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HomeMy WebLinkAbout0065 SASSAFRAS LANE - Health 65 Sassafras Lane - - A= 043-071 - Marstons Mills Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 SASSAFRAS LANE Property Address Jane Olson Owner Owner's Name information is required for every Marstons Mills MA 02648 4/29/14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms I on the computer, �I 1 use only the tab 1. Inspector: V key to move your cursor-do not Robert Paolini use the return key. Name of Inspector Robert Paolini Septic Service Company Name 17 Playground Lane Company Address Yarmouthport MA 02675 City/Town State Zip Code 508 362-3555 S 14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and thadhe information reported below is true, accurate and complete as of the time of the inspection. The insp etion was performed based on my training and experience in the proper function andrmaintenancei of onrsite sewage disposal systems. I am a DEP approved system inspector pursuant,;to Section 1,5.340,-6j Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ❑ Fails a;X3 ❑ Needs Further Eva uation by the Local Approving Authority , -n l/ 4/29/14 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different.conditions of use. t5ins•3113 Title 5 Official Inspection FoVSuswage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 SASSAFRAS LANE Property Address Jane Olson Owner Owner's Name information is required for every Marstons Mills MA 02648 4/29/14 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: 0 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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): t.5ins-3113 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 65 SASSAFRAS LANE Property Address Jane Olson Owner Owner's Name information is required for every Marstons Mills MA 02648 4129/14 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): 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•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 •''� 65 SASSAFRAS LANE Property Address Jane Olson Owner Owner's Name information is required for every Marstons Mills MA 02648 4129114 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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 ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ❑x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ M Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑x Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 65 SASSAFRAS LANE Property Address Jane Olson Owner Owner's Name information is required for every Marstons Mills MA 02648 4/29/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ❑x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ R Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑x Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ M Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑x The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Fond:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 SASSAFRAS LANE Property Address Jane Olson Owner owner's Name information is required for every Marstons Mills MA 02648 4/29/14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ED ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ❑x Were any of the system components pumped out in the previous two weeks? ❑ ❑x Has the system received normal flows in the previous two week period? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? 0 ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑x ❑ 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, 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: ❑ 0 Existing information. For example, a plan at the Board of Health. ❑ 0 Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Tifie 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 65 SASSAFRAS LANE Property Address Jane Olson Owner information is Owner's Name required for every Marstons Mills MA 02648 4/29/14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 II Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? 