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HomeMy WebLinkAbout0035 SAINT ANTON'S WAY - Health 35 Sall nt Anton's Wi Marstons Mills :P A = 031 . 001023 I I' I No. v 01 3 f Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftPtiLation for Misbosal*pstrm Construction permit Application for a Permit to Construct( ) Repair(:Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No._35 54�,A470n* Owner's Name,Address,and Tel.No. DOW fe$ ,-`"c.q Assessor's Map/Parcel 3// "013 E50 C Installer's Nam Addres �, s,and Tel.No. pr` Dto Desi ner's Name,Address d Tel.No. Con<.t_v 4ame 1' =21 Type of Building: Dwelling No.of Bedrooms Lot Size L sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 349 gpd Plan Date W64- le�W j,4- Number of sheets Revision Date 0 l A.- Title Ili Size of Septic Tank 1 ow aal Type of S.A.S. f �40.e- Description of Soil a i Nature of Repairs or Alterations(Answer when applicable) gzn 1 Qj 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 Environme !od�ea!not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt J�/ S' ed Date Application Approved by Date Application Disapproved by Date for the following reasons t Permit No. 3 Date Issued !� 0 ' S t , No. L/ ) r v Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: -PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for 33is sal:*pstem Construction Permit Application for a Permit to Construct( ) Repair(V,01**Upgrade( )'Abandon ) ❑Complete System ❑Individual Components i Location Address or Lot No.-35 54-.Av)40f-)S W Owner's Name,Address,and Tel.No. DU1 U res ", 'n�3 Assessor's Ma /Parcel J c� 1^clY'fl P G.GO* 1-790 CO'}Ui d- 0�(D 3!5 p 3/ 50 g• 4-20-S nstaller's Name,Address,and Tel.No.JE30f*D 10 Designer's Name,Address a d Tel.No. o /)CCU-P v Ar),S rtucvvt3.�yx, 4o- J:Z)(�us� R/ C itlt�erl`nIcrs� u,n6�fe `J AS006 M� ! 1 71- 39 r�•Gac� o�• Type of Building: t Dwelling No.of Bedrooms 3 Lot Size I sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures • I !1 Design Flow(min.required) gpd Design flow provided gpd Plan Date Au CKP_,w- 1rslW i t- Number of sheffs Revision Date ►.i /^', Title J Size of Septic Tank OW Type of S.A.S. OrA �1() CU Ilinleo-of S. Description of Soil C I Cl Cj e-, 1`j Nature of Repairs or Alterations(Answer when applicable) 1)t 6. i n' .5Un 0,(Ao o E`eac Date last inspected: Agreement: i 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 Environme ode d not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health S'gned _. Date K/.7 k`y Application Approved by Date Application Disapproved by Date for the following reasons Permit No. O`t/ _ f Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance _ THIS IS TO CERTIFY,that the tOn-site Sewage Disposal system Constructed( ) Repaired( �� Upgraded( ) Abandoned( )by _)OV Q)d4'F{ at 3.5 64. A(>�)F-N'�2 �ja&4 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Nop9O/`a`3�� dated Installer Designer #bedrooms Approved design flow C� gpd The issuance of this p rrri shall hot be construed as a guarantee that the system 11 func es ed. Date / / Inspector ------------------------------------------------------------------------------------------------------------------- No. '�f — 31 ) Fee / `y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS disposal �&pstPm Construction 'permit Permission is hereby granted to Construct( ) Repair(y ,. ` Upgrade( ) Abandon( �) System located at rj S�. V1���t`}"S K)(JQ.1,/ , vo.f and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction m bp complet d within three years of the date of this permit Date Approved by SEP-24-2014 20:18 From: To:15087906304 Pa9e:1J1 -Towu of Barnstable Regudatory Se ee9, Thomas F.Geiier,Director Rem a Public He2it n DiTWOU a6�g. tom° Thomas McKeam,Dise4oa No Simet,Hjr.=As,MA 02601 Office` 508-962-4644 Fax. 508-790-6304 Date: /7 l Sewage pe»t4 .20i11�31I Ass�ssdDY''s 11�[a�13Pa�ceit l ��z3 ti Desigmier: l QWA F221t � InstaIlfl¢r: _ Address: address: �LI �� �70 on '36 14 &4J'&+L issued a permftto in5t3ll a (date) (installer) ��}� 5 tiG at Dr cJ �+ - dlloW Ad based can a desip drawn by (adXess) A4u&lfi-. O%Xk dated 'R S I certify that the septic system.iefeznaced above was ins`,alled substantially accozding to the design,wbich may auclude minor approved changes such as lateral zelocati,on of the di s ribuHon box and/or septic tank. I ceeity that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS ox any ical relocation of any component of the septic system) but in accozdance with.Stattc&Local Regulations. Plan.revlisiOD.or certified as-Built by designer to follow. - fCy9 DANIE!A. n S (Wstaller's u' No 46". Cs`�•.ONAL E��a e f (Ax 1peT 9 Stamp-HM) P.S1�.P.I SulgLiafllx.) -_E,j,EAn 3dE'Y'iTW TO BALRNEIL� PiT�}.iL C MMIM MU QD1�T. Tf]f+TCATE OF Cv FArTCE NCD t � SST t7t II, BOTH Tffi5 FOAM PD �,;;-�LTlLT CARD ARE RECF VED H-X THE TABLE Uc LT'H pMMN. T aANK YOU. rprtif,rsifirm Fnrm 1-26-N.doc SENDER: COMPLETE THIS'SECTION . . . ■ Complete items 1,2,and 3.Also complete at item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name-and address on the reverse ❑Addressee so-that we.can return the card to you. B, eceivedC(Pr' ted Name) C. Date f De ery N Attach this card to the back of the mailpiece, 1`= or on the front if space permits. D. Is delivery dress different from item 1? Ye 1, Article Addressed to: If YES,e-4 delivery address below: ❑No I Cores K Lowe I -74xTracey.Road `I `CUlt, MA 02635 3. Service Type ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise — --- ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?.