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Home My WebLink About0891 SANTUIT-NEWTOWN ROAD - Health 01 SANTUIT-NEWTOWN �d Marstons Mills A - 027 -'037 7 j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , , 891 Santuit-Newtown Rd. Property Address Samuel Funk Owner Owner's Name information is required for every Marston Mills, MA 02648 11-15-13 page. Cityrrown 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: C � key to move your cursor-do not Darrell Stone use the return Name of Inspector key. Cape Cod Septic Inspection Company Name P.O. Box 1466 Company Address Harwich MA 02645 City/Town State Zip Code 508-240-2500 S14995 Telephone Number License Number B. Certification r� r-_I certify that I have personally inspected the sewage disposal system at this address and that the —informatign reported below is true, accurate and complete as of the time of the inspection.The inspection CC &was performed based on my training and experience in the proper function and maintenance of on site cY: w::sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of -Title 5(3,0 CMR 15.000).The system: c:N ct: �= ® F il e ❑ Conditionally.Passes ❑ Fails C—f ,,, ❑ s urther Eval n by the Local Ing Authority O Z= 11-17-13 s Sign 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 7�1e 5 Official InspectioWormbsuftce 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 ,•'� 891 Santuit-Newtown Rd. Property Address Samuel Funk Owner Owners Name information is required for.every Marston Mills, MA 02648 11-15-13 page. City/Town State Zip Code Date of Inspection i 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 t in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: t , 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): f t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 891 Santuit-Newtown Rd. Property Address Samuel Funk Owner Owner's Name information is Marston Mills required for every MA 02648 11-15-13. page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if 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): a 3 C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in orderto 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, F, safety and the environment: Y❑ , Cesspool or privy is within 50 feet of a surface water + -_ ❑ , Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s.' 891 Santuit-Newtown Rd. Property Address Samuel Funk Owner Owner's Name information is required for every Marston Mills MA 02648 11-15-13 page. City/Town State Zip Code Date of Inspection B. ,Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a'septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". _ .,Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: { I 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 i ❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow, t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 i t Commonwealth of Massachusetts x Title 5 Official Inspection Form Subsurface Sewage Disposal system Form-Not for Voluntary Assessments, °M s 891 Santuit-Newtown Rd. Property Address Samuel Funk Owner Owner's Name t information is required for every Marston Mills MA 02648 11-15-13 page. Cityrrown State Zip Code . Date of Inspection B. Certification (cont.) Yes No ❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ Any portion.of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ Any portion.of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a.DEP certified ` laboratory,for fecal coliform bacteria indicates absent;and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and,chain of custody mustibe attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ 10,000gpd. . ❑ The system fails. )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 supplywell 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 TrUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 M 891 Santuit-Newtown Rd. Property Address Samuel Funk Owner Owner's Name information is required for every Marston Mills, MA 02648 11-15-13 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? - ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) s ® ❑ 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 y stem(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): n/a 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 891 Santuit-Newtown Rd. Property Address Samuel Funk Owner owner's Name information is Marston Mills, MA 02648 11-15-13 required for every page. CityTrown State Zip Code Date of Inspection D. System Information Description: 3 Bedroom residential dwelling Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system.inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy:_,. 