0 Yes ❑ No Seasonaluse? ❑ Yes Z No Water meter readings, if available last 2 ears usage d na 9 ( Y 9 (9p ))� Detail: Sump pump? ❑ Yes EJ No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments se` Y 65 SASSAFRAS LANE Property Address Jane Olson Owner owner's Name information is required for every Marstons Mills MA 02648 4/29/14 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑x No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: 0 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 Tide 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 Vey'a 65 SASSAFRAS LANE Property Address Jane Olson Owner Owner's Name information is required for every Marstons Mills MA 02648 4/29/14 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ❑x No Building Sewer(locate on site plan): Dept! below grade: 2.5 feet Material of construction: ❑ cast iron ❑x 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the building vents. Septic Tank(locate on site plan): Depth below grade: 2' feet Material of construction: Z 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 gl. Sludge depth: 4" t5ins•3113 Title 5 Official Inspection Fort:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 SASSAFRAS LANE Property Address Jane Olson Owner Owner's Name information is required for every Marstons Mills MA 02648 4/29/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 5" 9 Distance from bottom of scum to bottom of outlet tee or baffle 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.): Pump tank every 2 years.Inlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. 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•3113 Title 5 Official Inspection Forth: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 65 SASSAFRAS LANE Property Address Jane Olson Owner Owner's Name information is required for every Marstons Mills MA 02648 4/29/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 SASSAFRAS LANE Property Address Jane Olson Owner Owner's Name information is required for every Marstons Mills MA 02648 4/29/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert No 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 is Ievel.Box has two outlet Iaterals.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 SASSAFRAS LANE Property Address Jane Olson Owner Owner's Name information is required for every Marstons Mills MA 02648 4/29/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑x leaching chambers number: 2 500 L.C. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leachingfields 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.): Sandy soil.No signs of hydraulic failure. Leaching Chambers were dry 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-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 SASSAFRAS LANE Property Address Jane Olson Owner Owner's Name information is required for every Marstons Mills MA 02648 4/29/14 page. City/Town State Zip Code Date of Inspection .D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 65 SASSAFRAS LANE Property Address Jane Olson Owner Owner's Name information is required for every Marstons Mills MA 02648 4/19/14 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 QA y z ON p H Y s i I t5ins-3113 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 -� 65 SASSAFRAS LANE Property Address Jane Olscn Owner Owner's Name information is required for every Marstons Mills MA 02648 4/29/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑x Check Slope Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 18' 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) n Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS observation well data.USED:Technical bulletin 92-0001 annual ranges of groundwater elevations. 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 SASSAFRAS LANE Property Adcress Jane Olso-i Owner Owner's Name information is required for every Marstons Mulls MA 02648 4/29/14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑O 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 fife t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 j' TOWN OF BARNSTABLE _"' .J,OCATION S� S'J9S'S F.�r 1�l,P. SEWAGE# VILLAGE N!/`P3POOJ 04i& ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. S08— 5`00-97-5,:T Joscpli SEPTIC TANK CAPACITY /000 LEACHING FACILITY:(type) /'S'(size) NO.OF BEDROOMS 3 OWNER O PERMIT DATE: — 2 7—0 q COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility . _ Feet Private Water Supply Well and Leaching Facility.(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BYF m �,, 6ac �Q' \� �_. �., .. � � � -W �' S �0` p 'vim No. Fee A/�J THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpliLAtion for bisposal *pstrm Construction permit Application for a Permit to Construct( ) Repair(Z—)-Upgrade(Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. t,J_s'4,554/�'�1-1 S' 141j a Owner's Name,Address,and Tel.No. cJ/41%-2 QlSo%J Assessor's Map/Parcel Installer's Name Add ss,and Tel.No.