(Extra Fee) ❑Yes 2: Article Number - f` (Transfer from service label) 7 012 1010 0000 2851 42 3 5 I PS Form 3811.February 2004 Domestic Return Receipt I ry p 02595-02-M-15401 i UNITED STATES POSTAL SERVICE First-Class Mai! Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • Town of Barnstable Public Health Division ` 200 Main Street F i Hyannis, MA 02601. a k. i r Town of Barnstable Barns`table Regulatory Services Department 1 59. ,.� Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7012 1010 0000 2851 4235 - August 7 2014 Dolores K Lowe 74 Tracey Road Cotuit. MA 02635 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 35 Saint Anton's Way, Marstons Mills, MA was last inspected on 7/ 01/2014 by Shawn Mcelroy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00). • Backup of sewage into facility or system component due to overloaded or clogged SAS. • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS. You are ordered to repair or replace the septic system within one (1) year from the date you receive this notification. Failure to repair the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Th as McKean, R.S., C • Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\35 Saint Anton's Way Cot 2014.doc . J Commonwealth of Massachusetts d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Saint Antons Way M Property Address Dolores Lowe Owner Owner's Name information is required for every Marstons Mills MA 02635 7-1-14 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 C7 tv Telephone Number License Number i� B. Certification = I, f I certify that I have personally inspected the sewage disposal system at this add ess and that the,' € information reported below is true, accurate and complete as of the time of the i p:spection.- he it ection was performed based on my training and experience in the proper function and haintena a of rn9 site sewage disposal systems. I am a DEP approved system inspector' ursuant to Sectio*�15.34�of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 7-1-14 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. I Z2, t5ins•3113 Title 5 Official Inspection FoVurfa.. age Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Saint Antons Way Property Address Dolores Lowe Owner Owner's Name information is required for every Marstons Mills MA 02635 7-1-14 page. CityTTown 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 3-10 CMR 15.303 or in 310 CMR 15.304 exist.-Any failure criteria not evaluated are indicated below. Comments: 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 35 Saint Antons Way Property Address Dolores Lowe Owner Owner's Name information is required for every Marstons Mills MA 02635 7-1-14 page. CityrTown 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fo rm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Saint Antons Way Property Address Dolores Lowe Owner Owner's Name information is required for every Marstons Mills MA 02635 7-1-14 page. City/Town 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'depthin cesspool is less than 6" below invert or available volume is less s than`'h.day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ,g Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 35 Saint Antons Way Property Address Dolores Lowe Owner Owner's Name information is required for every Marstons Mills MA 02635 7-1-14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cost.) 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•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 35 Saint Antons Way Property Address Dolores Lowe Owner Owner's Name information is required for every Marstons Mills MA 02635 7-1-14 page. City/Town 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•3M3 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 ,M s 35 Saint Antons Way Property Address Dolores Lowe Owner Owner's Name information is required for every Marstons Mills MA 02635 7-1-14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 7-2014 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-3113 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 0 35 Saint Antons Way Property Address Dolores Lowe Owner Owner's Name information is Marstons Mills MA 02635 7-1-14 required for every 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--pumped 6-2014 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance 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 W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 35 Saint Antons Way Property Address Dolores Lowe Owner Owner's Name information is required for every Marstons Mills MA 02635 7-1-14 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: 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ® cast iron E 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank (locate or,site plan): Depth below grade: 12"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 Sludge depth: 6" t5ins•3113 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 M 35 Saint Antons Way Property Address Dolores Lowe Owner Owner's Name information is required for every Marstons Mills MA 02635 7-1-14 page. City/Town 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 26" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 611 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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 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 G'M 35 Saint Antons Way Property Address Dolores Lowe Owner Owner's Name information is Marstons Mills MA 02635 7-1-14 required for every page. City/Town 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 �M 35 Saint Antons Way Property Address Dolores Lowe Owner Owner's Name information is required for every Marstons Mills MA 02635 7-1-14 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.): Good condition with water at working level and visible stain lines above invert. 