4 years agoDate CommerciaUlndustrial 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? El 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 891 Santuit-Newtown Rd. Property Address Samuel Funk Owner Owner's Name information is required for every Marston Mills MA 02648 11-15-13 page. Cityrrown _ _ State Zip Code Date of Inspection D. System Information (coot.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: ' > gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system , ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): ) t5ins•3113 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 891 Santuit-Newtown Rd. Property Address Samuel Funk Owner Owner's Name information is Marston Mills, MA 02648 11-15-13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known)and source of.information: Tank, D-box, Leach pit 1986, Cesspool Pre 1978 Per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer.(locate on site plan): Depth below grade: 18,E+/- 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.): Apparent good condition Septic Tank(locate on site plan): ` 12" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years , Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon 8" 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 9 P Y , , 891 Santuit-Newtown Rd. Property Address Samuel Funk Owner Owner's Name information is Marston Mills, MA 02648 11-15-13 required for 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 24" 0" Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Normal liquid level No sign of leakage Concrete outlet tee OK Recommended'next maintenance pumping within 1.5 years Recommended maintenance pumping every 2-3 years 1 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 891 Santuit-Newtown Rd. Property Address Samuel Funk Owner Owners Name information is required for every Marston Mills, MA 02648 11-15-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.j Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ` e II 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•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 891 Santuit-Newtown Rd. 7 Property Address Samuel Funk Owner Owner's Name ' information is required for every Marston Mills, MA 02648 11-15-13 page. Citylrown' State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan}:' Depth of liquid level I above outlet invert off 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.): Grade to box 23" OK condition 2 Outlets. Normal liquid level No sign of leakage No scum No sign of failure Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ Noy' Alarms in working order: ❑ Yes ❑ No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Me 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 891 Santuit-Newtown Rd. Property Address Samuel Funk Owner Owner's Name information is Marston Mills, MA 02648 11-15-13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits , number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): One cesspool and one(6x6').pit with 3'stone Grade to cesspool 5" Bottom 128" Dry Effective depth T-8" No sign of hydraulic failure Grade to leach pit 15" Bottom 96" Dry Staining 4-5'from bottom No sign of hydraulic failure 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 or 17 Co mmonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 891 Santuit-Newtown Rd. Property Address Samuel Funk Owner Owner's Name information is required for every Marston Mills MA 02648 11-15-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i 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, I . a I l r I r is t5ins•311 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 891 Santuit-Newtown Rd. Property Address Samuel Funk Owner Owner's Name information is required for every Marston Mills MA 02648 11-15-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I I C ' k 1 1'7.- Z j 2 3 27-� 30- 4 U-0 y- t5ins-3113 Tille 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y< 891 Santuit-Newtown R M d Property Address Samuel Funk Owner Owner's Name information is l . required for every Marston Mills, MA 02648 11-15-13 page_ Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >4 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: See below You must describe how you established the high ground water elevation: Elevations from USGS maps Approximate property ELV. 88.0-89.0 Approximate bottom of CP ELV. 77.34-78.34 Approximate bottom of LP ELV. 80.0-81.0 Approximate GW ELV. 39.0-46.0 Adjustment 2.8' SDW-253 Zone B 48.59 October 2013 Separation >4' P Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 891 Santuit-Newtown Rd. Property Address Samuel Funk Owner Owner's Name information qreforis Marston Mills MA 02648 11-15-13 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C,,.D, or E checked .. ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 17 of 17 i __L_ V, COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL A�AI°RS l r DEPARTMENT OF ENVIRONMENTAL PROTE CTION R ONE WINTER STREET, BOSTON MA 02108 (617) 292-55, 4' \ q ��f Oce TRUDY CORE 'y q➢� 1000 Q Secretary ��Fi�Sr-4g 0 ARGEO PAUL CELLUCCI T lF DAVID B.STRUHS Governor �' Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �J PART A al CERTIFICATION , Property Address: �/�� js / // � Name of Owner S fl�GJ /3 �A d� Llf� dress of Owner: 14 �t Date of Inspection: �i'�/1G�yl� 02�02'XJ Name of Inspector:(Please Print) ,P";�I jw 'z"/f,/V 1 am a DEP ap o ed sy' em inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Marring Address: •P• OWK Telephone Number: CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails C Inspectors Signature: �1 AAM�il/(/�/�a,L�� Date: O2 o?V oD The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of.Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS Cis/' T C2) �/Y revised 9/2/98 Page Iof11 h t� Printed on Recycled Paper I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: INSPECTION SUMMARY: Check A, B, C, Or D: A. SYSTEM PASSES: _Y I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. t/ 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. Indicate yes, no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection.or the septic tank,whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 revised 9/2/98 Page 2ofIt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: f'1 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: a Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 112 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. fE. LARGE SYSTEM FAILS: You must indicate either"Yes"or "No" to each of the following. The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. .i revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done:You must indicate either"Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant,or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving non .al flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,ap proximation of distance is unacceptable) 115.302(3)(b)] _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. i revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL:Design flow:�ann g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms(actual): Total DESIGN flow 3,30 Number of current residents: Garbage grinder(yes or no):.O Laundry(separate system) (yes or no)311 If yes,separate inspection required. Laundry system inspected (yes or no) Seasonal use(yes or no):�0 ,//�� / Water meter readings,if available(last two year's usage(gpd): /VOW 11?f//�G/1 , �/j¢S Wf/j Sump Pump(yes or no):yA Last date of occupancy: x/T�(� COMMERCIAL/INDUSTRIAL: 1� Type of establishment: Design flow: opd ( Based on 15.203) Basis of design flow 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: OTHER:(Describe) '.ast date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of informas�jc, 0 y Sy tem pumped as part of inspection:(yes or no)ffS If yes, volume pumped: gEM _gallons Reason for pumping: �Z�l,;�/�[jY/�£ TYPE OF SYSTEM V 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known) and source of information: 4 PYIII-1411 Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) `—Depth below grade - - Material of construction: cast iron 40 PVC other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade 'ILA Material of construction:Aconcrete—metal—Fiberglass —Polyethylene—other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: Z Distance from top of sludge to bottom of outlet tee or baffle: 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: iow dimensions were determined: 2-,4^ Comments: (recommendation for,pumping, conditiop of inlet and outlet sees or baffles,depth of lI level in relation outlet invert,structural integrity, evidence of leakage,etc.) 4e. ?p Dl 10'0f& A&Q oLfooz /d GREASE TRAP: ,7r1 (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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: f� (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if leyei and distribution is a ual, evidence of solids carryover, evidence of leakage' t or out of box, etc.) O OU'� A 5 k� iv PUMP CHAMBER:n)_ (locate on site pla 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.) r revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS)--I( (locate on site plan,if possible:excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:. leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields,number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition otsoil,signs of hydraulic failure,level of ponding, damp soil,conditi not veg tation, etc.) f!