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HomeMy WebLinkAbout0047 SANDY VALLEY ROAD - Health 47 SANDY VALLEY ROAD ' A= 101111 - - - - Commonwealth of Massachusetts W Titleficlal Inspection Forr �°r� -031 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 47 Sandy Valley Rd M 1' Property Address GI Steven Downing Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/17/17 page. City/Town State Zip Code Date of Inspection Sa'I sa 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. filling out forms A. General Information filling out forms ' a 1� on the computer, use only the tab 1. Inspector: �- key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain aln Company Name 8 Johns path Company Address S Yarmouth Ma 02664 City/Town State Zip Code 508-364-9587 S103522 Telephone Number License Number B. Certification I certify that 16nave 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 1/17/17 nspector'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. � 0 l5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments- 47 Sandy Valley Rd Property Address Steven Downing Owner Owners Name information is required for every Marstons Mills Ma 02648-- 1/17/17 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return key. Name of Inspector DiBuono Sewer and Drain Company Name 8 Johns path Company Address S Yarmouth Ma 02664 Cityrrown State Zip Code 508-364-9587 S103522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the tinspection. 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 1/17/17 nspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection F®rn1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Sandy Valley Rd Property Address Steven Downing Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/17/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C;D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 31.0 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 W Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �a, e 47 Sandy Valley Rd Property Address Steven Dowrin Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/17/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ' ' ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is remove d ❑ Y N ND (Explain ❑ ❑ n below ( P I ) ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): Dbox is rotted and in need of replacement. ❑ 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 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Saner Valley Rd �M Property Address Steven Downing Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/17/17 page. City/Town State Zip Code Date of Inspection Be 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 47 Sandy Valley Rd _ Property Address Steven Downing Owner Owner's Name information is required for every Marstons Mills Ma 026-48- 1/17/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or ® obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3.+13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Sandy Valley Rd Property Address Steven Downing Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/17/17 page. CityFrown, State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection For' m Subsurface Sewage Disposal System Form - Noe for Voluntary Assessments i 47 Sandy Valley Rd Property Address Steven Downing Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/17/17 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1,000 Gallon septic tank as well as a Distribution box and 4 Infultrators Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 197 GPD Detail Sump pump? ❑ Yes ®. No Last date of occupancy: 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 47 Sandy Valley Rd _ Property Address Steven Downing _ Owner Owner's Name information is Marstons Mills Ma 02648 1/17/17 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: 6/13/13 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 1,000 gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface S6wage Disposal System Form - Not for Voluntary Assessments 47 Sandy Valley Rd Property Address Steven Downing Owner Owner's Name information is required for every Marstons Mills Ma' _02648 1/17/17 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: 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 2 feet Material of con struction: ® 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.): System is vented at the roof line Septic Tank (locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1,000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts `Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Sandy Valley Rd Property Address Steven Downing Owner Owner's Name information is Marstons Mills Ma 02648 1/17/17 required for every page. CitylTown 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 24" 3" Scum thickness Distance from top of scum to top of outlet tee or baffle - 42" — Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. 