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: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM , 35 Saint Antons Way Property Address Dolores Lowe Owner Owner's Name information is required for every Marstons Mills MA 02635 7-1-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit had visible stain lines above the inlet invert. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 35 Saint Antons Way Property Address Dolores Lowe Owner Owner's Name information is required for every Marstons Mills MA 02635 7-1-14 page. City/Town 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: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): .s t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form gSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Saint Antons Way Property Address Dolores Lowe Owner Owner's Name information is required for every Marstons Mills MA 02635 7-1-14 page. Cityrrown 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 he area below ❑ drawing attached separately r6�, , f 0 i 10 . I t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 35 Saint Antons Way Property Address Dolores Lowe Owner Owner's Name information is required for every Marstons.Mills MA 02635 7-1-14 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: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts m W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 35 Saint Antons Way Property Address Dolores Lowe Owner Owner's Name information is required for every Marstons Mills MA 02635 7-1-14 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 T�DVVhT ►lF BARNST ��. , MWAG Lodh TION ,p�� .► ASSESSOVS MA"X'&b.Ox .... INSTALLER'S NAIM-EjAy hit{V SEE LTV T� NK CAPACI ............. IT'I X. 03 p3) r . . P?kOomS_,_.3 PIE /ilTfl"i' + _ �.:�ONI1bCrI�N4 ►ATE, � . S�pr�ratio[[R�utucarr l3ctv�ee[►Sk��, ;. Nl�xiiquml��ljustcclGiau[�dwatec'l'�blelatlicB�ttotndiX,c;auhtcc�I7ncilit+i ....�.....����. ��i P►W.�w s 601Ay V Il-.micl Y. hing C?F[c [)► uwy VI(Ills ehis't (c� [M os,within; Q{l Feat uk l ii hio► frt il►ty) .: ._ -----..b-� 13c1�i;(if wet9 nd(Uld URCI ng 6611ity(if airy IFee wiflilli 300 feet of eaching facility) � � � ' � ��. c L c1 NL c` CID a - 1 ' L 0 C A T f vs� 35 SEWAGE. PERMIT NO. . S U I L 0 E R OR MiER )DATE PERMIT ISSUED Cc, �i J9 THE COMMONWEALTH OF MASSACHUSETTS 72a�m.............OF...10. . ......... ................. ................................. Application is hereby made for a Permit to Construct (4,'5'-or Repair an Individual Sewage Disposal Location-44dress or I- Owner Address Installer Address Type of Building Size Lot.t.5 q L�......Sq. feet -------------- Dwelling—No. of Bedrooms_ Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area............../S Z Other Distribution box Dosing P Percolation Test Results Performed by.4.. 14 Test Pit No. 1 _55......minutesperinch Depth of7est Pit ..... Depth4o ground water......................... A.L..minutesper inch Depth of T it.................... Depth to ground water....... Test Pit No4 est P .. ... W .......a..-i�------ The undersigned agrees to install the aforedescribed Individual Sewage Disposal Systemin accordance with the provisions of TL I'=� 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the j�qard of heaW igned I . - 4-111, % I ate Application Disapproved, for the reasons:.................................................................................. ..................... --- ........................................................................................................................................................................................................ Date Permit Date ' --'-'---------'—'---'—'—' '—'---'—''''—''--'--' —' -- w 1 � No.._.`�'St 6.-1`t A Fimic......)................. _ THE COMMONWEALTH OF MASSACHUSETTS BOARD,,QF HEAyL�T/H 1 ... .!t' ..............OF... ,JC �5 �.��,+- C .............................................. Appliration for Uigponttl Works Tonstrurtion rrrnti# Application is hereby made for a Permit to Construct ( ,''or Repair ( ) an Individual Sewage Disposal System at s^ Location- dress .es= t ..................... j � Owner d Address ............................... ............................... ................... Installer Address 1 Type of Building Size Lot.=... ... feet Dwelling—No. of Bedrooms..._ M. ................................Expansion Attic ( t) Garbage Grinder (4 c) '4 Other—T e of Building No. of persons...................... Showers QI YP g --------•...............•--- P -•---- ( ) Cafeteria ( ) 04 Other .................... w Design Flow......... .._ ...............gallons per person per day. Total daily flow..........T.*'_..5-......_..........gallons. W Septic Tank—Liquid capacity,_ .O.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No.................