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HomeMy WebLinkAbout0068 SANDY VALLEY ROAD - Health ---------------------- 68 Sandy Valley Road Marstons Mills F/R _ A = 101 087 j i TOWN OF BARNSTABLE V LOCATION �n �i�e U�.��, �� SEWAGE #Aee,? J'I'-7 VILLAG ASSESSOR'S MAP & LOT 0L7 INSTALLER'S NAME&PHONE NO. /lni�i��ofY' /o.✓�fi✓ce✓ y�Y' 8`9?(a SEPTIC TANK CAPACITY ";w LEACHING FACILITY: (type) Lb�,CL�in�ra �`!� (size)1el- .A ILK-1 ' NO.OF BEDROOM 3 BUILDER O OWNER iT 10 PERMTTDATE: //, ?/��� COMPLIANCE DATE: 11_ 25--U2 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 h v`7�� r ,No. VQ)-^557 Fee 'S 0.O0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for ]Bigool 6pgtem Cow6truction Permit Application for a Permit to Construct( )Repair( )Upgrade(✓)Abandon( ) O Complete System I/Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,AVress and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(14�/D Other Type of Building o.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow J169 gallons per day. Calculated daily flow gallons. Plan Date Zigllj ZV Number of sheets Revisio Date Title 51 It 2t se _ 6' v�Q' Size of Septic Tank /4 sue/! Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 been issued d alt -- / Signed � Date Jd`�✓�z Application Approved by �,)�d/✓1� L /AV Date Application Disapproved for the following reasons Permit No _oog S J 7 Date Issued l /- -———————————————————————— -� ©Q - 5 5 7 NO. Fee y - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes w t V 2pprication for Migpogaf *potent Congtruction Permit Application for a Permit to Construct( _.)Repair( )Upgrade(✓ )Abandon( ) El Complete System Z Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. d f �savvll ,tea Assessor's Map/P©ea 7 - A6'/ c7 Installer's Name,Address,and Tel.No. Designer's Name,A40ress and Tel.No. ;7/7 Type of Building: 7 Dwelling No.of Bedrooms J A Lot Size sq.ft. Garbage Grinder(14�10 Other Type of Building S r° o.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow ..�?'3p gallons. Plan Date /D/0 3 ze Number of sheets Revisio Date d J`Title /le t:S'C A1,1;� � ` Size of Septic Tank /C� Dili/✓7`/�1's Type of S.A.S. Description of Soil 5 I ( Nature of Repairs or Alterations(Answer when applicable) j 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 been issued th' daf alth__.___�.._... Signed .i% 3 � '' Date ////1 Z Application Approved by I /4 t/!1? / c�/�i�t/ Date /��� /, . r _ Application Disapproved for the following reasons Permit No. ca�OOa SS�l Date Issued --------------------------------------- - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CER FY, that theJ n-sit Sewage Disposal System Constructed( )Repaired( )Upgraded( Abandoned )by do at i Jr�' �,/ /��' J/ l /�/°.�.5 © -'�/ as been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N4ZOe6l". J'7 datedInstaller Designer Designer 'r The issuance of this permit shall not be construed as a guarantee that the syste wild f nction as desi(g ed. Date ! I_ C— n Inspector Aj) . I --------------------------------------- c Fee I � r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpogar *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( /)Upgrade( Abandon( ) System located at 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. �E Provided:Construction must be completed within three years of the date of this permit. I{ Date: r 1 r I 1 0(}_ Approved by tL' / r/-yJ�r_K444,71'-..,, j r f i TOWN OF BARNSTABLE LOCATION e SEWAGE fI-7 VILLAGE ASSESSOR'S MAP & LOT 10l-U7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /,��10 zw jG LEAC.IING ) ACILITY: (type) r,11Y A-4--, �!l (size)/4•Y3 ,c 30 `X� NO.OF BEDROOM 3 BUILDER OLCOWNER PERMUDATE: COMPLIANCE DATE: I I— 2 S Separation Distance Between the: Maximum Adjusted,Groundwater Table to the Bottom of Leaching Facility S 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 �f6g 3 i O I � i d I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 SANDY VALLEY RD Property Address PORRINO Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/20/13 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the I computer,use 1. Inspector: l only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 City/Town State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/20/13 Ins or'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. W I t5ins•3/13 Title 5 officijins .