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 & Massachusetts Title 5 Official Inspection ,Form 'Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M a' 47 Sandy Valley Rd Property Address Steven Downing Owner Owners Name information is required for every Marstons Mills__ _ ___ _ _ Ma 02648 1/17/17 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.): Tees are in place and levels are normal 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 El 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 l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Tale 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Sandy Valley Rd Property Address Steven Downing Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/17/17 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 Rotted and needs replacement. 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.): 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•3/13 Title 5 Official Inspection onForm:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Oisposal System Form - Not for Voluntary Assessments 47 Sandy Valley Rd Property Address Steven Downing Owner Owners Name information is Marstons i M Its required for every Ma 02648 1/17/17 page. City/Town State Zip Code Date of Inspection D. System Information cont. Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 4 Infultrators ❑ 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.): No pondLng no break out 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 Indicatior of groundwater inflow ❑ Yes ❑ No 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i.. Commonwealth .of..Massao.husetts W Title 5 Official. Inspection Form , Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Sandy Valley Rd Property Address Steven Downing Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/17/17 page. CitylTown 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.): No pond ing,-no-.break=out 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Sandy Valley Rd Property Address Steven Downing Owner Owners Name information is required for every Marstons Mills Ma 02648 1/17/17 page. City/Town State Zip Code Date-of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hanc-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts W Title 5, Official Inspection Form ; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 47 Sandy Valley Rd Property Address Steven Downing Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/17/17 page. Cityfrown 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: 10+ ft 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: USGS Maps You must describe how you established the high ground water elevation: USGS maps indicate ground water at 25' 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 Assessing As-Built Cards Page 1 of 2 fE� R + tl TOWN OF BARNSTABLE by LOCATION_ i Ur>�^+ � SEWAGb#�� - VILLAGE N , ASSESSOR'S MAP&LOT 1• f t L INSTALLER'S NAME&PHONE NO. , U SEPTIC TANK CAPACITY 6o0 �• -C 1 LEACHING FACILITY:(type)- f (size) NO,OF BEDROOMS 3 t BUILDER OR OWNER ( PERMITDAT.E: q t COMPLIANCE DATE:_/7 E Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility.. Fat _ E. Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of teaching facility) Fcet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Fumisbed by 81,33 , t i i s 9 � I littp://www,townofbamstable.us/Assessing/HMdisplay.asp?mappar=101111&seq=1 1/16/2017 1 Commonwealth of Massachusetts A F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 47 Sandy Valley Rd Property Address Steven Downing Owner Owner's Name information is required for every Marstons Mills _ Ma 02648 1/17/17 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketcn 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 1 No. 2,6 Q Fee ®bar THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes IpYILatIDtt for MI8p0$AY ipBtPIYI COYYStCUttlOttPCllttt ,M Ima Application for a Permit to Construct( ) Repair W Upgrade( ) Abandon( ) ❑Complete System [,Individual Components a-• Location Address or Lot No. V12 �[ llklleqOwner,, )ame,Address,and Tel.No.,.3* 2/.360, 9 , a Assessor's Map/Parcel /'O �Co Installer's Name,Address,and Tel.No.�,�49-991— 9-3 j9 Designer's Name,Address,and Tel.No. Na r}-t�iad (26r)S' TW(_44O1'1,ZnC. 19 Gox and M Type of Building: Dwelling No.of Bedrooms ; Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank �I—XI15��"n9 /G j�� Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) S ` pIV Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Cod and not place the system in operation until a Certificate of Compliance has been issued by this Board of Health. r Si a - Date / Application Approved by' f PIUSIDate Application Disapproved by Date for the following reasons Permit No. , Date Issued _ No. ����� Fee ©6 Entered in computer: A THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE, MASSACHUSETTS Rpplitation for Disposal *pstem Construction 3permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System [Wndividual Components Location Address or Lot No. V,73064 Owner's Name,Address,and Tel.No. 340 95�7R' T� M0.t'S tn•1�5 t�1,'j�5 �17�:GCU{)1/ �1�G�s����r�jYCdl„��I• -� Assessor's Map/Parcel IG f V4 f411-1a PA 4 A,�j A 6P14'X - ; Installer's Name,Address,and Tel.No. S-L* Designer's Name,Address,sand Tel.No.