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing ) ,w Percolation Test Results Performed by..r ..... "-,"? � ' '� r rr'r' Date....... /.... _f�. a Test Pit No. l r' ......minutes per inch Depth of `6st Pit_ . _ ..... Depth-to ground water.. Test Pit No4ra_1,.s:P..minutes per inch Depth of Test Pit...-''�.......... Depth to ground water........... �J 4 ------ ---- •---....._ ..... D Description of Soil _! � � � . Gf? OC x t w 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 TITU 5 of the State Sanitary Code` The undersigned further agrees not to place the system i operation until a Certificate of Compliance has been issued by the hoard of heal 1 Igned. dy�fr _ 4 '11'w/1 �* F4 '� D Application Approved By.....................JIM. ' ............................ ........... at Application Disapproved for the f ollo i g reasons:...............•------...---.--------.-.---- •-------------------- ........... - ..............•-----.......•--------•--•----------------.......----------------:..--------.._..--•------'---------------------------------•-----...-----------------------------------------•----'------ Date PermitNo........................................7---------------- Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , ...........0F.... y�... ': !.. ............................ Trr#ifiratr of 6ntplianrr IS IS TO C IFY, That l)e Individual Sewage Disposal System constructed ( or Repaired ( ) by. 7e!;; .... '"" xY C )--1 c/r--... ----•- ..... .................. ....................... ------------ taller has been installed in accordance with the provisions of TIT! Z 5 of The State Sanitary Code as d scribed in the application for Disposal Works Construction Permit No.....c�f2_�_t.�f7............ dated_..T . ................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......... -l k(8 ------------------'•---- Inspector --•---....-------------------•--"-•'---•'-'-"._....._......-- THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH � NO. L3 ...............OF... `:_� "• �-:..C..�... 5r.......................... FEE �to�o��i orkon�fr #uan �rrntit Permission is hereby granted.. ........ to Construct ( or Pair f) an Individual Sewage at posal stem �" ----- Street �3-17.. Dated-------- �/as shown on the application for Disposal Works Construction Permit No.... .............. ./ .. .._._....___.,....... ................................. ...................... • (+ Board of Health DATE................. =.....K ................................... sr FORM 1255 A. M. 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Z /t ,ki`� 4 ,`� � S / ' r �W �k P; g f Ptt1UP. r� � � �'a4ft Ct ` r` n e+ r e T _;t '�N ; 11�ER r1. ,-1 S R] t `I a -h' C Y � .i•"f.. 2 t ,r 9� 4IJ� �.:�i'.. 3 Y4r r ' ". /N! v k� - SQ ,nP� �r /q- § r St/ � st yr r.raC jG,f /L §2 a,.t .s i V f 4 i PA ,,e,�tl' F ,� :,5 r t x r_. ;' �.t?�Y d �'s tr.'+w�5 r / �5� ` . :LEGEND F =k �... µEItINTINA SPOT 'ELEVATION 0,�0 � ,{ ¢ , t CERTLFIED` PLOT`: = PLAN ,P� ERIQT.IN® ` CONTOUR --- 0 t . '� FFINISHED - SPOT. 'ELEVATION _ (�' fi �t1a01�NE0. C:ONTOUR:, 0 4 o" �:®.� sr itrlTaN, . �A g/ h ,�,�s�' �vs f c.c�t NWE;rThe .;iocation of:_aoy existing' under g.ou d sewer``a sewerage :- 1. I. w1.alls,,°orrother ,utilities shown-_ow this .plan i approx- , I`N,, „ _ -- . �` r�Y f�` mate`:onl as .,determined from records and/:or verbal; X �' �► a�.� 1'Ja W �x�'J� �. = nformation {The cont`xactor is responsible for. -, I ` r °, :.. -Lrs zx t. +�xi£icaton of the` existing locations �n µthe field.'1.r 9CAiE,! n".� DATE 2 S , ..,,. r $ , �� :.. 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T .4.T'52 .,,411, D/,NG I66,:o, FT ,_ R' Z — 1 ,., _�',.- . x,, t..,Y, �,: _ .�.. ,'-s NLET SEPT/C p � k k ,t :rf N J r- r DU Tr ET SEPT7`C'T.4'N K % r/rT i 11", F �#. q aa< s s 4 ,b:°q t't i r '`, d *""T t4 :�c 'R At V I,'..T - '��' -1 ! /p %s y s !t GRD .N Itl�l f ABLE t r1/LET;DJSTi4 BUj N `BOX' FT i. SEG7IONhaF -� . I. _ _h U Z.r ,j _7 A(1T/UI11',1 ioS,Z. =FT _ 'r T .S AGEu�/S,=t SAL°- SY.STE/i! (;e: �' LE;T[Est CN/'1V�r / /';T oaf: -.,' 7• Ew - x , -�— F k a7"ABULATIDN w Y? i >t -, , r A!/Y P%T. r L EACH, G ;. t ,� SCf1LE '4 - / —D , D.E�/G/Y tCRlTERlA w _ of t,Ftisto,N . 8 F7 j, '` t f i! , Sti.� t ,Vw:. l '1i 4 0 d d t 't 'I •�•. /'/,!Y ,.' :� r` r t D/HENS/ON C T�. � ;�, ` ,!'U> B�R OF BEDROO/ti15 3 y;. �. sc _ r n T _ f .i,.:- f `y, 1i 'r:'.e i t r r ter "y A A� ,: P. L.-/ Y f- so � 0C a., GEo s asA uwlr_- - t �,� t 4 T r SD/L. TEST ', f �' arA :ESTIMATED`MFcoa�.' 33� Y`, .S01<L.TEST #/ SO/L:TEST.#2 s1. 1. _ GAL: DA V.. _'M,lR:OF 4,`ACNnv4, ,o/z'S,. F, E� /°7•l EL l�8 T �`� , .r _-„-L_ 1. DATE OF 501, 'TES:. 7lp�'1 A�=HYNG.PER P/T (SS, -•S , �FT +. TNESSEO PBY P:/M J"� Gc�•lt.e.3 t f RESULTS 1?l/ �'' : _ .<. /rl11 �'OTTOM LE,4.CH/KG PER P/T_�S"S` $Q ,FT `Oi. 3 �. ,»' PEIt CdL.AT/ON RATE / L. Z ''OTAL,GEAC/-//NG,r4:4cA ZG? -,.5<;1 FT 5 FArCOL.47"/ON•RATE L Z MIN. /NCH v3se�c 1. zEsFRv .r. fi,l///NG�41.REA:�2 _SQ..':FT z; 1. % 211 } ���;�� t 3t -3�MIr�� 5 Seim. 7�5Y' t�'.F?:'�f�jUB' + ^� , �y,., rcrrl tle �t U7 , 5srr-t� c _ f , .9 ��,w �."' P� 1,�� Cts�, fps. ?�v ,, SJ: R�- anrES. �1/Ay� / r �s: /a �G r, 1 4 F. J. �AYLST7i✓S /t��s:. /'t. Pit4 ire . eT1. t! 4VE►t gEl�. - � (� [��+'—. r a �'J 2 hl Z ft 8 G ✓�5�7 y li LtJita L' y A w i '. 