/ �Q CESSPOOLS:_ . 1 (locate on site plan) Number and configuration: ')epth-top of liquid to inlet invert: lepth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) PRIVY:_ L (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.) � 1 revised 9/2/98 Page 9of11 L - l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) i r C � • 1R4.14 R D a � t c Q tRewT g R . w revised 9/2/98 Page loorn u SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health ' Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Pagenorn MO-RTGAG-E l]VSP_ECTTO.N PLAN -' APPLICANT: MESSIER TOWN: MARSTONS MILLS. LOT 7 158.431 Q 0 fy— DRIVEWAY GARAGE_ DECK :S LOT 15 `° LOT 8 i c , 01l O> 173,97' LOT '9 �D FLOOD PANEL: 250001 0015 C FLOOD ZONE: "C" DATE MAP REVISED: 8/19/1985 I HEREDY CERYIFY THAT THIS MORTGAGE INSPECTION PLAN HAS UEEN PREPARED FOR: DATE: 12/26/13 SCALE. 1" = 30'. THE CAPE COD FIVE CENTS SAVINGS BANK CERT REF: 192365 PLAN REF: 38446 B (1) THE LOCATION OF THE DWELLING alOWN DOES NOT FALL WMUN A SPECIAL MOOD HAZARD"ZONE. PER TAPED INSPECTION THE DWELLING APPEARS TO CONFORM TG THE LOCAL 20NIN0 DYLAm IN EFFECT THE STRUCTURES SHOWN ON THIS MORTGAGE INSPECTION PLAN ARE LOCATED HY TAPE fiURVE'l AT.TIIE"TIME OF CONSTRUCTION V41H RE'SPECT T'D HORIZONTAL DIMENSIONAL SETBACK REQUIREMENTS ONLY ND INSTRUMENT SURVEY WAS PERFORMED AND LOCATIONS SHOWN ARe APPROXIMATE, OR 15 EXEMPT'FROM VIOLATION DOMRGU04T ACTION UNDER.MA GENERAL LAWS CHAPTER 40A AN IM-MUMENT SURVEY 15 NECESSARY FOR PRECIS!:DETFJIMINATION QF BUILDtNG LOCATIONS SECTION 7. REFERENCE DEED SUBJECT WAND MATH THE RENEMY OF ALL, RIGHTS, RIONIS OF WAY, AND ENCROACHG9ENT5, IF ANY EXIST. EITHER WAY ACROSS PROPERTY LINES. YANKEE'LAND EASLT.Ik M. REX"AlON9 AND RE.+MICITON9 OF RECORD, IF ANY THERE'SHALL BE, AND INSOFAR SURVEY COMPANY INC.&WALL NOT BE HELD UAGLE FOR DAMAGES RESIkTING FROM ANY USE AS THE.SAME ARE Of LEGAL FORCE AND EFFECT, OF THIS PLAN FOR PURP059S OTHER THAN MORTWE INSPECTION. TELEPHONE: 508-428-0055 YANKEE LAND SURVEY COMPANY INC FAX:, 508-420-5553 119 ROUTE 149, Marstons Mills, MA 02648 yankeesurvey0com cast.net www.yankeesurvey.net 83029 JM TO/T0 dJbd T 99000Zt,809 bb:01 £TOZ/9Z/ZT n 1 McKenzie, Marybeth From: Ray Messier <raymes65@gmail.com> Sent: Wednesday,June 03, 2020 2:57 PM To: McKenzie, Marybeth Subject: Site Plan Marybeth, The dimension between leeching field and closest point of 3 season room is 14 feet. I tried to call but didn't have your extension. Only MacKenkie found was Debby. Let me know if you are now all set... Thank You, Ray Messier CAUTION:This email originated from outside of the Town of Barnstable! Do not click links, open attachments or reply, unless you recognize the sender's email address and know the content is safe! i r� Rom. McKenzie, Marybeth From: McKenzie, Marybeth Sent: Thursday, May 14, 2020 9:31 AM To: 'BRIAN PATCH' Subject: RE: building permit application ViewPermit, Permit No:TB-20-1170 Thanks Brian, but can you please show the SAS(septic system)on the site plan with distance from the new addition to the system. From: BRIAN PATCH fmailto:bdpatch@cox.net] Sent: Thursday, May 14, 2020 3:36 AM To: McKenzie, Marybeth Subject: Re: building permit application ViewPermit, Permit No: TB-20-1170 Hi Marybeth, Attached drawings showing septic system location, sono-tube footings, HVAC in wall, and approximately 45% glass. Best, Brian On May 13, 2020 at 12:24 PM "McKenzie, Marybeth" <Marybeth.McKenzie@town.bamstable.ma.us>wrote: Hello, I would like to approve your application, for the health department, regarding the building a sunroom. To do that, I need a site plan with you sewage disposal system on the plan due to the change in footprint. Also, could you tell me if it is going to be built on sono tubes or a foundation. Will there be heat in the room and what is the percentage of glass in the sunroom. If you have any questions please let me know. Marybeth McKenzie R. S. Health Inspector Town of Barnstable (508) 862-4644 i 'CAUTION:This email originated from outside of the Town of Barnstable! Do not click links, open attachments or reply, unless you recognize the sender's email address and know the content is safe!:' �n r s fi - k } { a 4 � z Lu 1 TOWN OF BARNSTABLE ,5-AnTuiT- 6-1101 LOCATION 891 Newtown Rd. , SEWAGE # 8 VILLAGE Marstons Mills ASSESSOR'S MAP & LOT 6 '7 53 INSTALLER'S NAME & PHONE NO.CASH I S TRUCKING INC./362-3221 SEPTIC TANK CAPACITY 1,000 Gal (3' Stone Packed) Existing 10' Cesspool LEACHING FACILITY:(type) P.re_= ,.,- (size) 1,000 Gal NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATERanixat_e, BUILDER OR OWNER Eugene Dion DATE PERMIT ISSUED: 10/17/86 DATE ,COMPLIANCE ISSUED: 9`I VARIANCE GRANTED: Yes X No `- i � - � 33 � . , � `� 'J r No.A.J1. ) Fizs vl ...._ THE COMMONWEALTH OF MASSACHUSETTS y �Ap /l�JY1,s.J1 BOARD OF HEALTH c�'� �► �f � � ..............oF... �.4'4 C�...---------------......-------- Applirtt#inn for Disposal Works Tons#rur#ilan rrrnti# Application is hereby made for a Permit to Construct ( ) or Repair (1,,J'an Individual Sewage Disposal System at �9.....: � ::...... -. ..�1..�..... ............•------------------. --.........----.....----.................. i Locat1 11 ess or Lot No. .._ _ _ ..... ............ caner,. Address a � f. .................. ...........••.•-•.............-..---.........--dres.---.....-----.--.....----.--................ • Installe Address Type of Building �j .4 ? Size Lot............................Sq. feet ., Dwelling—No. of Bedrooms................1...... ----`.............Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—Type T e of Building .... No. of YP g ------•----------------- persons.-------------------------.. Showers ( ) — Cafeteria ( ) d Other fixtures ............... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter..--..--........ Depth................ x Disposal Trench—No..........:.......... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter........------------ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f1 Test Pit No. 2................minutes per inch Depth of Test Pit..--.............--. Depth to ground water.............--......... a ----•--••----------------------------------------------------------•-----------...........---.....--......................................................... 0 Description of Soil................................................................................................----------------------------------------------------......•--•--........ W V ...............•-•-••--•---•-••••----••..............--•-•-•••••........•.•-•---••--•-....-•-----•-•-•.....-••••-•-•••..................-•-••--••--••-• ..-•-•...................---...--•-•-•---•-- ---....................................................................................---------------------- .................•--•• •---• -•-• ;..... U Nature of Repairs or Alterati ns—Answ w en pplicabf e. ..-----•--••-----------------------------------• Z d_:E1...: ( = �Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI'I'i.i; 5 of the State Sanitary Code— The undersign d furl:er agrees not to place the system in operation until a Certificate of Compliance has been-issued by the bbooar of he h. Signed.....-- - . --- .�_..��,. 1L0.'..�.: IIn�to Application Approved BY -------------------- - '. b. .C .... .�o Date Application Disapproved for the following reasons-----------------------------•--------•--------•--------------------------------•-------•••••••-•.............._ ..---•................•---•---.........---•--------•---------•---•-------.....-------------•--••--------•..........-----...------------------------•---------------------------•---•••••................. Date PermitNo......................................................... Issued-....................................................... Date , No. � ..- ....... FEsVLV� THE COMMONWEALTH OF MASSACHUSETTS JJ�/ /BOARD ,OF HEALTHY( r C7 J Appliratiun for Disposal Works Tonstrnrtiun Vkrmit Application is hereby made for a Permit to Construct ( ) or Repair O an Individual Sewage Disposal System at: /?91 /1fl�tfl/ t tr9it 1 t ........ ...i /?r•... E f �9� �' (.�.._........ ................ . .._,.._.... ------------...........------...----------...---•••------•-•-•..---- .........:... -Location.-Address or Lot No. W +} f w /r A I cC� -----•......•.Address................•..----•---•---......