�O$--We-7752 Designer,'s Name,Address,and Tel.No,.SO$—�jy%_S,5i3 ��/'��''dS •/Ct��-G ��<:'S!OvtS' �,jls GinnSSGicf��/1��ri S/' ��` Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when,Applicable) j'y)STg11 - j'00 61-, Date last inspected: Agreement: The undersigned agrees to ensure the construction V.and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Date f Application Approved by Date f Application Disapproved by Date for the following reasons Permit No.�� ^ �� Date Issued No. Fee THE COMMONWEALTH OF'MASSACHUSE7A —6, Entered in computer: V _ Yes PUBLIEA HLTHIDIVISION -TOWN OF BARNSTABLE- MASSACHUSET in yApplication for ]Disposal *pstem ar truction Permit Application for a Permit to Construct O Repair(, ,Tpgrade(4)-Abandon( r) ❑ stem Complete Sy stem y ❑individual Components Location Address or Lot No.4!�r_S7455,4 IC'-�IV5 L V,�je Owner's Name,Address,and Tel.No. Assessor's Map/Parcel S lLf,e- Installer's Name Addr ss,and Tel.No.,SO$-28'U-77 -g Designers Name,Address,and Tel.No. SOZ-410�/ _S•3/3 Josc/J�i l�ti [lp�os ��19�hc eviti ,64/ 0/'S S'/ C -e- r2 0/0 e OtiS / s Cry s Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil • q Y 1 Nature of Repairs or Alterations(Answer when pplicable)1.,VI,w// ✓1-,SOO w,� , Date last inspected: Agreement: a i The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5'of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sign �-f Date Application Approved by Date q Application Disapproved by Date for the following reasons Permit No. Date Issued /" i. __ _ _ a_____.______._____________ _________________________________________________ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(4-)- Upgraded Abandoned( )by josr1 SA/ _0._5 at S. ss��r� L,qh� �y/,s`,ToH S �1// has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.p'"_,)-?qdated Installer , 956,0/ 04 Designer #bedrooms Approved design flow "3 30 gpd The issuance of this permit shall not be construed as a guarantee that the systemj11 funJct�o'as designe�I Date k"I 7J `� Inspector / 76V' r ----- ------------ --- - - No. DcV 9 ( Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS \ ]Disposal &pstem Construction Permit Permission is hereby granted to Construct( ) Repair(L-)-- Upgrade Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction rust be completed within three years of the date of this permit. } Date � Approved` 08/28/2009 05:48 5084775313 ENGINEERING WORKS PAGE 01 Town of Barnstable RepUtory Services Thomas F.Geiler,Director $ Public Health Division Thomas McKee Director �e» 200 Main Street, gyannis,MA 02601 Fax: SOS.790.6304 office: 50941624644 g Assessor's Mxp/Parcel 9 3 `07 k Ante: 69 Sewage Permit# IMW er e , ?4L t-ci C_ �Qe k S tL J C, ;�nt� C - Installer: Designer: � 4 s .�1�( � Address: _ Address: TZ- W. Ge ZL` lq 'Mors was issued a permit to install a �) (ins lei S45 �M based on a design drawn by septic s) M c_&t--f_A F . dated 4 �� esigner) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if required)was inspected and the soils were found satisfactory. N OF�Ag PETER T. er sSignature) McENTEE CIVIL CA .0 9 No.35109 a LWL ' 9 FO i- ) 's Sin (Affix -DA i§ PLEASE TURN TO B C N PCX OF COWLIANQ L NOT �T CM ARE C q:\Offi-for= om>bwm dm m� VC W I Dc W tK EXISTING HOUSE (#65) T.0.F.=102.38' J r SWING TIES 65 SASSAFRAS LAN E A. a. TRANS, NO.: CITY/TOWN APPLICANT: ADDRESS: seS5C s ti DESIGN-FLOW: 3SIC :gPa REVIEWED BY: fiw DATE: N/A _ OK _ NU 11111ill Ill,I'll Mill: Legal boundaries denoted 310 CMR 15.220(4)(a)] �✓ Street, Lot, tax parcel number and lot number noted on plan [310 ✓ CMR 15.220(4)W] Locus Provided 310 CMR 15.2204(t)] ✓ Plan proper scale? (1"=40'for plot plans, 1"=20' or fewer for ✓ components) 310 CMR 15.220(4)] . Easements shown 3.1.0 CMR 15.220(4)(b)] i System located totafly on lot served [310 CMR 15.405(1)(a) for ✓ upgrades]-if not, a variance is required 310 CMR 15.412(4)] Location of impervious surfaces (driveways, parking areas etc.) 310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR ✓, 15.220(4)(c)] Location and dimensions of system components and reserve areas. ✓, 310 CMR 15.220 4 e System Calculations 310 CMR 15.220(4)(0] ✓ daily flow ✓ septic tank capacity(required andprovided) soil