1. ' a 3/ _` p EL DREDG %/Y.EEI z m w , f� �,EldG , r T A �. r air a ,a_ : �.. i4` v. = a 7%2'/+%IA/M'ST` ; L/>'•4iVN141 M:a�s y, �' �'�T < ,, s S ,,..v, ,, v t'V` .r d t+" 4,, ¢"::F i a- , r �s1. . <f� . >, A, ,s:w a s -M, c L:/.ENT' D.4T�...m s ti�:vx . „ .L�/V GRO NI) �P �odt /- tie YLL' ,2' �/g(., - O V LYi�iTEe� ENCOlJN7"g�2 ,.. 9' Q N h' _ 8 aE19 ZOF,. Cam"f `,/^],/ t,` n ..:_. _ _ � .. t - {{ P y S t _."_c -: .., a..a ,G''' x, ... .c5'. r.,...- dd -, ...d. k n$°" r 1 - i. 4:: - { �.. .,�. '"a Fl. ,. ,. ::,- ..i �- t-v.,. .. :-.-G '. . ..r.. iY. fi L"Y i'' 4 -,.:' A+e„;"� tLs,4.^ t: .rw,f, FORM 30 C&W HOBBS&WARREN TM 'THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEART CIT /TOW ` � DEPARTMENT � ADDRESS 2— TELEPHONE � C) Address — Occupan Floor Apartment No. No. of Occupants No.of Habitable Rooms . No.Sleeping Rooms No.dwelling or rooming units No. tories Name and address of owner _ Remarks Reg. Vio. YARD Out BI s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: k r V W , ►'' Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof ) Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: • Dampness: r Stairs: Lighting: I /1 STRUCTURE INT. Hall,Stairway: XV j / f \ 1 Obst'n.: Hall, Floor,Wall,Ceiling.-- Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L trj . Outlets _Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room t V Bedroom 1 Bedroom 2 l 36 E y Bedroom 3 /D 0 E Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stags, Flues,Vents.,Sefeties: Kitchen Facilities nk T 'S tcrle Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other.- Egress Dual and Obst'n: General Building Posted Locks on Doors: ! ONE OR MORE OF THE VIOLATIONS VHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SI NED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." INSPECTOR TITLE h f ) A.M. DATE TIME I 1 P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410,251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. ,/TOWN OF BARNSTABLE .,t6CATION � �%e-'0 P We—) SEWAGE# 4014—3 Of 'VIL'LAGE VU ; Q D��ASSESSOR'S MAP&/PARCEL 31 INSTALLER'S NAME&PHONE NO.?- r 1 (.^' 4 7 . TQ_ ?71-1_14P-1 SEPTIC TANK CAPACITY �S�t_r �� f o� (a!{� 4/0 LEACHING FACILITY:(type)_--Z-tSZC%1t.C44- (size) ;5-X- (4-13 ok_�-, NO.OF BEDROOMS 3 ZO mil.- C OWNER LOWC-7 l PERMIT DATE: O,�L COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility)) Feet FURNISHED BY �J iY f 7rLl �6~ O .J Town of Barnstable ' Department of Regulatory.Services ar�r� Public Health Division Date AMLAUM p� F. s' 200 Main Street,Hyannis MA 02601 Date Scheduled 0/1a Ti ma r �� - Fee]Pd. Soil Suata zlity ,Assessment for Se v�i .Dlsp® l Perforrrted-By: �a� / l_ l GGn�� �(/ �S Witnessed By: LOCATION&GENERAL INFORMATION Location Address �iVllt Owner's Name n',�f y� Address Assessor's Ma /Parcel: P 3�/00/ �� Bngincer's Name, �D W''�- L.tt-p 2 NEW CONSTRUCTION REPAIR Telephone# Land Use:I of Slopes(%) f Surface Stoaes h�n Distance's from: Open Water Body D I 001 it Possible Wet-Area��lw ft Dr.nking Water Well �`� ft Drainage Way �� ft Property Line 2// J ft Other ft SIM,TCII: (Street name,dimensions of lot,exact loeadons of test holes&pert tests,locate wetlands-�n proximity to holes) 0 £yi$-fiA9 1 =d Ln 01 C7D r-- a-;e Parent material(geologic) "l Depth tq 13aClrpcl{ Depth-toGrouadwatec StandlugWaterinHole: / � _ Weeping frotn Pit,Faoe /-//4- Estimated Seasonal High Groundwater TETER1V�A.TION FOR SEASONAL HIGJEI'�A.TER TABLE Method Used: (j V fi Depth Observed standing in obs.hole: Ia, Deptlt to 5911 rctottlas: Itt, Depth to weeping from side of obs.hole: In, Groundwater Adjustment f[. Index Well# Reading Date: Index Well]oval - Adj.Actor,.,,,._.,,. Adj,GrowidwaterLeval PERCOLATION TEST bake- Time,__ y Observation I Hole# �J Tima at 9" Depth of Perc I Time at G' Start Pre-soak Time @ Time(9"-6") End Pre-soak / Rate Mln./Inch L Site Sultability Assessment: Site Passed Sitq Failed: Additional Testing Needcd(Y/N) Original: Public Health Division Observation Hole,Data To Be Completed on Back------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conse�vatlon Division at least one(I)weep prior to beginnwg. Q:\S RPTIC\P3RCFORM.D 0 C DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Sdil Color Soil, Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders, gT12istenoti 96'Gravel) v `v FIN DEEP OBSERVATION HOLt LOG Hole�k 2 Depth from Soil horizon Sail Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsis en co Grave 7 DEEP OBSERVATION HOLE LOG 11010�. Depth-from Soil Horizon Sap Texture Sol]Color Soil Other' Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Co i to c G e DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color 81311 Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stouts'.Boulders. Co si ton ]flood Insptrance Rate Map. " Above 500 year flood boundary No Yes-IL Within 500 year boundary No Yes Within 100 year flood boundary No.