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HomeMy WebLinkAbout0100 SADDLER LANE - Health 100 Saddler Lane A= 151 -052 Marstons Mills I No. Fee �Q V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rpphration for Miow6ar �&pgtem Cow5tructiou Permit Application for a Permit to Construct( ) Repair K Upgrade( ) Abandon( ) ❑ Complete System Individual Components Location Address or Lot No. 100 SADDLER LA,01�- Owner's Name,Address,and Tel.No. I"(AR�Tc�tvs rc c. MA ORM, U (?>(- KLEY Assessor's Map/Parcel ( 5 f a 5--1 767 f7ALKA&Ib P-b u4tjC0 v ciAoA>4 Installer's Name,Address,and Tel.No. 50i' (A77� 7� Designer's Name Address and Tel.No. Cr46t-wIvE c0TSWIUS'ES c-(-C- ,�y 4 t Co Type of Building: Dwelling No.of Bedrooms Lot Size q%S � sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ---- Bo Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date Application Approved by Date IN 1 Application Disapproved by: Date for the following reasons Permit No. 57-, '3 " Date Issued A 4 1 \� VV v 1 c".� " No. � Fee / 'THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes l ZIpprtcation for Dt5po.5ai *p!tem Cowaruction Permit Application for a Permit to Construct( ) Repair f)<) Upgrade( ) Abandon( ) ❑ Complete System EX Individual Components Location Address or Lot No. 100 _<AT)'pLjEV L,045' Owner's Name,Address,and Tel.No. MAa5TON5 utru. eta s 3cx c,6Y ^Assessor's Map/Parcel ( 5 ' o 5 qest *'(Q 7 �'A 'q-AN4b KP VANC J U>� D l� cmot-st 4 3 - ^� Installer's Name,Address,and Tel.No. 50'g- 977-S S7 1 Designer's Name,Address and Tel.No. ��� 151 Co S a4s-+�p Type of Building: j Dwelling No.of Bedrooms Lot Size (p (3bGG 2-y sq.ft. Garbage Grinder ( ) i Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Desigl4low(min.required) gpd Design flow provided gpd a Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) E!ci> Knox Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date Application Disapproved by: Date for the following reasons I� Permit No. c c�— Date Issued ' J THE COMMONWEALTH OF MASSACHUSETTS 7� BARNSTABLE, MASSACHUSETTS Certificate of Compliance •4s'+b+'`� tF THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (�) Upgraded ( ) ,:;Abandbpeedd( )by CAp w, rb cc � i E�. L�. at n S A fl Ts LC L-N !"!A:k S-r,)jJ S I WS has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. G/ - �� , dated It 13. Installer (!A067,i )(hi5�- t-'{ �.)..*.- Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system twillfunctd6A as1designed. Date ( 'trt l (� Inspector \ \ I �� —No Fee���% � — / _. —_— —_._. _..—_---—— ..———— s THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS pgtem Construction Permit Permission is hereby granted to Construct ( ) Repair O Upgrade ( ) Abandon System ( ) System located at 100 5 AM 4 eP- Ak it M A;Z Smp 0 S; i � and as described in the above Application foi>Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. ' t Provided: Construction must be completed within three years of the date of this •e mite` Date ( Approved by- i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "( 100 Saddler Ln. Property Address Maureen Johnson Revocable Trust Owner Owner's Name �/ information is required for every stab* I f A 0fl MA 02668 11-8-13 page. City/Town 1 5 1 , D 5& 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 A. General Information filling out fortes A. on the computer, ��������tt1 OF 4 ����i�, use only the tab �.�` �' � 1. Inspector: ��'' key to move your cursor-do not James D.Searuse s ? JAMES key,the return Name of Inspector `__0; SEARS Ca ewideEnter rises,LLC =* P P <1 my Company Name %�j•'•.•.RTIF� .•;�O\ F 153 Commercial St. I N SPE Company Address Mashpee MA 02649 City/Town State Zip Code 508477-8877 S1623 Telephone Number License Number B. Certification I certify that l 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 11-12-13 spector'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 th e same or different conditions-of use. t5im•3113 Title 5 ofl5cad hVecbw Fomr SubsuRac9 Sewage Disposal System•Page 1 of 17 N Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Saddler Ln. Property Address Maureen Johnson Revocable Trust Owner Owner's Name information is required for every West Barnstable MA 02666 11-8-13 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/ahvays 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: 8) 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): trim•3113 Us 5 ores kq)ecbm Fomr.st6surface SwW Dim system,.flee 2 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Saddler Ln. Property Address Maureen Johnson Revocable Trust Owner Owner's Name information is required for every West Barnstable MA 02668 11-8-13 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 pumpstalarms are repaired. B) System Conditionally Passes(cant.): ❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts U"< Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Saddler Ln. Property Address Maureen Johnson Revocable Trust Owner Owner's Name information is West Barnstable MA 02668 11-8-13 required for every page. City/Town State Zip Code Date of Inspedion 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 eaaspwl is less than 6°below invert or available volume is less than Y2 day flow P17— t5ins•3M 3 Title 5 Official inspection Fanx Sutis+aface Sewage Disposed System•Page 4 of 17 Commonwealth of Massachusetts lug Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Saddler Ln. Property Address Maureen Johnson Revocable Trust Owner Owner's Name