absorption system(required andprovided) whether system designed for garbage grinder ✓ North arrow 310 CMR 15.220 4 Existing and ro osed contours 310 CNM 15.220 4 ✓ Location and log of deep observation holes(existing grade el. on each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative [310 CMR 15.220 4 h and i Location and dale of percolation tests (performed at proper elevation?) [310 CMR 15.220(4)(i)] Percolation test results match loading rate? 310 CMR 15.242 Certification statement by Soil Evaluator [310 CMR 15,220(4)0)] Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)] Address Sheet 1.of 9 v N/A OK x NO, Location of every water supply, public and private, [310 CMR 15.220(4)(k)) ' within 4.00'feet of the proposed system location in the case of surface water.supplies and gravel packed public water supply within 250 feet of the proposed system location in the case within 150 feet of the proposed system location in the case of private water soply wells Location of all surface waters and wetlands located up to 100 ft. / ibeyond setbacks fisted in 310 CNM 15.211.and any.catch basins jocated wltlun SQ ft 310 CMR 15.220 4 1 . Water lines and other subsurface utilities located 1-310 CM R 15,220 4 m eater-line cross see 310-CMR 15.211 1 '1 Profile of system<showing invert elevations of all system corrm onents'andtl e bottom ofthe.SA$. 3IQ CMR15.22 4 0: Stamp of desi er 310 CMR 15.220 1 wi&'346CMR15120 2 Stamp of Registered Land Surveyor (required if construction activities-within 5 ft. of lot line) 3.10.CMR 15,220 3 - Test Holes adequate(two in each of the primary and reserve / unless.trenches as-permitted in 31.0 CMR 15,102(2) or as approved for an uplEade under LUA at 310 CMR'15.405 l k' ; Test«hole adequate.to demonstrate four feet of suitable material? 310 CMR 15.19301 ✓ ` Test Roles adequate to confirm adequate groundwater separation? 310 CMR 15.103(1)1 ' Benchmark within-50-75' of.s- stem, 310,CMR 15.220 4 Mate rials=specifications noted?_[various sections of 310 CMR System components.not> 36" deep (unless:Local Upgrade ' A ppr&al orIUA re uested)., 310 CMR 15.405 1;-_, Address Sheet 2 of 9 N/A OK NO Size OK? 310 CMR 15.223 1 Inlet tee located ten inches below flow line 310 CMR 15.227(6)] ✓ Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR 15.227 6 Outlet tee with gas baffle or approved filter 310 CMR 15.227 4 Note regarding installation on stable compacted base[310 CMR 15.228 1 Separation between inlet and outlet tees(no less than liquid depth) 310 CMR 15.227(2)] Inlet/Outlet elevations at least 12" above high groundwater / (except as descried 310 CMR 15.227(5)) or permitted for upgrades under LUA 310 CMR 15.405 1 k Minimum cover . (Tanks.buried more than 9" must have risers on all openings and on the d-box) [310 CMR 15.2228(1) and 310 CMR 15.232 3 Three access cowers (inlet and outlet must be 20" or greater) - � middle access at least 8" 7/07 310 CMR 15.228(2)] Access to within 6 of grade -one port for systems<i 000gpd, two forsystem.s=>1000 gpd 310 CMR 15.228(2)] All at-grade covers secured to unauthorized access? (310 CMR 15.228(2)] > 10 ft from builft foundation 310 CMR 15.211 1 Buoyancy calculation Required/Done 310 CMR 15.221 8 H-20 Where appropriate? 310 CMR 15.226 3 Setbacks from resources 1310 CMR 15.211. Required when gther than single-family dwelling or flow>1000 d 310 CMR 15.223 1 First compartment 200% daily flow; Second compartment 100% „ r daily flow 310 CNIR 15.224(2) and .3 !w "U" pipe through or over baffle, outlet of each compartment with as bale or appToved filter 310 CMR 15.224(4)] Address Sheet 3 of 9 N/A OK NO Located at least ten feet from any water line? [310 CMR 15.222 2 - Disposal piping it least 18" below water line(when water and / sewer cross,.see 3.10 CMR 15.211 1 1 - Cleanouts'r ' uired/ rovided ? 310 CMR 15.222 8 Thrust blocks s ed in forte mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable V 310 CMR 1''S.222.6. Proper pitch'on all runs? (.005 within gravity-distributed trenches and beds) [310 CMR 15.251 9 and 310 CMR 15.252(2)(c)] .Siphonproblem/ eaclihfield below pump chamber Endca s or vent manifold ed? / Size and orientation of discharge holes specified?.(not smaller than 3/8 11not larger than 5/8 ) [310 CMR 15.251(8) and 310 CMR 15.252 2 Materials specified (310 CMR 15.251(5) specifies various pipe types allowed gigiNg Stable compacted base [310 CMR 15.221(2) and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided?(when pressure sewer to d-box or steep'pitch of gravity sewer) [310 CMR 15.323(3)(a)] Riser'if,dee er than 9 310 CMR 15.232 3 Inside minimum dimension 12" 3.10 CMR 15.232 2 Minimum sump 310 CMR15.232 3 e Watertight cover if<20009pd)' waterproof manhole if>2000gpd 310 CMR 15.232(3)(d)] Capacity,(emergency storage above working=design flow)? [310 CMR~231(2. Proper setbacks f310 CMR 15.211 same as septic tanks)] Watertight.20-in minium access manhole at least 20" MUST BE TO GRADE 310 CMR 15.231 5 Service components accessible(not too deep with piping, disconnects accessible Alarm floats - alarm on circuit separate from pumpsspecified? Exceeds two units must have two pumps operating in lead-lag mode. 310 CMR 15.231 6 and 8 Stable Co ed.Base 310 CMR 15.221(2)] Address Sheet 4 of 9 Buo anc ,calculations needed?Provided? 310 CNM 15.221 8 t y Address Sheet 5:0f 9 N/A OK NO Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240 1 Required separation to oundwater? 310 CMR 15.212 Aggregate specified as double washed 310 CMR 15.247(2)] System Venting requimd/provided?-(system under driveway or >36" d 310 CMR 15.241 Inspection ports.specified and within 3"final grade? [310 CMR 15.240 13 Breakout requirements met? (No violation of breakout elevation within 15 ft of SA-S unless barrier) [310 CMR 15.211(1)[4] and Guidance Document Chambers and Gal. in trench configuration supplied with inlet / every 20 ft. 310 CMR 15.253 6 Each structure vyrith one inspection manhole(if>2000 gpd must be tograde) 310 CMR 15.253 2 A ate 1' minimum-4' maximum: 310 CMR 15.253 l 2' sidewall credit maximum 310 CMR 15.253 1 a In bed configuration, inlet every 40 ft. 310 CMR 15.253 6 I I i Width 2'minimum 3' maximum 310 CMR 15.251 1 b 100 feet -maximum length 310 CMR 15.251 1 a ] Minimum separation 2x effective depth or width whichever greater j 3x if reserve between trenches _ 310 CMR 251 1 d Situated along cpntours 310 CMR 15.251 2 Breakout OK? �10 CMR 15.211 1 4 an�Guid�anoeD�ocumfint minimum 2 distribution lines 3.10 CMR 15.252(2)(a)] Maximum separation between lines 6' 310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15.252 e N Aggregate depth below discharge pipes 6" minimum, 12" maximum. 310 CMR 15.252 2 separation between beds 10' minimum- 310 CMR 15.252 2 Bottom area used in calculations only 310 CMR 15.252(2)(i)] Address Sheet 6 of 9 N/A OK NO- Pressure Dosed System ? Provided pump and piping calculations as required 310 CMR 15.220(4)(r)] Pressure dosing Tequired on all systems>2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and I/A Remedial Use ovals If used in gravelless system -make sure jet-is directed as not to scour soil interface LC7uidmce Document Inspections once per year(systems<2000 gpd) or quarterly >2000 dgood to note on plan 310 CMR 15.254(2)(d)] Construction in fill -Did the plan specify that the fill shall meet the specification pf 310 CMR 15.255 3 ? Impervious barrieer and/or retaining wall ? Guidance Document Impervious barrier installation must be supervised by designer 310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer 310 CMR 15.255 2 a Side slope not exceed 3:1 ? 310 CMR 15.255 2 Breakout retluirements met? [310 CMR 15.252(2)and Guidance Document At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended 10 CMR 15.255 2 e Check DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scour soil interface Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a rote on the plan regarding the requirement for perpetual maintenanceagreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has appli4nt submitted a cffi of a maintenanceagreement? Are the variances listed on the plan ? [310 CMR 15.220 y 4 v RLS Stamp.-necessary on plan if a component is within five feet of ro dine 310 CMR 15.412(4)] Address Sheet 7 of 9 New construction or increased flow pr:.oposed - [Refer to 310 CMRY15.414 . . a Address Sheet:8 of 9 r N/A OK NO. Is the system in a Designated Nitrogen Sensitive Area(Zone II for a public supply Nell)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.210 also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well ? 310 CMR 15.214 2 Are the nitrogen loads proposed in compliance? [310 CMR d 15.21 1 4 Pumping to septic tank ? 