��� *��• Go r4­a l0ttZ i26 nS4 UCA40n,Zne_. Pam.$x Eby ,J�3�sx on rt c ,Rt E t(< AA Type of Building: 1 Dwelling No.of Bedrooms � Lot Size. sq.ft. Garbage Grinder I .:i Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures I' 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. v � t Description of Soil r Nature of Repairs or Alterations(Answer when applicable) �Ct(!P �i S r t .`1'!Q-i Noe 6 !u Date last inspected: Agreement: / The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal.system ins-r—, accordance with the provisions of Title 5 of the Environmental Code`a'nd o to place the system in`p ation until a Certificate of Compliance has been issued by this,Boardof Health. Signed-N cS3 Date ���•�" Application Approved by /LY ✓_ ( Date ' Application Disapproved by Date for the following reasons Permit No. Date Issued --------- --------- ----- _. ___ , THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS P certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by �,Jp f'#tom t�a t t t� ( �'a r2�� CC� ®fl . ��G ' at has been constructed in accordance with the provisions of Title5 and thehfor Disposal System Construction Permit No. ,2 v/7- 0 3%ted 7 )�I �/[ 7 Installer INi-toll C r ,r,� Yt tpy� l C Designer ulA ,2 Ar,k An r f' 4 #bedrooms Approved design flow s'✓ gpd f ' The issuance of this permit shall p0t be construed as a guarantee that the system will function designed. Date �// Inspector �. No. a l-7- 03 C! Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS s Disposal *p8tem Construction J)ermit • ; Permission is hereby'granted to Construct( ) Repair(A Upgrade( ' ) Abandon( ) System located at r 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. l i Provided:Construction must be completed within three years of the date of this permit}: Date / / ( � Approved by i} °1r✓.',�f{� f�� E ssessing As-Built Cards Page I of 2 ...... TOWN OF B ARNSTABLE v 1 LOCATION J II/vim tGV SEWAGE VILLAGE— ��� ASSESSOR'S MAP&LOT�[• f r l INSTALLER'S NAME&PHONE NO. RI a SEPTIC TANK CAPACITY ��6 o D_�, D •t�� LEACHING FACILITY:(hype) (size) NO.OF BEDROOMS 3 BUILDER OR OWNER [ q E PERMITDATE: COMPLIANCE DATE:_9l- 1 7 a Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching faculty) z Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Fumished by s P ic./4 U \ 1 33 I i I 4 http://tivww.townofbamstable.us/Assessing/HMdisplay.asp?mappar=101111&seq=1 1/16/2017 TOWN OF BARNSTABLEjU LOCATION 7 SEWAGE # VU1,AGE— , ASSESSOR'S MAP & LOT I , ji t INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �6vo � 9. .�•r LEACHING FACILITY: (type) V.►K (size) -'5fZwLe NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: 2 — 7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 ral /,,!0- 6133 :? S t No. r Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF.BARNSTABLES MASSACHUSETTS Zipphration for lhzpaai *potem Conotruction Permit Application for a Permit to Construct( )Repair(1.4upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 4-7 Owner's Name,Address and Tel.No. Assessor's Map/Parcel V\%ks cel �© ( i f i4 O Installer's Name Address,and Tel.No. Designer's Name,,Address and Tel.No. afteew" Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow > gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. �� .�rd3 Description of Soil i_r�® 5AIA9 Nature of Repairs or Alterations(Answer when applicable) -E;4 W tk �rGrG sL� �r 'it ,v dl- .� w c� 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 Certifi- cate of Compliance has bPgL:, s rd o e lth. Signed Date Application Approved by Date Application Disapproved for th reasons MPermit No. Date Issued ----------------------------.------ ------- I - _---,.,.,,, �'].R:'},.Eta � '•`r' No. Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF-BARNSTABLE., MASSACHUSETTS rication for :i�po�a1 *pgtem Construction Permit Application for a Permits to Construct )Repair(vl"Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel /O ! ' ) 1A O Installer's Name Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3�' gallons per day. Calculated daily flow 7-"?` �( gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank � Type of S.A.S. \-\, L i �Zcf}S Ll v r C,j Description of Soil eM C't 3 S r4".G' Nature of Repairs or Alterations(Answer when applicable) __rtti 1 1 �V ✓ 1��}.