information is West Barnstable required for every MA 02668 11-8-13 page. Cityrrown State Zip Code Date of Inspection B. Certification(cunt:) 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 collform 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 MUStr 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•3113 True 5 offidal tnspedion Form:Sutsurfam Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Saddler Ln. Property Address Maureen Johnson Revocable Trust Owner Owner's Name information is required for every West Barnstable MA 02668 11-8-13 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 Sol[Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. for example, a plan at the Board of Health. ❑ 0 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)1 D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 f DESIGN flow based on 310 CMR 15.203 for example: 110 d x#of bedrooms): 330 ( P 9P ) t5ins•3113 Trde 5 Of dal Inspection Forth:Subarfaw Sewage Disposal System•Pape 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Saddler Ln. Property Address Maureen Johnson Revocable Trust Owner Owners Name Information is required for every West Barnstable MA 02668 11-8-13 City/Town page. State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal.tank, D Box and pit. Number of current residents. 0 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 Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2011-102,000Gal g ( y g (gPd))' 2012-183,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title.5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 100 Saddler Ln. Property Address Maureen Johnson Revocable Trust Owner Owners Name information is required for every West Barnstable MA 02668 11-8-13 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: NA 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): Wins•W13 Me 5 OffidW hVed w Fomr.Subwdbw Smap Disposal System•Page 8 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments , 100 Saddler Ln. Property Address Maureen Johnson Revocable Trust Owner Owner's Name information is required for every West Barnstable MA 02668 11-8-13 page. City/Tom State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 1985 permit # 85-913 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30"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.): Pipeing is 4"PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 20"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 Gal. Precast Sludge depth: 2" !Sins•3113 Title 5 Officd Inspectim Form:Subsurface Sewage Disposal System•Page 9 or 17 Commonwealth of Massachusetts T DI Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Saddler Ln. Property Address Maureen Johnson Revocable Trust Owner Owner's Flame information is required for every West Barnstable MA 02668 11-8-13 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 28" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge 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 at working level. Tank and cover's at 20"below grade. Inlet tee, outlet baffle. No sign of leakage or over loading. 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•3H 3 Title 5 Offidal Impaction Form: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 "e 100 Saddler Ln. Property Address Maureen Johnson Revocable Trust Owner Owner's Name information is required for every West Barnstable MA 02668 11-8-13 page. Cityfrown 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 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 100 Saddler Ln. Property Address Maureen Johnson Revocable Trust Owner Owner's Name information is required for every West Barnstable MA 02668 11-8-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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 16"x16"-34"below grade w/cover at 6". D Box is new 11-2013 Wone line out. 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: a t5ins•3H3 Title 5 t)MCkel bspection Fomr.Sibssrace Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Saddler Ln, Property Address Maureen Johnson Revocable Trust Owner Owner's Name information is required for every West Barnstable MA 02668 11-8-13 page. Cityrrown State Zip Code Date.of Inspection D. System Information (cont.) Type: ® leaching pits number. 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: �I ❑ 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 is a 1000 Gal. Precast pit w/1'stone. Pit at 3' below grade w cover at 2". Pit is wet bottom w/stain line at 3. No sign of over loading or solid cans over. 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•W 3 Title 5 Offiaal UMPeCbW Form:SLOS08 a Sewage OMp)W System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments "< 100 Saddler Ln. Property Address Maureen Johnson Revocable Trust Owner Owner's Name information is required for every West Barnstable MA 02668 11=8-13 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): I Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins•3113 Title 5 Ofrbat Inspection Form:Subsurface Sewage Dispose!System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Saddler Ln. Property Address Maureen Johnson Revocable Trust Owner Owner's Narne information is required for every West Barnstable MA 02668 11-8-13 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately /A-1 ' 13-i - 3 ,4 `9= 33�g' 13-a Z7 J:a EAR A -3 o o ❑ O � tNm•3113 Me 5 Of oal bspechm Fomr&ftHfaoa Sewage Owposel System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 100 Saddler Ln. Property Address Maureen Johnson Revocable Trust Owner Owner's Name information is required for every West Barnstable MA 02668 11-8-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells yo Estimated depth t4ihigh ground water 11'-611+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: 6-11-85 Date ❑ Observed site(abutting propertylobservation 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: T.H.on Design Plan no G.W.at 11'-6"+. Bottom of pit at 9'below grade. Bottom of pit at 2'above T.H. Depth. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•3113 Title 5 OMCW tnsP8CtiW FOME&&Wftoe Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "f 100 Saddler Ln. Property Address Maureen Johnson Revocable Trust Owner Owner's Name information is required for every West Barnstable MA 02668 11-8-13 page. City/Town 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 5ins-3113 Tide 5 0MCkd Inspection Form:Sibwrfeoe Sewage Disposal System•Page 17 of 17 '7 V. LOCATION #vvsLz: 99'� /00 SEWAGE PERMIT NO. VILLAGE a I N S T A LLER'S NAME i ADDRESS tq �� HiC,� d UILDER OR. OWNER DATE PERMIT ISSUED to/ii?1,CS DAT E COMPLIANCE ISSUED 12 _ — � �- b3 4 4- r . K@B ................... ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD GF HEALTH Pij 11!:�.................. --k . ­ 0 ..............OF.....................O..Vr.....�..T Appliration for Dig posal Works Tomitrurtion Prrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System a ...........0....... -f-P.! J2 .......................... -------- ---- oc ion-Address, r I L No Y -7..........�4 ......�:................................... ....... ......... 0, ner es. ................... -- ------ .. .. ............................ 4� Yta er Address Type of Building Size Lot../-7. U Dwelling—No. of Bedrooms..:...3 "a/0 - ----Sq. feet ....................................Expansion Attic Garbage Grinder pa Other—Type of Building ............................ No. of persons......_..._......._..__._... Showers Cafeteria P4Other fixtures -------------------------------------------------------------------------------------------------------------------------_---------_------------- < 7 Ions. DesignFlow............................................gallons per person per day. Total daily flow............................................gal Septic Tank—Liquid capacit3�Ma_ allons Length...... Width...-ft—p_ Diameter................ Depth.. epth................ Disposal Trench—. No..._........`......_* Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------- --------- Diameter......20......... Depth below inlet:._.....-__.... Total leaching area_20,1....sq. ft. Z Other Distribution box Dosing nk e-l?—A ............ .. .... .. 1.4 Percolation Test Result Performed by._...A./_ ........... Date.............. -test Pit No. I_/,_'2___._!inutes per inch Depth of Test Pit----/V........ Depth to ground wate -- ------ - rT4 Test Pit No. 2................minutes per inch Depth of Test Pit....._.........._._. Depth to ground water------------------------ % 4. ..................................... 0 ................... Description of Soil . ........... ......... .......... ....... ................................................... ......... ............... .......................................................................... ............................................................................................................ U . Nature of Repairs or Alterations—Answer when applicable. .................................................................................................................................................................I..................................... Agreement: The under7si�\Dq ere�epst'o install the aforedescribed Individual Sewage Disposal System in accordance with IT k A. in the provisions of TIZ- 5 of the State Sanitary'Code—The�Pdersigned further agrees not to place the system operation until a Certificate of Compliance has bee sued by We b of health. ed ............ Application Approved By........... ................ ............. ....................... ....... Date Application Disapproved for the following reasons:--- ..........................................................................................................- Date Issued........................................ Permit No...... d:_�_ ............ Date Fri— V #� V ... . .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................­..........._0F................................. Appliration for Disposal Works Tonstrurtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System t j ................ ..W..... .. .. .. ............................................. .... ..... ....3.......... tion-Addres t N�o. 17 Z X ...............�..dk_ 6........ ......V. .............................. ..... . ... .. .... ...... Owner dress ........... ..................................................................... ............H �nstaller--- Address Type of Building Size Lot./%7 0? .....Sq. feet Dwelling—No. of Bedrooms_____ .................................Expansion Attic Garbage Grinder kle `LI PLI Other—Type of Building ............................ No. of persons............................ Showers Cafeteria P4Other fixtures ...................................................................................................................................................... Design Flow________________________________ ______gallons per person per day. Total daily flow............................................gallons. 