� onn: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 M 68 SANDY VALLEY RD Property Address PORRINO Owner Owner's Name information its required for MARSTONS MILLS MA 02648 4/20/13 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM DID NOT SHOW ANY SIGNS OF FAILURE AT TIME OF INSPECTION, TANK WAS PUMPED FOR MAINTENANCE 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): I t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form _ a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 SANDY VALLEY RD Property Address PORRINO Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/20/13 every page. Cityrrown 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 Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 68 SANDY VALLEY RD Property Address PORRINO Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/20/13 every page. Cityfrown 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 68 SANDY VALLEY RD Property Address PORRINO Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/20/13 every 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 qual I analysis. [This system passes if the well water analysis, performed at j 1) certified laboratory,for fecal coliform bacteria indicates absent-4A'".he pressnice of ammonia nitrogen and nitrate nitrogen is equal to or less—than 5 opm, 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 El El Area 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 68 SANDY VALLEY RD Property Address PORRINO Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/20/13 every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on sife? ® ❑ 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•3113 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 , 68 SANDY VALLEY RD Property Address PORRINO Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/20/13 every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT SYSTEM CONSISTS OF A 1000 GALLON TANK D-BOX AND A 10.83X30X2' S.A.S.CONSISTING OF INFILTRATORS 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2011----------289 2012-------303 Sump pump? ❑ Yes ❑ No Last date of occupancy: APR 3013 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 68 SANDY VALLEY RD Property Address PORRINO Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/20/13 every page. Cityrrown 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: DEBARROS SEPTIC Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? PUMP TRUCK 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 68 SANDY VALLEY RD Property Address PORRINO Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/20/13 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: S.AS INSTALLED IN NOV OF 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ' ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1.5 Depth belowgrade: 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 I Sludge depth: MODERATE t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 SANDY VALLEY RD Property Address PORRINO Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/20/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 4 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK WAS PUMPED AFTER INSPECTION FOR MAINTENANCE 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 68 SANDY VALLEY RD Property Address PORRINO Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/20/13 every page. Citylrown 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 68 SANDY VALLEY RD Property Address PORRINO Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/20/13 every 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.): BOX LEVEL HAD RISER IN PLACE NO SIGNS OF BACK-UP OR FAILURE AT TIME OF INSPECTION 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: NO OBSERVATION PORTS FOUND t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 68 SANDY VALLEY RD Property Address PORRINO Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/20/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 INFILTRATORS ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO SIGNS OF FAILURE AT TIME OF INSPECTION Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , . 68 SANDY VALLEY RD Property Address PORRINO Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/20/13 every page. Cityfrown 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 68 SANDY VALLEY RD Property Address PORRINO Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/20/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately 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 68 SANDY VALLEY RD Property Address PORRINO Owner Owner's Name information is required fof MARSTONS MILLS MA 02648 4/20/13 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: GREATER THAN 5 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 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: DESIGN PLAN Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s 68 SANDY VALLEY RD Property Address PORRINO Owner Owner's Name information is required for MARSTONS MILLS MA 02648 4/20/13 every page. CitylTown 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 Assessing As-Built Cards Page 1 of 1 TOWN OF BARNSTABLE LOCATION RJ SEWAGE#Ak ?- 1 r77 �y1 T7 VILLAGE ASSESSOR'S MAP&LOT 0J-ae! INSTALLER'S NAME&PHONE NO. irye, SEPTIC TANK CAPACnY I, /,W G LEACH]NG FAC]IM:(type)�,, 't t�h lY.) (size),a.8- A 3, NO.OF BEDROO 3 BUILDER O OWNER PERMITDA'IE: (1 1166Z COMPLIANCE DATE: 1!-2 S a l Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S f 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) 'f Feet Furnished by l�aail ,i97rJoW/ 3f 3 �.7 :t& 0 i \ hq://www.town.bamstable.ma.us/Assessing4 Mdisplay.asp?mappar=101087&seq=l 4/20/2013 RECEIVED OCT 15 2002 COMMONWEALTH OF MASSACHUSETTS TOWN OF BARNSTABLE EXECUTIVE OFFICE OF ENVIRONMENTAL_AEr- `RS'DEPT. =DEPARTMENT OF ENVIRONMENTAL PROTECTION U11 tx %z I 4 FAILED INSPECTION TITLE 5 TS OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARYASSSEESS�SMEN .SUBSURFACE SEWAGE DISPOSAL SYSTE ;x PART A CERTIFICATION Property Address:68 SANDYNALLEY RD ` 7 MARSTONS MILLS,MA 02648 Owner's Name: NANNE JAMES Owner's Address: 61 WEST.ELM$T PEMBROKE,,MA,02359 Date of Inspection:9/27/02 ; Name of Inspector: (pleasepi?nt) JOHN GRACI Company Name: JOHN'GRACI SEPTIC INSPECTIONS,INC. Mailing Address: PO BOX 2119 TEATICKET,MA 02536 Telephone Number: (508).56476813' 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 aid 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: Pje� sses onditionally Passes eeds Further Evaluation by the Local Approving Authority Fails Date• Inspector's Signature:The system inspector shall su this inspection report to the Approving Aut rity oard of Health or DEP)within 30 days of compection.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 owner and copies sent to the buyer,if applicable,and the approving DEP.The original should be sent to the system own authority. Notes and Comments SYSTEM FAILED TITLE V INSPECTION.LIQUID LEVEL IN LEACH PIT IS UP TO PIPE. SAS NEED§TO BE UPGRADED ,. ****This report only describes.":conditions at the time of inspection and under the conditions of use at that time.This inspection ttoesnot address how the system will perform in the future under the same or different conditions of use. u; , f Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 68 SANDY VALLEY RD MARSTONS-MILLS;"MA 02648 Inspection Summary: Check A;B,C,D`or E/ALWAYS complete all of Section D A. System Passes: I have not found any information`,which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304'exist.Any failure criteria not evaluated are indicated below. Comments: 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 co'inpletion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. ' The septic tank is metal and over 20 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. ND explain: 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): f broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required.pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed i'•'. ND explain: 't Page 3 of 1 I , OFFICIAL INSPECTION1 FORM -NOT FOR VOLUNTARY ASSESSMENTS 1.SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 SANDYVALLEY RD MARSTONS MILLS,MA 02648 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;healtli,,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 i 1� 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning)iwa manner that protects the public health,safety and environment: _ The system has aseptic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply on4ibutary 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 ayseptic.f 4 and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply:.,.wel1** Method used to determine distance 5: **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile=:organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: q .t i� ` Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE;SEV, AGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION(continued) Property Address: 68 SANDY VALLEY RD MARSTONS'MILLS,MA 02648 D. System Failure Criteria'applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X _ Backup of sewage'ini6facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool, _ Static liquid level in,the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped.. _ Any portion of the SAS,cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone I of a public well. _ Any portion of a cesspool or`privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is.free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) W5 (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310.6MR 15403,therefore the system fails.The system owner should contact the Board of Health to determine What,will be necessary to correct the failure. r E. Large Systems: To be considered a large system.the system must serve a facility with a design flow of 10,000 gild to 15,000 gild. You must indicate either"yes'".,or,"no"to_each of the following: (The following criteria apply.,to,large,systems in addition to flee criteria above) yes no the system is within 4qQ feet of a surface drinking water supply the system is within 290 feet of a tributary to a surface drinking water supply the system is located ina nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 1I of a.public water:'supply well If you have answered"yes,„to racy queNtiun in Section L the System is considered��significant Ihre:;�l. nr nn� vend "yes"in Section D above lhc,lOrgc:system has failed.The owner or operator of any large syslcni crniHidered n significant threat undMSection E or failed under Section D shall upgrade the system in accordance Willi 310(W I5.304.The system owner should contact die appropriate regional office of the Department. i Page 5 of 11 y OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOS AL SYSTEM INSPECTION FORM PART B a... , CHECKLIST Property Address: 68 SANDY VALLEY RD MARSTONS MILLS,MA 02648 t Check if the following have been`#done You must indicate"yes"or"no"as to each of the following: Yes No X_ — 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? X 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? X Was the site inspected for signs of break out? _X— — 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,matenal of constriction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ 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 no X — Existing information.For example,a plan at the Board of Health. X— Determined in•the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable),[310;CW.115.302(3)(b)] <, Page 6 of 11 OFFICIAL INSPECTIOMFORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 68 SANDY VALLEY RD MARSTONS MILLS,MA 02648 ;e FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 ' Number of bedrooms(actual): 3 DESIGN flow based on 310 GIvIIt 15:203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): OD [if yes separate inspection required] Laundry system inspected,(yes or,no):_X_ Seasonal use: (yes or no): Water meter readings,if available(last.2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: COMMERCIALANDUST", I Type of establishment: ; Design flow(based on 310 CMR t5.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged-to the Title 5 system(yes or no):— Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records ;. Source of information: EVERY THREE YEARS BY ABCO Was system pumped as part of the inspection(yes or no):— If yes,volume pumped:,_$allons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution.box,soil absorption system _Single cesspool Overflow cesspool _—Privy ,`k _Shared system(yes or no)(i�yes,attach previous inspection records, if any) _Innovative/Alternative technology.,Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank —Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1982 BY OWNER p Were sewage odors detected when arriving at the site(yes or 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: 68 SANDY VALLEY RD MARSTONS MILLS,MA 02648 BUILDING SEWER(locate on site plan) Depth below grade: 18 Materials of construction:_cast iron 40 PVC_X_other(explain):20 PVC Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK:—(locate on site plan) Depth below grade: 12 Material of construction:' X_concr'ete=metal_fiberglass_polyethylene _other(explain) 9 ' If tank is metal list age: Is;age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 1000 GALLONS Sludge depth: 1 . ;,�,�°-: Distance from top of sludge"06!b0ttom of outlet tee or baffle: 33 Scum thickness: 1 Distance from top of scum'to,top of outlet tee or baffle: 4 Distance from bottom of scum to bottom of outlet tee or baffle: 19 How were dimensions determined: MEASURED Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND,PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade:— 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: Comments(on pumping,recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,._evidence of leakage,etc.): Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART C 4 ,.,;;,SYSTEM INFORMATION(continued) Property Address: 68 SANDY,VALLEY RD MARSTONS MILLS,MA 02648 TIGHT or HOLDING.TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: +5+, Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons,. Design Flow: Y 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: X_(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.):f D-BOX WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND. .f' l PUMP CHAMBER: t (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): `k S ,f E • 2 S I I Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 SANDY VALLEY RD MARSTONS MILLS,MA 02648 SOIL ABSORPTION SYSTEM(SAS):_X—(locate on site plan,excavation not required) If SAS not located explain why: Type 1 leaching pits 1000 GALLON 6'X 6' 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 4hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): LIQUID LEVEL IN LEACH PIT IS FULL UP TO PIPE.SAS NEEDS TO BE UPGRADED. 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: >y Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): i i Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:68 SANDY VALLEY RD MARSTONS MILLS,MA 02648 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 l00 feet. Locate where public water supply enters the building. Ar 021Lo Ab31� �) ,5,533 A C 30 9 e �r i . L Page I 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 SANDY VALLEY RD MARSTONS MILLS,MA 02648 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground wate'r,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: X Observed site(abutting property/ob§ervation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators histallers-(attach documentation) Accessed USGS database-explain: You must describe how you establis4:edmthe high ground water elevation: HAND AUGER- 12+FT. _1 b. ( f L 0 C A T I E W A 6 E PERMIT NO. 1-O t V`tLLACE / wa o z&� INSTALLER'S NAME m AD NESS c -� � �z- - 0 U I L D E R OR OWNER DATE PERMIT ISSUED • DATE COMPLIANCE ISSUED � 5eR rc� LOT NO. : �.7 ADDRESS : 5fiyo!� OWNERS NAME : 6u 1--pv�G✓� — SEWAGE PERMIT NO. : Q 6�NEW: REFNIR: DATE ISSUED: DATE INSTALLED: _ INSTALLERS NAME : 4�5el-t s 15,*-f INSTALLATION OF: lood "7/ANp WATER TABLE :. FINAL INSPECTIO DRAWING OF INSTALLATION ON REV RSE SID: `` A4 Ito 4 � _ 7 � . ,NO.8'3 3 Fxs.. �................. THE COMMONWEALTH OF MASSACHUSETTS ^"`F BOAR® O HEALTH ....................OF...... 1 1�✓ � ............................ Appliratinn for Disposal Works Toustrnrtiun ramit Application is hereby made for a Permit to Construct ( ?.?or Repair ( ) an Individual Sewage Disposal System at: / �� ....��....�.... ..........fir----•------��.- •---------tea... .�,�./.� �....�------. .�.........-•�-©�`-=�`•= . --------:..............-- Loca tion-Addr ss ,........... � . ✓ o/�'I :....................................... ,Owner �C/s�<!17 :.!Z dr.. ....W ....... ......................................... Instiller Address loo dType of Building Size Lot--_------------------------Sq. feet U Dwelling—No. of Bedrooms.__....-.:.3..............................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type of Building .............. No. of persons......_..............______. Showers — Cafeteria Ga Other fixtures -------------------------------- WDesign Flow...............,�._.._....._.._.__gallons per person per day. Total daily flow.... ............................gallons. WSeptic Tank—Liquid*capacityil?90.gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.............._..... Total Length..._..__.___.__.____ Total leaching area....................sq. ft. Seepage Pit No....... ........... Diameter......&I........ Depth below inlet.................... Total leaching area..................sq. ft.. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed'by--•...................................••--•-•........-••...----•-......... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Lz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -•..............•---•------•.......•--------.......................-------------•--........••....--•....................................... -............. ... 0 Description of Soil.................................•--•-•----------------•-----•-•-•-•---•---••--------------------------•----•-••------................................................. 0 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 iTl;r. 5 of the State Sanitary Code—Th ndersigne u l:er agrees not to place the system in operation until a Certificate of Compliance hVbDeen 'ssu the board o he th.Si e Application Approved BYIffo -Cur- S�............................... Date Application Disapproved foring reasons-----------------------------•--------------------------------------------------••---------...-••---------....... .....................•----------.....-------------------------•--•--------••-----.............------------•---------------------------------•-•----------------••--•----•--••••---••----••--•----•.-•••- Date PermitNo......................................................... Issued....................................................... Date o.vk3 3 _. .. Fxs.. ................- THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH _.................OF....... +'? / P.r`?' ............................ ,�.:ppfiratiou for Bi_qgnsal Works Tnnitrnr#iun ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at r r Location Address ,t �' or LgtN f } +� ` C!�'°+ re G � V f/�... -•--•-�---......................... ...... Owner afidress Installer Address QType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms........--3...............................Expansion Attic ( ) Garbage Grinder ( ) Other Type of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures --------------- --------------- . Design Flow............... ,__ --------___.____.gallons per person per day. Total daily flow...._. _......_,_..__._..__._._.__.__......gallons. W W Septic Tank—Liquld capacityl�n.gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......f............ Diameter.__-- ----------- Depth below inlet____________________ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........................•----------------------....-•--...----______..__.. Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water•-___-_--__-_-________-. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ............................................................................................................................................................ 0 Description of Soil......................................................................•---.._..--•-••••••--•-•-•-•-•-•••--•--•••-••-------------•-••---•----------•--•---------------•- x -------------------------------------------------------------------------------- ------••-••-••---•----••------------------------••------•----------••---••-•-••------•----------....---...........•---- U 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 LITTIE 5 of the State Sanitary Code— Th , I dersign u ther agrees not to place the system in operation until a Certificate of Compliance has been issu;d�the board of h th. . Si ed - Application Approved Bleff ��' - ={/` ���-__.._.... PP PP y---- ---='.:.... ...............................•---. Date Application Disapproved forwing reasons--------------••-••-•-----------•--•---•-••--••--------•---•--••••----•----•---•--..._------•-•••---------•---- ..................................•----•--------------•-------------------•-----------.........--•-----••---------------•--•-----------------•-----------------------------....---------•---•••-••--•--- Date I PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... (9rdif iratr of Tumpfianrr TH-,, J 0 CERTIFY, That the Individual Sewage Disposal System constructed 4�r Repaired ( ) b � �`�,°............. 1 .......... .....•-•-•-----._....._........•••••--•-•••••---•......_..._..._...-----....._ y---•- - Install r� / s �__ /f l �: � � has been installed m accordance witlYtlie provision of TITLE r of The State Sanitary Co e as,described in the application for Disposal Works Construction P it No.- ::__ .................. dated-6_�%';,"�_.