310 CMR 15.229 Shared System �10 CMR 15.290 1 . Address Sheet 9 of 9 op� Town of Barnstable P#J) 7k Department of Regulatory Services r Public Health Division a 6 ems. Date � i63q �e� 200 Main Street,Hyannis MA 02601 ,yfOMA't� Date Scheduled U cl Time D Fee Pd, Soil Suitability Assessment for Sewage isposal Performed By: 'Fe 4 Q r' vFh t_� y Witnessed By: �V 1 �• ✓j LOCATION& GENERAL INFORMATION Location Address S� Owner's Name� Tre OISo" 1� Address 5! 54 S.S c1 4qb,S CAr-'E MCA Assessor's Map/Parcel: D'A3 —0 '7 / Engineer's Name 5 _l S MA Z� (fie Kr'(Vt C.� NEW CONSTRUCTION REPAIR X Telephone# Su =y,-7 7�—S 313 Land Use'T—, , Slopes•(%) � Surface Stones P" Distances from: Open Water Body �� ft Possible Wet Area 21 J ft Drinking Water Well 2_��ft Drainage Way '7��ft Property Line ft Other` ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) • z i CO a Parent material(geologic) r 4c c.( cJ p lu Depth to Bedrock i Z Depth to Groundwater. Standing Water in Hole: /_j - Weeping from Pit Face Estimated Seasonal High Groundwater 1 DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in, Depth to sell mottles: in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adl,factor— Adj,Ciroundwater Level PERCOLATION TEST Date Time.Yv Observation �O Hole# TO Time at 4" Depth of Perc g �y Time at 6" Start Pre-soak Time® �. N C-� e 9 •6") End Pre-soak Rate MinJlnch Site Suitability Assessment: Site Passed Site Failed: _ Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\S EPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole. # _ Depth from, Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure;Stones;Boulders. itGravel) Iq to I j2y/L , (� S� 1® . BLS DEEP OBSERVATION HOLE LOG . Hole# Depth from . Soil Horizon Soil Texture ,Soil Color. Soil'' Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.' Gravel) t3. ' ' ' .c_c . . . ��� �1. • �� to ''(�-`(I DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. to d DEEP OBSERVATION BOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,.Stones`,Boulders. Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes __2t ". Within 500 year boundary No Yes Within 100 year flood boundary No Yes Denth of Naturally Occurrinl=_Pervious Material Does at least four feet.of naturally occurring pervious material exist in all areas observed throughoutthe area proposed for the soil absorption system? , If not,.what is the depth of naturally occurring pervio material? Certification I certify that on 1 Sl date)I have passed the soil evaluator examination approved by the Department of Env ronm ntal Protection and that the above analysis was performed by me consistent with . the required tra' Mg, pert se and experience described in�10 CMR 15.017.17 Date Signature e1 Q.%SEPTIGIPBRCFORM.DOC TOWN OF BARN/STABLE 40 _LOCATION � � ^�' � �`� � SEWAGE # VILLAGE_ IT 0• tr-k A 5-SSESSOR'S`MAP&LOT�!' -a 71' INSTALLER'S NAME&PHONE NO. d%f�l XF�I T -8r SEPTIC TANK CAPACITY I LEACHING FACILrrY: (type) (size) b NO.OF BEDROOMS _ BUILDER OR OWNER e J 5 PERMTTDATE: �`g � COMPLIANCE DATE: Separation Distance Between the: V - `�� Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 3 A (/ S � No ..... F�$........ ......_ THE COMMONWEALTH OF MASSACHUSE*S BOARD OF HEALTH ----..� ..........oF...` � ,C. Tq/,t. Appliration for Disposal Works Tonstrudiun Prrutit \\J Application is hereby made for a Permit to Construct ( t/f or Repair ( ) an Individual Sewage Disposal System at: MA!W�7 ,/V S'/rl i J_4S ............................... �.©T'3o s.� s AFrPgs��✓'---• / ivsTa @ c E M r� Location-Address or Lot No. ---7:....../..,..i..(.`.._.._...`i!f:...sr,.r.' 1.-f.... ._..: ..-----•-- a* R&fofj Sr�&C' _a.2.6 3 0 n, P ° � Address •_•.••.. W ;..� . .... ...... ...............c, .q.e li, L.7 ............................ da I,, In„stiller ' . _ / Address Type of Building pYl ii(� 6v/G���e1 Size Lot.....�.r�r--✓----�.Sq. feet U Dwelling—No. of Bedrooms........ ... .....Expansion Attic We? Garbage Grinder WO) '34 Other—T e of Building No. of persons............................ Showers Cafeteria Other fixtures .. -••-----------•----•-------------------•-•---•-•--•------- . W Design Flow............1_.1_D.....................gallons per person per day., Total daily flow... 3.2.�......___.._............gallons. WSeptic Tank—Liquid capacity)PR.O.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.....................Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......1............. Diameter......LPP........ Depth below inlet...2.'