-7 Yes Depth of 1 atnrally Occurring Pervious Material Does at least four feet of naturally occurring pe vious material exist in all areas nbgtrved throughout th6 area proposed for the soil absorption systeml Ye s If not, what is the depth of naturally occurring pervlous material'? _ ceftification ' I certify that on S// (date)T have passed the soil evaluator examination approved by the Department ofBnvironmental Protection and that the above analysis was performed by me consistent with the requited training,expertise and experience described in�10 CMR 15.017. Signature � �� �� Datb 31 / Q:\S,EPT1aPE1ZCn0RM.D0 C FORM 30 �w HOBRSRWARRENTM THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HE T CIT /TOW . � w DE ARTME T ADDRESS 570 �0 gG A G„M Svey`0W � �L_._ TELWHONE 9 Address 35 5 — tccupant_'A,,--, �' Floor Apartment No. No.of Occupants No. of Habitable Rooms 5 No.Sleeping Rooms No.dwelling or rooming units No tories Name and address of owner Remarks Reg. Vio. YARD Out BI s.: Fences: Garbage and Rubbish Containers: Drainage 6 Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceilin Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: 11110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Fff- Bedroom 3 0 a Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Sja4s, Flues,Vent ties: Kitchen Facilities rink e Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other.- Egress Dual and Obst'n: General Building Posted _ Locks on Doors: ONE OR MORE OF THE VIOLATIONS Ul -FCKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SI ED AND CERTIFIED UNDER TH PAINS AND PENALTIES OF PER,1 RY." INSPECTORS TITLE I U r ] A.M. DATE 5 _ ( '— TIME l I P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. ib 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold,to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. ZL Is COMMONWEALTH OF MASSACHUSETTS ' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION A " --IVE® P Rc"Ci : 0� 0'Z3_ =i; 15 2004 • � 20 A w._ �.:. .,... tSTABLE TITLE 5 _ _ _ ` JFPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 35 S-/AfC:z—,5 A. Owner's Name:AV �rtc�.✓ Owner's Address: Date of Inspection: /%-/S-0, Name of Inspector: (please print0dualas A.Brown Company Name: Donglas A ar^Wn Septic Inspections Mailing Address: RO per 145 Centervi'le ANAI Telephone Number: A 02632 CERTIFICATION STATEMENT 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 inspd-ction.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 Secti Y5.340 of Title 5(310 CMR 15.000). The system: asses Conditionally Passes- Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: //L Date: f��/ mil 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 ��v�s«� �TQ /C/3/2av t Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3 S,40 rs Nva. Owner's Name: Owner's Address:. Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste asses: I have not found any information which indicates that any of the failure criteria described in 310 CUR 15.303 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: f ! r ` fj .✓ CrIC, y' . B. Syste nditionally Passes: one or more system nents as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon cam on of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N, in the following statements.If"not determined"please explain. The septic tank is metal and over 20 years ld*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltra n or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank approved by the Board of Health. *A metal septic tank will pass inspection if it is struc sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is availabl ND explain: Observation of sewage backup or break out or high static ter level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distn ion x System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than 4 tunes a year due to broken or obstni ed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed i_ Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: A Owner's Name: Owner's Address: . Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions ea 'ch require fiuther evaluation by the Board of Health in order to determine if the system is failing to protect public he ety or the environment. 1. System will pass unless Board of H rmines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which ect 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 o t marsh 2. System will fail unless the Board of Health(and Public Water Supplier,Many)determines that the system is functioning in a manner that protects the public health,safety and environment: _ the inhas a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water or tributary to a surface water supply. _ The system has a septic SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS a SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is 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 ratory,for coliform bacteria and volatile organic compounds indicates that the well is free from 1pmollutio om that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,pr ed that no other failure criteria are triggered. A copy of the analysis must be attached to this form 3, her: OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 5S- -1 Owner's Name:_�(�jY� 5�i✓yit Owner's Address: Date of Inspection; D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No / 3ckup 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 c lygged SAS or cesspool & tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or ces�_ool _quid depth in cesspool is less than 6"below invert or available volume is less than%2 day flow _ CAI Nuired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of ' es pumped rtion 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. ��ortion of a cesspool or privy is within a Zone 1 of a public well. _ ✓Any , rtion of a cesspool or privy is within 50 feet of a private water supply well. portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP.certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To&considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gP