__._.........._._...... THE ISSUANCE OF THIS CERTIFICATE SHALE. NOT BE CONSTRU D AS A GUARANTEE THAT THE SYSTEM NAIL //Fi/ iION SATISFACTORY. DATE... 7 .l,Y . --_____-•-•-•-----•-•---••------------------•---____. Inspector . ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF..................................................................................... � !? No.__-___ . FEE..................•••--- Tnnitrnr#ion Virrmit Permission is hereby granted._._. ............................................. to Constr> r( ') or Repair ( ) 4n Ind 'idua� e e Dts asal fgystem t atNo •••` ...............................................'7 ...............�/r , Street as shown on the a plicat' n for Disposal�V 7orks Construction Permit No. ... ............ Dated........................................... / ........................•- ----......--•-- ...................................................... �• � /(/ Board of Health DATE: •• •-............................................. FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - I `,,�WGLC FAMU-Y - BEoczr�oM j ua GXQeAGE 6wND62 D is►L•( FLOW A 110 X 3 = SEPTIC TASK = 330x15o% = 4956.P. q8.`. 1/i.I Usc 100o GAL. Dti5Po5AL Prr u5E too GAL. A •�iI �S.co' 5 t DSiV�AIL AR61► - 1�o s.t= � �b ' --� � � 150 50TTOM AREA: . l�P 5F• 9 '��° Sp - -TOTA 1- -roTA�_ DA 4-1 PE2G0LATI0N RATE ] 1"IN 2MIN 0V_Lf=- 55 gZ•z '� I, I tH OF ,fir � : RICHARD , ALAN ' w A. I o d�C� BAXTER JOKES No.21048 ` No. 25 1Vj O G/STAR /ST` r SU' �� , a•. v Top FNto 1OF, ©. NoL� 3�c-S3 -too ►oov INV. SfJ L.r 1)1 ST. INV.II Cp A L..bGVT1G �'� ii Z (Ooo IldY, 0Ux C1S'L TANK . PIT INV., INY. WIT14UeAd q8•Z 9�'¢ WASMSD M 6TON6 I Sal�D. JI.� � �I•� , � �l G E RT 1 F 1 G o PRUFIL� �l= Lo�4-T1oN �A125TA�1� :I+�I��i •L NO. SGALE = CoD VA•TE S .74'g3 FOL Aniz,, ` ,oPostro P1-AN REPS ZeN C.E 1 GEcZTIFY THAT TNE. �H0VS 5No4YN NERCzON GOMP�-Y5 WITN'THS SIoE>_11JE �( AWP 66T�e.GK s�6QvtQEMi✓N7� F -T�1�E -ro wN o� -6A Ul5rA(jL4 An1U i S '�1 I I�� . �►c. 33 . I G , t_ocp.TED 'WITNI TN G1.000 PL9.{N DLT E �•t�3 �J1 .,.- BAXTEQ.e ►.IYE INC. REG I SZ E.V-rmrD I,Au Ds u F-V EYoeS Tull PL&KI 1<> W&T z>a AN os•T-EtzvlLt.E- • MASS• I� . lu5T?-uMEN'I' Sv9-VG-y �-TNE 0FF'SETS 6WOUtID No"T' 5c- Val" r'TC► CSC'-'Tt:.t•lnl►-IC t_�n trllat=�� APPLIrAr.IT' ���� ( IBC r i 5-iWGLr-- FAMtt-Y - BEORQoM uo GA�tBaGE 6wNo�I� a�/at t_•( FLOW x 110 x 3 S.q. ,v 5F-PTrc 'rAQK = a3oxt5o% = a95�.PR i usc- %000 GAL. q8•` - �15Po5A1_ PIT V 6E 1000 (SAL. o%D A Z Ga z tO-SR � iI 15 5 F X 35 . r'�• z $OTTOM ARE.Ar jo 5,F• 4 5O S.F x 1• o r : 40 6.P0 -ToTA I-. c>S51 GN o 4Z 5 G.P D. +1 �•20�? /oo -ToTA%- DA t uY FI..OV,( = 330 G,PO, 471 U� 4-1 j PE2Cot_ATtOt� RATE + I''IN 2M1N o�.�t~55 _ y.Z•z.�. -� I. �S 90.E vZH Of RICHARD ALAN (�Q A. :". W. lca BAXTER w JONES 4' Na 21048 No. 25I0044>4 0 O F Q�� ;r IST- / TO P FNn-s kov, O .yy �.S�9•G ��t��� ��rT�c 1�' g9 �a • - i 1yti44� Ioov INV. II SIJRj701L.. D►5T. (N�, GAS• bGPT% Z l o0o INY. Box el 40 TAN K 98 1„•EAGu PIT INY. INY. w/I-r41 � I'/3/4-I%L! CCeAtJ WASKGD 6Ta N6 ' CER.TIFIso PLOT P1-A►.1 PRUFIL.� LoZA.7101J /�Ar25T'w1 Aul, NO- i R E F 6 ze N GE 1 CERTIFY THAT THE too 51.104YN NEQFs01�1 GOMFL\ 6 WITN-TNE S 1 t�E1.lt�1 E i AWP Sr="T5AGK R.6Qt)rR.EMEN'f� F 'C-1-►E �� -To W W 0 l✓ -'6A rLA15WA ',6 A N v ►s Imo' �L L0CP.TE0 -WITFII TN FC.oaD PL N DA-rES,2.4'if3 �• BAXTE2e Wys IN REG I ST EQ6U'I-AN 1,5 u 7.v EYoeS ' Tull P�o.N ►�� ^IaT 4c.5r r1 o►d AN 05 rC-Q.VILLr-- • MA55. •Iu5j-R,uM6N'l' SUZVC_Y �--r14E OPVSE75 SW000 NoT DG- v,�r C�-cC+ C7C:Tt=.�'1�1►-IC t_�� l►111C��„ �+PP�-Ir ArJT ��� I I �C V , , �L � ASSESSORS MAP : PARCEL : -- TEST HOLE LOGS ._ -- -. - - --- ', I 1/ FLOOD ZONE: t�-l� ���� � SOIL EVALUATOR �tt.�t L, WITNESS : � REFERENCE: 15 DATE: - r PERCOLATION RATE: L- Z, I1 ,u, TH- 1 TH-2 LPLN ,� I t 5/� LOCAT ION MAP mow. 67, V_��,_ SEPT I C SYSTEM DESIGN -- -- -- .,. \ FLOW ESTIMATE -T 3.BEDROOMS AT I ID GAL/DAY/BEDROOM - 35 j GAL/DAY SEPTIC TANK - \\ � �LobAL/DAY x 2 DAYS - a GAL USE IGALLON SEPTIC TANK SOIL ABISORPT 1 ON SYSTEM I - - ` V/i: ) �.+�' - �,_ SIDE AREA: �X + joj /�x D,7 VQ BOTTOM AREA: / 1 >t �'� p �... - _ _ S I C: S_Y S-T EM S EC_T.. Q N_L , ,5, 3` / `� �f�b� 76,1 N7� _,2 I000 GAL 7��Z3 z - _ �b SEPTIC TANK ,,-, S 1 TE AND SEWAGE PLAN LOCATION : -� PREPARED F 0 L�iJ'A� �1Q�C SCALE: I � 1 W ------ _ V � L I � 'D � ._ DAV I D B . MASON ?S DATE: DBC ENV I RONMEN�AL DESIGNS EAST SANDWICH . MA W DATE HEALTH AGENT ( 508 ) 833- 2 177