------ ►-a ...t _ Address 1 Owner, stalle �q Type of Building 7 Size Lot...........................:Sq. feet U Dwelling—No. of Bedrooms_______________ Expansion Attic p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.........._..___..__.__.___. Showers ( . ) — Cafeteria d Other fixtures ......................... ----•-- W Design Flow............................................gallons per person per day. Total daily flow___............................•............gallons. W Septic Tank—Liquid capacity_......._...gallons Length................ Width..._.__.__..___. Diameter--------_....... Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...................... Diameter_________________------------------ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing iank ( ) Percolation Test Results Performed by.......................................................... _._....:__._._... Date.................................................. ,a Test Pit., No. ......minutes per inch Deptl of Test Pit--------- � `Depth to ground water........................ 44 Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a O Description of Soil...................---•--...-•-••-••...............•-• . W V .._...•---•-••-•-......••-••••••-•-••......................••---•••-•--•---••••-•-••-•----......----------••-•-------------------•••......--..._-•-•- ----------------------------------------------•----------•-•------------_.... ----•---•••---•-_...• --•••---• - Q !� Nature of Repairs or Alterations—Answer when a licable.✓1, 42z i.. f_ C� P PP . •.............................................. ( '4 ff ?d �-_ r•-1 A.= " �r 91?r >...... Agreement: It f,= ��---� •-The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITil, 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 .: .D..,3...t.... .... Application Approved By-•-••-• 1� (7 (p -- = ......................................... Date Application Disapproved for the following reasons-------------------------------------•-----------------...._..........-------••-_..... .--••••--••--- ...................................................•-----------------•--•-------•-------•-----•-----..............---------•----•-----------------•---------------•------•----•----...:=•-•........_.... Date Permit No................. .......... ------ -- Issued--...--------------n�..•--•--•----------.......---.... `. �_._,___.._..__—_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........:. ? I'/1!2...............OF....... : .. 1 ... .............................................................. Trrtifiratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �) by................ -•--- ................ .. t Installer r at............` -I l - � , . t r+�7.2� ?,9 t �'`l I I �3)/��':-,t •.•- ----------------•-•-----.......-----------•......--•-•-•-•-•---•---••--- has been installed 'in accordance with the provisions of Tj`rL._, 5 of The State Sanitary Code as describpA in the application for Disposal Works Construction Permit No.. __. .................. dated: .. �.U_ __._ �.� p........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT 6E CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............. I !. ...................................... ..........--••----•-•-• Inspector.................................................................................... _. THE COMMONWEALTH OF MASSACHUSETTS S�r1Li -J 3� BOARD OF HEALTH �Ii�l til f° -`1' t/ OF._.... {„'� C t1; .1 1 !! �aa rr� 11 ..............................`................_..............._.. No..�- •-••...._.. FEE.. .-C?e_........... Disposal. Works %Tonutrnrtiun f rrmit Permission is hereby granted........../J/I `_../},.j tr l:.t r� ::. -------------------•---•------...........-•--.......... to Construct?( ) or Repair (0 an Individual Sewage Disposal System � at No. e i i � /fi reQ 1 / i 1 ,{.�try- e..- _ r - Street as shown on the application for Disposal Works Construction ermit No�_�___.j�__ Dated--------/.: ( /0 1 -----------•-------------------••- Board of tfealth DATE......... 8/18/2021 ShowAsbuilt(1700x2800) TOWN OF BARNSTABLE L o"I W7biT_ 86-1101 LOCATION 891 Newtown lid., SEWAGE N VILLAGE rarstons Mills ASSESSOR'S MAP e&LOT!10 f7- b_3 7 INSTALLER'S NAME S+PHONE NO.CASH'S TRUCKING INC./362-32P1 SEPTIC TANK CAPACITY 1,000 Gal (3' Stone Packed) Existing 10' Cesspool LEACHING FACILITY{type) paP_Cant �(slze) 1,000 Gar NO.OP BEDROOMS 3 PRIVATE WELL OR PUBLIC WATEWj,.,,tP BUILDER OR OWNER Eugene Dion DATE PERMIT ISSUED: 10/17/86 DATE COMPLIANCE ISSUED; / 4I VARIANCE GRANTED: Yes X No i I I I i i https://itsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=027037&sq=1 1/1