•.V� C a f:Lac k51_ '1 n. .i=-_! 01,: ice-� `t�=� �Q cc� t._t, V tn.d:.�✓ , i Date last inspected: F 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 Certifi- cate of Compliance has been-issued by-tl�'s B d o, He lth. " ;Signed-\ Date �1" v -Application Approved by.a'• u. Date ^ Application Disapproved for the lowing reasons Permit No. 7 Date Issued ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,�t}at �/_ vo site Sewage Disposal System Constructed( )Repaired ( )Upgraded Abandoned( )by ohs/ e 6 at t_ N a e _ NWAV, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - t dated Installer �~ Designer The issuance of this ermit shall not be construed as a guarantee that the system will function as designed. Date - g " 9 Inspector. . --------------------------------------- No. C77— Y T L/ Fee f7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Moozat *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( 4pgrade( )Abandon( ) ! System located at -A ') 5 Ag, nIA U(&,_ QQj ltil U and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: - ^7 Approved by . t : fr. NO TICE: This Form is to lie used for the Repair of Failed • , •,� .r Septic Systems Only CERTIfICA'I'ION Of SKETCH AND APPLICATION TOIL A DISPOSAL 1VORKS C;ONS]BUCTION PEIMIT (1VI'17IOUT DESIGNED MANS) hereby certify that the application for disposal works construction permit signed by me dated (F7 concerning the property located at '-��7 SAn,O ��w-- ty� meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system There are no private wells within 150 feel of(lie proposed septic system The observed groundwater table is 14 feet or greater below the bottom of the leaching facility There is no increase in now and/or change In use proposed There are no variances requested or needed. SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if(lie licensed Installer posesses a certified plot plan, this plan should be submil(cdl. ^1M . r ; TOWN OF BARNSTABLE LOCATION 2L SEWAGE # VILLAGE �^ ►nn ASSESSOR'S MAP &LOT/n 1 1l C INSTALLER'S NAME 8c PHONE N0. SEPTIC TANK CAPACITY LAC:) LEACHING FACILITY: (type) lil t.N 1.t' (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE:�` 7 Separation Distance Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private.Water Supply Well and Leaching Facility (If any wells exist feet of leaching facility) Feet 00 f w' 'n 2 8 on si te or ttlu Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by ; Vr ! � -r/7 N V 1 -�. BORTOLOTTI CONSTRUCTION INC. �SLTBSORYJ►CL.: 'BExAO.E •DZBPOBAZ; BYSTEH INSPECTION POFU` Ile 11�du4ss got. property ---- �Qvitsrrsit�ama.s __ ...._ ewe " `��peEa`ot�Ynspaction . _ b / PART A CHECKLIST It the tollowin have been done:,. Q R�um�-ixao ^nfQreaation _vas requested of the owner, occupant , and 8�> � Hone Ai! the system; components :.have been pumped for at least t o end the `systetebeen receivi"nq normal flow rates during that period. •.Largs: volumes: oi' water, have-..not been introduced into the ystais racentl:y or'•:4z part of::this` inspection .. :11s -built.�phans 'have .-been obtained' and ..xr,rined . Note if they a r vairabla with0000 00 N/1►. 1000. The La`ei is or dwel'.li`n vas" ins ectei * s ' ns s Wa 5ac.�: Y 9 P � ,� ig of . e ge Th• it to "was. -inspected: for signs' of breab�,:,ut . :ZAA1 system components , excluding the :off S stave been 1 oca ter sita;:: .The septic tank aianholes..were. uncoveres opened , and the inter the" saptiC- .tank .was., inspected . for .cond tine of baffles or tees , -eater allot construction, ditoensions, depth of liquid , depth of sludg4, dapt., ot scum. �Tha size and •location of' the SAS on the site has been determiner r:; :.• on "existing intormation :or approximated by non-intrusive method= The Lacility' owner. (and ,.Occupants, .. if different from owner+ Provided'-with.* iiiformation' on the -proper maintenance of SSDs . k } & �.4 71 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INYORKATION FLOW CONDITIONS If"residential _. -number-.of bedrooms nu er of current residents garbage grinder,,: yes or no, laundry ..connected. to system, yes or no _seasonal 'use; yes. or no It nonresidential-, calculated flow: Water._:.met :er `readings; if available: ure�T Last date of occupancy. GENERAL INFORMATION Pumping records and source of information: Systeia pumped 'as;part.. of :inspection, yes or no if ye volume, pumped Rea:on for puri+ping; =. SdptiC: tank/distribution or syst'etn box/soil absorption system µ y Sing" 3f .tis L..0 4dtj 1'.. Overflow "cesspool - . :Shared system. (yes or. no) (if yes, attach previous if a inspection records; ny) Other (explain) Approximate age of" all components information. . ,Date installed, if known . Source o, : Sewage od edors detect when arriving at the site, yes or no I _ SUBSU"ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: " (locate on `site plan) depth below. grade:= material of construction: concrete metal FRP other (expla: n ) dimensions. �' SSG X ✓`' X 6 --.