d You mus ' dicate either"yes"or"no"to each of the following: (The follow' criteria,apply to large systems in addition to the criteria above) yes no — _ the system is wi ' 400 feet of a surface drinlang water supply _ the system is within 200 t of a tributary to a surface drinking water supply — = the system is located in a nitrogen five 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 stem is considered a significant threat,or answered "yes".in Section D above the large system has failed.The owne operator of any large system considered a significant threat under Section E or failed under Section D shall up a the system in accordance with 310 CUR Page 5 of 11 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 71— Owner• Date of Inspection: Check if the following have been done.You must indicate`yes»or"no"as to each of the following: Yes No Pumping.information was provided b the owner,occupant,or Board of Health P Y > P > +� ere any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? "-large volumes of water been introduced to the system recently or as part of this inspection? _ WW e as built plans of the system obtained and examined?(If they were not available note as N/A) V Was the facilityor dwelling inspected ? - � g p for signs of sewage back up . v Was the site inspected for signs of break out? e y,.z%vJ,� Were all system components, 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: Yes Existing information.For.example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: A4 Owner's Name: 44 Owner's Address: Date of Inspection:�� �• , �! RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design):I Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms) 226 Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):A Lk[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no):-Z _ i®v`3 SG,cap cJ�1 Water meter readings,if available(last 2 years usage(gpd)): Je,N c ,jc v�0 y i 15 Ct Sump pump(yes or no):A Last date of occupancy: r V�f- COMNIERCIAL/INDUSTRIAL: of establishment: Design w(based on 310 CMR 15.203): gpd Basis of d ' flow(seats/persons/sgft,etc.): Grease trap pres (yes or no):— Industrial waste hol ' tank present(yes or no):— Non-sanitary waste disc to the Title 5 system(yes or no):— Water meter readings,if availa Last date of occupancy/use: OTHER(describe): Pumping Records GENERAL INFORMATION Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:____gallons—How was quantity pumped determined? Reason for ping: TYP SYSTEM eptic tank,distribution box, soil absorption system _Single cesspool Overflow cesspool `ivy Shared system(yes or no)(if yes,attach previous inspection records,if any) T Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from-system owner) —Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: i t A JT ro- ,\SCCAJ Were sewage odors detected when arriving at the site(ves o no). Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART C SYSTEM INFORMATION(continued) Property Address% Cr Owner's Name: 15 nncw Owner's Address: Date of Inspection: 6 L - 1 'S -0 e DING SEWER(locate on site plan) Depth below Materials of construe cast iron —40 PVC_other(explain): Distance from private water sup ll or suction line: Comments(on condition of joints,ventin , ence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade:Q)4 Material of construction:=concrete—metal fiberglass_polyethylene other(explain) If tank is metal list.age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions:_i o0o G C3 Sludge depth: +jae r- Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 4 t eye r Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or bale: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or bale condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): A TRAP: (locate on site plan) Depth below de:_ Material of co n: concrete—metal fiberglass—polyethylene_other (explain): — — Dimensions: Scum thickness: Distance from top of scum to top of outlet or baffle: Distance from bottom of scum to bottom of ou tee or baffle: Date of last pumping: Comments(on.pumping recommendations,inlet and outle or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 5- S k Ato lyron k6ot,v Ad a ; 1u,)% ALI Owner's Name: fa , CV%1.) Owner's Address: Date of Inspection: _I i- i or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below Material of construch concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): / PUS CHAMBER:_—(locate 6A site plan) Pumps g order(yes or no): Alarms in workin (yes or no): Comments(note condition chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner's Name: Owner's Address: Date of Inspection:-A]- I S -6 Lt SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required) If SAS not located explain why: Type a/leaching pits,number: i leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number innovative/alternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): P _ CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Nnmbe configuration: Depth-top o 'd to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic fail , evel of ponding,condition of vegetation,etc.): PRIVY: ate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs a ulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: SIN' Owner's Name:_?,\.tlf jts�r^ Owner's Address: Date of inspection: —it - 15 ! SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. y E ' Q, I T)r%ile n ° l Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 S S4 Owner's Name: M?e�.