .- Use: 5 INFILTRATOR HIGH CAPAC 1 -10' UNITS, HAVING A 0.83,(10 INCHES) EFFECTIVE DEPTH, AL 1 =20' DRAWN $Y: CE5 DATE: DUNE 4, 2004 USE EXISTING 1000 GALLON H 10 SEPTIC TANK U O SCALE:TO BE USED WITH .3.58' OF WASHED S ON THE SIDES. AND 3.0� ' WASHED STONE NOT TO SCALE ON THE ENDS. NO STONE'UNDER. PROJECT SD580 FILENAME: SD580PP.DWG SHEET 1 OF 1