- 2 sludge .depth distance from top of sludge to bottom of outlet tee or baffle scum° thickness b' distance from top of scum to top. of outlet tee or baffle /y distance from bottom of scum to ,bottom of outlet tee or baffle Comments- (recomiendati on : for . pumping, condition of . inlet and outlet tees or baffle, , ' depth of .;liquid;_level' in relation to outlet. invert, structural integrity , `evid.ence ;of -leak ge , recommendations for. 'repa,irs, etc. ) !DISTRIBUTION::BOX:: `(locate n site plan. r'. 'depth .of liquid level above outlet invert Comments`: (note: if: level`.:and .distribution is .equal, . evidence of solids carryover , evidence..,of l.e kage into or out of re comr9enda ipn for Repairs , etc . ) mhzorl" Cei' 6t¢�`/C 1p��/ PUMP. CHAMBER: (locate ; on:;site.:%plan) pumps ;in. workinq order, yes or no . Comments: (note,, condition ..of. pump chamber, condition of pumps and appurtenances , recommendations :for maintenance or repairs, etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART. B SYSTEM INFORMATION continued SOIL..ABSORPTION. SYSTEM (SAS) : V (locate- on; site plan, if. 'possible.; excavation not required , but may bc- approxiicated by non -intrusive methods) If not determined to be present, explain: Type leaching •pits;and number l - �OG'� ��� ��7- 1 Bach ing -onaAb;rs ana number laaching'."galleries ..and number - - leachinq ;trenches, number, length leaching..fields, number., dimensions . .... overflow cesspool, .'number - Comments (note condition :of soil, signs of. hydraulic failure, level of ponding , conditi,on ,of: Vegetatio , recommendations for maintenance or repairs , etc . ; /i,J CESSPOOLS. -A.loca.te on :site plan) : number: .and :°configuration depth top of ;liquid to inlet invert -- -- depth eptti of .acum`<=layer -- -- �din►enaions of cesspool ---- aaterriahs of :construction - andicaton" "oft=:groundwater -- - inflow% (cesspool must be pumped as part.: of a,nspection). ` (note ; condition:of 'soil, . signs ,of_hydraulic failure, level of ponding , conditiori: of vegetat on, ;recommendations for maintenance or repairs , etc . ) PRIVY: (locate on site eplan) . T� "ter fals. of::construction dimensions- .-of..solids - - Comments; -- . (note' conditfon. of `:soil, signs of hydraulid failure, level of ponding eondition`'of .vegetation, recommendations for maintenance or re airs p , etc . ) l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORHATION .continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate. all wells within 100 ' y I I � i DEPTH TO .GROUNDWATER / . depth to groundwater method of determination or approximation: e., c �'- i _ SDBSDRF]10E ;SEWAQE DISPOSAL SYSTEM INSPECTION FORM PART C . FAILDRE' CRITERIA Indicate yes, no, . or. not determined (Y, N, or ND) . Describe basis of .determination :in all : iristances. If "not determined" , explain why not) Al Backup.•of sewage into facility? Discharge or ponding of effluent to the surface of the ground or- surface waters? /" . Static :.liquid level in the distribution box above outlet invert' Liquid depth in cesspool <6" below invert or available volume< 1/21 d;+ . flow? 14/Required: .pumping 4 times or more in the last year? number 'of times pumped .m_,A/Septic. tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any. portion of ,the .SAS, cesspool or privy; below. the high groundwater elevation? within. 50 feet of a surface water? within.: l00 :feet .:of a surface water supply or tributary to a surface water supply? within- a .*.Zone -I of. a public well? �.. within -50 feet .of.. a :borderin vegetated wetland g. 9 or salt marsh (cesspools :andprivies `only, Il the SAS) ? 'Al. within. 50 feet of a private water supply well . less: than .100 -feet but greater than 50 feet from a private water supply, ,well:.with`no.:acceptable water quality analysis? If the well has :been analyZe,d to be ,acceptable, attach copy of well water analy= for ."66lif,drm .bacteiia, volatile organic compounds, ammonia nitrogen and ;;nitrates trogen, sussURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION PORN PART D CERTIFICATION Name of Inspector ' '�:l_ �0/1:�0 Lo-r71 � i ,J� Company Name lea lU o� �Ur�s 74V�; Company Address 111 A ✓v1 4n-s ✓w4- Ci {r�/ rertification Statement I certif thaw .I have !�ersnnal. {rs ect�d tr > sewage dis osa 1. system at Y. y P-- . � �'- P , this .addrats and that the information reported is true, accurate and complete*' as of .'the time of inspection. The inspection was performed ar.; any recommendations: regarding upgrade, maintenance and repair are consistenti:with my training and experience in the proper function and manitenance. of'on-site sewage disposal systems . Check. ne: I have not.. found. any. information which indicates that the system to,.zadequately 'protect.. public health or the environment as defined it,. 