� Owner's Address: Date of Inspection: SITE EXAM Slope% L-eoe Surface water% nj o ro-Q- Check cellar: k Shallow wells Estimated depth to ground water 12. feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-e L%m Checked with local excavators,installers-(attach documentation) T Accessed USGS database-explain: You must describe h�ow�you established the high ground water elevation: ALL STE SHALL SYSTEM PROFILE MAR ED WITHCMAGNETICTTAPE OR BE NOTES PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS APPROX. NAVD88 ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 2" PEASTONE OR GEOTEXTILE CONCRETE COVERS TO WITHIN 3" GRADE �c. 2. MUNICIPAL WATER IS EXISTING \ TOP FOUND. EL. 107.0' FILTER FABRIC OVER STONE F2% SLOPE REQUIRED OVER SYSTEM lO5' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. ea aee MINIMUM .75' OF COVER OVER PRECAST Gc NOTE: 2" MIN. WALL 4. DESIGN LOADING FOR ALL PROPOSED PRECAST PRECAST H-10 THICKNESS REQUIRED BLOCKS OR UNITS TO BE AASHO H-]Q RISERS (TYP.) PRECAST RISERS 2'o 104.2f* 4"OSCH40 PVC MORTAR ALL H-10 PIPES LEVEL 1ST 2' �4. COMPONENTS 5. PIPE JOINTS TO BE MADE WATERTIGHT. (TYP.) 17' 4 ENDS SIDES 102.0' 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE Locus o 10- EXIST. o,o,o,ono " T 3 0 C WITH 1 MR 15.000 TITLE 5.) TEE SEPTIC TANK** TEE ° ° ° 0mm- 0©�� aoma- __mm \LO2.7±*' o 0000000000 MIN. 6" SUMP o 0 0 0 0 0 0 o o o od o 0 0 0 0 0 0 0 0 0 0 ' °LOOL. As Mei s ° o ;°o° ° ° 000�o�oo�o� 0000a000aao ,00 sc ao1 GAS BAFFLE :1 ° 00000 ° ° MIN. 12" INT. DIM. 00000000 ����������� M�����aoa�® °° 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND ° O ° ° > ° ° ° °"°"°^°^°_ N '°°°°O°O° 0������0�0� a0000000ao® :00 NOT TO BE USED FOR LOT LINE STAKING OR ANY ;°°°°O°O° O ,101 .45 101 .28 °o°o°o°o •, 7 OTHER PURPOSE. a tiG Qr c � 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. �' Q� 3 �e� H-10 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL. a Rd 1-1/4"-1-1/2" DOUBLE WASHED STONE 4' MIN. S Z ALL AROUND PRECAST STRUCTURES (2) UNITS REQUIRED 9. COMPONENTS NOT TO BE BACKFILLED OR 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.00' X 12.83' CONCEALED WITHOUT INSPECTION BY BOARD OF t� COMPACTION. (15.221 [2]) m HEALTH AND PERMISSION OBTAINED FROM BOARD �' / 1° ri OF HEALTH. ( 8 SLOPE) ( 1 % SLOPE) 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING DIGSAFE (1-888-344-7233) AND LOCUS MAP FOUNDATION- EXIST. SEPTIC TANK 16' LEACHING N BOTTOM TH-1 VERIFYING THE LOCATION OF ALL UNDERGROUND & D BOX 13 3.2' FACILITY OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF NO GROUNDWATER FOUND WORK. NOT TO SCALE *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE 11. ANY UNSUITABLE MATERIAL ENCOUNTERED ASSESSORS MAP 31 PARCEL 1-23 PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM WITH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE SHALL BE REMOVED 5' BENEATH AND AROUND THE CONDITIONS IF NOT SUITABLE PROPOSED LEACHING FACILITY. 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN LEGEND SAND. 99 EXISTING CONTOUR \� X 106.07 X -9-9-1 EXIST. SPOT ELEV. x i 05.94 \ � 99 PROPOSED CONTOUR x x 6' � � 198.4] PROPOSED SPOT EL. x 105.55 SYSTEM DESIGN: TH1 TEST HOLE x 105.93 "Z GARBAGE DISPOSER IS NOT ALLOWED 2� SLOPE OF GROUND x BENCH MARK - TOP OF BOTTOM x1 0 STEP. ELEVATION = 106.3' ��po �o Z DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD UTILITY POLE 68 ■ 1 �M� 6 �1 , TV DISH �� � � USE A 330 GPD DESIGN FLOW X 0�.�� �� \ 38 OS ti 01 FIRE HYDRANT 105 o. OS.9 O c31 \� SEDT,O TANK- 73n� 0nn - '50 6.28 7 5. NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING x O O � ,. x 10 3, x 104.70 **RE-USE EXISTING 1000 GAL. SEPTIC TANK 2�3 61 h. x 105 86 DRYWELL _ /� x 6.08 o j G/C106.32 LEACHING: o. 21 G/ I SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD 106 �I 06.10� TEST HOLE LOGS x 105.28 4.2 I BOTTOM 25 x 12.83 (.74) = 237 GPD x1o5.� 2 ' ( .92 I TOTAL: 472 S.F. 349 GPD 7 - - TH 1 2?'� - ENGINEER: DANIEL E. GONSALVES, SE #13587 0`' 105..: - DONNA MIORANDI, IRS /^ 0 0 � I USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) WITNESS: L - DATE: 8/13/14 105 105.13 sT*�T• I DECK LOT 20A I WITH 4' STONE ALL AROUND x 105.07 19,915±SF I < 2 MIN/INCH �05 1105.91 PERC. RATE _ 1 04.8bp p 00 i 03 4 J O� CLASS I SOILS P# 14460 vL�2 O EXIST. DWELL. wow 9 0 !� I < 1 0',.44 x 1 58 TF = 107.0' C 4 ELEV. n ELEV. � 5 83 S I 0 104.2' 0" V 104.6, v 05. 1.74 FILL FILL 0 4.7 3 _ I __ _ MA 10" 10" X _5.41 APPROVED DATE BOARD OF HEALTH A A �>> x 104.50 105.72 .45 �o I TITLE 5 SITE PLAN LS LS \ 05.39 OF 12" 10YR 3/2 12„ 10YR 3/2 -- 105 PAVED DRIVE 105.28 s Tys�� II B B SL SL T_ I 35 ST. ANTON'S WAY x 104.80 07 1 J40. 1 C 7 05. MARSTONS MILLS I 04.81 \ �' I 1OYR 5/6 1OYR 5/6 160.00' 104.78 34" 101.4' 34' 101 7' II PREPARED FOR 04.70 C C 104.36 I BORTOLOTTI CONSTRUCTION/LOWE PERC 104.28 �x AUGUST 15, 2014 1(14.04 Irl M/CS M/CS 0 5 8- 103.80 _ - ,r off 508-362-4541 DAIAI-L fax 508-362-9880 a. ti� ° � I 132" 1 OYR 7/4 93 2' 132" 1 OYR 7/4 93.6' - - - - - - - � SHARED DRIVE a A'�CANIEL downcape.com No� �z f Oj'c!A j down cope engineering, hm NO GROUNDWATER ENCOUNTERED o <� civil engineers Scale: 1 "= 20' S �01, (_ ,/ land surveyors 939 Main Street ( Rte 6A) 14- 189 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675