04 Septic Tank—Liquid capacity''��. . allons Length___.-� J,J? Width.l.'r.-'o... Diameter________________ Depth_..._._______... Disposal Trench—No_.................... Width_____............... Total Length.________...___.____ Total leaching area....................sq. ft. Seepage Pit No........ .......... Diameter..... I...... Depth below inlet.....ee'............. Total leaching areaZOV.....sq. f t. Other Distribution box Dosingynk Percolation Test Results Performed by_ .................... Date________________ 04 Test Pit No. 142------minutes per inch Depth of Test Pit'-/' . Depth to ground water....;.` Test Pit No. 2................minutes per inch Depth of Test Pit_____.._____________ Depth to ground water.______.._..____.__.___- ............../. ....... .............7... .... ......... . ..............0 Description of Soil. `_Z= ...........dt.. ---------5Tx1.,^.e 4r....... li ............................................ WU --------- ........................................................................................................................................................................................................ �4 U Nature ot,Repairs or Alterations—Answer when applicable............................................................................................... ....................................................................................................................................................................................................... Agreement: The underXgRes to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'2ITIZ 5 of the State Sanitary Code— The rdersigned further agrees not to place the system in operation until a Certificate of Compliance has be i,sued by ekyd of health. -Signed . .. . . .............................................. D Application Approved BY---------- .... ........................ ............................ ..... Date Application Disapproved for the-following reasons:.............................................................................................................. ...............w...................................................................................................................................................................................... Date PermitNo......<.-S----- ------------- Issued....................................................... Date "?HP_ COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... • xf ............................ (Intifirab of Toutpliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed �r Repaired by............ ..,.,../.....5...... _21 -----------t------------ -------------------------------- ------------------------- C Installer......................... a. &.................. has been installed in accordance with the provisions of MILE 5 of The State Sanitary C s ad,in the application for Disposal Works Construction Permit ..... dated------- . .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............. 1 .. ............................. Inspector...... ----�- ----------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 317..... ................. FEE........................ Disposal Works Tons ution "prrmit Permission is hereby granted.--------- ......... --------------------------------- to Constru r 12epair an In ividual Sewage DISDosal System at N treet as shown on the application for Disposal Works Construction Permit NF................... a T:5.................... ................ ........................................................................— DATE-----1.6.1-11alix... Board of Health ......................I ..................... ...... FORM 1255 A. M. SULKIN, INC.. BOSTON SECTION - SEWAGE I -SEPTIC TANK - `j -"D"BOX - �jt -LEACH P I Y j TOP OFFDN 1 Einn a00(MSL)A -••2••OF t/8TO Yz" WASHED STONE rnin I co 148 IN• OUT 4 IN• /JQ15� q =1;1gGOUT• 9NI.. GELEV. ELEV. ELEV. el-7 I ELEV. fKAy L 1ST G ELEV. ELEV. CDC h � G 5 a9 r rS WASHED STONE TEST HOLE LOG Z1 I q•oo ' ES TEST BY 1Z:�a,�rbor��.C�'E� J.C�orrint't�C?�•©.I-I. J '-.a _15� WITNESS k' TEST DATE DESIGN BEDROOM HOUSE, a T.H: T.H. # 2 _ ELEV. IJ�/ ELEV. DISPOSER DISPGSSER G �-- PERC RATE �MINAN. NO 5 ( FLOW.RATE.3-6n (GAL-/DAY) �2 itA / lid' (�� SEPTIC TANK 3� (t.5)= ,/ ` T., �J5 M t rn REQ'DSEPTIC TANK SIZE \O s LEACH FACILITY SIDE .WALL �5TC(l '7?77,0 G/D. '5Z � � �"' ��., ---�.. �9� S• 15t� . n BOTTOM '�_' Sl).3 r ,ao ) a G/D. Tiro, S Salk- TOTAL o� Ll USE: �`'►� LEACHING (4-S If WATER ENCOUNTERED NOTES: (UNLESS OTHERWISE NOTED) 1.DATUM(MSL)+TAKEN FROM �-''"���G�11 QUADRANGLE MAP 2.MUNICIPAL WATER AVAILABLE 3.PIPE PITCH:VA"PER FOOT ' 4.DESIGN LOADING FOR ALL PRE-CAST UNITS:AASHO- .44 /- 1 S.MIN.GROUND COVER OVERALL SEWAGE FACILITIES:(1)FT. �l�K OF 6:PIPE JOINTS SHALL BE MADE WATERTIGHT 7-CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. �� ty SITE �! /!1s1 STATE ENVIRONMENTAL CODE TITLE S g ARNE H. G SITE a- rl..AN a. T�-itS Pt�A►• 1 Fob 7P� .� wiOLJC O�a``C a..�sp bsa-b OJALA �' I..tCsT �� U�b r=aZ., '�ra�Z�`•f L...,c— �-dr.,+..�� L� Idl cn ° ..LOCUS: S0 l_�E t,At,-T;; Lo P °t 21- _ 11 tJ nrrAt �t , uN ► aer Of 3le WITH GJNGODtsE To iECtuM Io Fo? I<l>t INEER o' ARNE REF: look cape eftglfteerietbf i� � PREPARED FOR: " CIVIL ENGINEERS LAND SURVEYORS - BOARD OF HEALTH CONTOURS (EXISTING)--- l �f�1�7�i � ° lA�i'� SCALE � - � S (PROPOSED)-O-O-O-O- APPROVED GATE MA �A ►y r�,�' D TE gE'2I S _ I