310:.-.CMR 15:.303. Any failure criteria not evaluated are as stated ir• the PAILURE .CRITZRIA:°section of this form. I have,';determi:hed -that the system fails to protect public health < r,:' the -env-ironment as def:ined . in 3.10:. CMR 15 .303 . The basis for thi-. determination 'ins` provided in the : FAILURE CRITERIA section of this form. . : Inspector.'s Signature Date ��— original to system owner Copies to: Buyer (it applicable) Approving authority L O`C A T 10 S-E-W A C E PERMIT NO. VIIIAGE INSTALLER'S NAME i ADDRESS I U I L 0 E R OR OWNER DA T E PERMIT ISSU E D DAT E COMPLIANCE ISSUED ///,�- I w w IN O ` e,17 f�\V� � � No----Q.0 Fxs.... .................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® JqF HEALTH Appiiratiou for DiopooFai Works Tomitrurtiora ramit Application is hereby made for a Permit to Construct ( r Repair ( ) an Individual Sewage Disposal System at: .. ... � Loca ion-Address or Lot No. .........AJ..-1?-Z.a11_......J4 areL-az------------------------•-------- ...... O.x--------a2_-v----.... s.rr�.Y� Owner Address aA1, 5......(ak!Q.5......C:0.r.V.a.-�..--.....•.................... AA...... .--'V'0RrnovT"r Installer Address Type of Building Size Lot...... 1 __Sq. feet �., Dwelling—No. of Bedrooms......-.�.............................Expansion Attic ( ) Garbage Grinder (No) P14 Other—Type of Building ............................ No. of persons--_--------.-._-_-.---.---- Showers ( ) — Cafeteria ( ) Q' Other fixt r ......................... d Design Flow.................a .............----gallons per person per day. Total daily flow..............13a.0...._-•-------gallons. WSeptic Tank—Liquid capacity. `. .gallons Length................ Width................ Diameter--.------.---.-. Depth................ x Disposal Trench—No. .................... Width.... j.....--..... Total Length.............. Total leaching area ........sq. ft. Seepage Pit No........... iameter.........0...... Depth below inlet.--...&........ Total leaching area....._._..0....sq. ft. z Other Distribution box ( � Dosin tank n '—' Percolation Test Results Performed by 1T�--=t _ .._.. .:�1�> ___.0 Date.... _"" .:":15'-. Test Pit No. L..._ -minutes P 1.7 Pth of Test Pit P inch De . Depth to -ground water-.---------- -_----. . (x, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..--.................... A+' •-••---••--------------------•-•--••-••-....•---.•-•-•--•-•---•-•••--•....._.............---•----•...........•-----••-••----•---•-•••-•••..._.._............. O Description of Soil---------------•--•. .................................. x W ----•-•----•----------------=--------------•------- -----------•---•--••--------•-•-••--.----••---••----I--....................................................................................... 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 iITLL 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 board of health. /9k U rary AooMe..s Signed....0-1 ,r e n,. rY1......... ................ ...17.E Y...... .�. Date Application Approved By. � ,/1/�� y ty�'�� ----•-.......... v� Date Application Disapproved for the following reasons:---------------•----------------------------------------------------------------------------------•-----•••----- --•-••••-•--••-•-•-••-•-•.............•--...•--•-•-------••••--•-•-•-•-•---•--•••-•-•••-•-•••-•••---•••-........•-•--•--•-•--•---••-•---•--•----•-•----------•--••---••---•-----•----------••-•-••-•-••-- Date PermitNo......................................................... Issued_....................................................... Date 41 No...a..ep .'�.� w Fim.... .... THE COMMONWEALTH OF_MASSACHUSETTS BOARD OF HEALTH_ ��.........._ ......... r 1........................................... Appliration for Disposal Works Tonkrurtion Errant Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: f ................_........ 7....... "a! . .....L "....................... --•---•-----..............----•-•-----...... '" ...........-- .......................... Locajion.Address or Lot No. ......................—.......................................................................... ..........--...................................................................................... Owner Address W Installer Address Type of Building Size Lot....... 1__ 6.1..Sq. feet .-, Dwelling—No. of Bedrooms........:••.�.`a:;S............................. Attic ( ) Garbage Grinder (wo) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfix�r�s -------------------------------------------------------•----------------------_------------------ ---------—-------••-......... •....... ........ WDesign Flow............................................gallons per person per day. Total daily flow.......... �_:a1 f...............gallons. W Septic Tank—Liquid capacity f?D.gallons Length---------------- Width................ Diameter---------------- Depth................ x Disposal Trench—No.................... Width.......;............. Total Length..........,_.;...... Total leaching area ...........sq. ft. Seepage Pit No._.________I_.__-Diameter..._.__.%r_...._ Depth below inlet___._._._______ Total leaching area......P. �_...sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by_".............................................................., - ` _��? Date.._ ..` _ .-.._ :'... - .... �-7 Test Pit No. 1.....__ '"..minutes per inch Depth of Test Pit............ ..... Depth to ground water................_...__. LZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Y •---------------------------------------------•----•----•--•--------.......----••. _ 0 Description of Soil-----•--••-----------= ...................................== x 1 . ........... eJ : .............. ............................... - _ _ _.......... UW -----------------------------------------------------------------------------------------------------------•.I....----------...----•-•--•---------•-------••-----------•----•-••-•-•-........_......... Nature 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 TITL% 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 board of health. Signed...................................................................................... ................................ Date Application Approved B ---------- Date Application Disapproved for the following reasons--------------------------------------------------------•--------------- ...................................... --------•-•------•...............•-•----...----------••------•--•-•---•------------------•••--•-------......----•---------------•----------------------•----------------•--...------.Date--•-------.... PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH E LTH OF MASSACHUSETTS BOARD OF HEALTH .................................OF..................................................................................... Qrrtifiratr of Tuut liaurr THIS IS T CE 9t IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by................... ---------------------------•••••...---- ---- --•---•------•--............... ...•-----................•-••-•----••----•---•--•......--- Zen l / J has been installed in accordance witl the provisions of TITLE5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----- ._=:�z'.................. d ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... ...........OF..................................................................................... No. ..._.-�z- ................................ .. FEE........... ........... Disposal urku t nutr ion rruti# Permission is hereby granted - -------•------•------- .--•------•-----•-•------•----•----•----••-•-----••----•-..........-•........................... to Construct i�7) or Repair ( ) an Individual S.wage Disp sal System atNo.••--9.; ------- ..�� .. /!! ................................................. Street as shown on the application for Disposal Works Construction Permit No..................... 1,dated.......................................... .................................•-•-.._ oard of Health DATE................ ,� �/__.., ------_..... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS 51►JGI.E FAMtt_Y - BEDROOM uo GActe+A.GE"Grzl�►o�cZ. DA►LY FLOW z IIO X 3 s 5EPTIG TANK =. 33Ox150% =.495G.P. { w U5>= %000 6AL. +5Po5AL PtT v4E 1000 6At_. . D,_�......... _ _eoo 51p%WALt_ AR-SA. .150-5.1; 6 4 o 31 41, BOTTOM ARE.Ajr . 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Id A O5TC-6ZVILLE MA-'SS• T5 '4L1{+1- RA-DSGN I --- ----- I I I I f I - ' I 26 I • 1 CHARLES LANE I SREEN PORCH, PORCH FALMOUTH•MA 02540 I I i I 310 994-9235 I I I I I i O I . 11 I GARAGE ryan@ro-dsgn.com DINING BATH ra-dsgn.com ------------ -\\`3 BEDROOM BEDROOM KITCHEN --------------- EXISTING BASEMENT __ - --I -I ". x__IL_-u-- -- i 1 I I -- ------------ _ BEDROOM -- -- EXISTING WALLS,DOORS TO BE DEMOLISHED UP LIVING ------- ------ CLOSET Existing Basement Plan Existing/Demo First Floor Plan q Existing Second Floor Plan O -------------- n, W N ------ ------, I 0 RN PORCH I I I I I I I I it l i• > }S PORCH --------- N I I I I , I I I ' I I I I s-------- GARAGE BATH BATH r'^) PostABovE DOWN ro li". DINING I �,I' I to � �/ J I I EXISTING BEAM AND2X4WALL ��.I �- -- --- - -- \`{ BEDROOM ❑ BEDROOM , I I n KITCHEN I I I EXISTING BASEMENT =_ ------------ -- __ ————————— I -- ---------- . ._. BEDROOM 7 — — — — — PROPOSED BEAM BELOW CLOSET / UP LIVING ------ CLOSET A Proposed Basement Plan 5 Proposed First Floor Plan 6 Proposed Second Floor Plan /� (� EXISTING/ PROPOSED PLANS V\2o �� A 101 R