.s..... Total leaching area-2.0..2....sq. ft. Z Other Distribution box ( ) Dosing tank ( �ry a /'1 '-' Percolation Test Results Performed by._V P _CA to .. �-r''....._.. _- Date....l_..+Z..P. -_�C T Test Pit No. 14..�r..._...Z.minutes per inch Depth of Test Pit.../•- ...__... Depth to ground water..�/__............. r.4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ C4 .......-•.......... • • ------------------•-•-•----••.--•-•............................ O Description of Soil..d.''. .�.I'U P._..z.D�} N� x w ----------------------------•---•------•-----••-•-----•------•-•--•-------------.....•--...------............... ....--............. - -- .............................� U Nature of Repairs or Alterations—Answer when applicable..- - .._ .�rr- ' A eement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI"LU' 5 of the State Sanitary Code—The undersigns urt r agrees not to place the system in b operation— until a Certificate of Compliance has been iss d by t and h h. 3`i 1_1361 � Signed-.vC .. . --a---•................./...._ �.. Application Approved By.. . .. ........ . ........ D--e Application Disapproved for the following re o s:.............. •-------------------------•------------------------------------------------------ W..... ........ Date..._... emu— ` 3 4�i �t Permit No..... . r :... --.. Issued_ .................... cz� l� No.'......... ,,../1� Fps......... ✓........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................-----------•....OF.......................................................................................... Appliration for Disposal Works Tonstrurtion Prrmit Application is hereby made for a Permit to Construct (✓f or Repair ( ) an Individual Sewage Disposal System at: _ t",4/?.ID ro ms m + <.. Location-Address or Lot No Owner , Address W Installer Address Type of Building Size Lot...) .8.K .-.��..Sq. feet U Dwelling—No. of Bedrooms........ ............ ..........Expansion Attic ( ) Garbage Grinder (VIO) Other—T e of Building No. of persons............................ Showers — Cafeteria Pa Other fixtures ..----•.......................................•-- . w Design Flow............1.1.0......................gallons per person per day. Total daily flow..... .1. ........................gallons. WSeptic Tank—Liquid'capacityk;W.gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......f_............. Diameter.....LP......... Depth below inlet.._:.°:4....... Total leaching area.'ZP3....sq. ft. z Other Distribution box ( ) Dosing tank ( Percolation Test Results Performed by.e_ff.v� �E ................. Date... -___"'_��. ,+ � •------------ -------- Depth to ground water_.' .� _Test Pit No. :.= _._._._ minutes per Inch Depth of Test Pit._ _ _ ep gr l..�._......__. P� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----------• -- :.- _. O Description of Soil-- --"". .}..D - �Ql._ .. ...... ..`.. .r __ .. c.� --••-•-•-••••.......•••----••••--•-•••......----••---•----• ...........-••..................•-•--•------•-•-.... ------------------------..............------.........--•---.._....--••----...... w UNatur/eL of Repairs or Alterations—Answer when applicable_'.. �./,_... ✓_.//:� .. /. - ......... /q. �. �, :+_.._!/ '__r.!...... ,......_ _ .�^�-'f �+..Y��y ,ram ✓ !I Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI,L 5 of the State Sanitary Code—The undersi ed further agrees not to place the system in opTition until a Certificate of Compliance has been 'ss ed y t e boar f o health. Signed..;:: 16 ' � p - Application Approved By .. !�!y...: ��• � ff 1r j= •`k� . Application Disapproved for the following ret#s:.............................................................................................................. � ......................................�;- -----•-- •- -f----------...-------•---- '4�`.,,,�,--------------------------------�-]---- --------. ._-------------...Date�---------._ Permit No... -- (tr ...._.......- Issued.. .I. 7 -...__...- is THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH "N ..........................................OF..................................................................................... Trrtif iratr of Toutnliatur- THIS IS TO CERTLFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by-------------------------------jf _Joaw-hw-T-----------------------.-- ----- Installer at..................................................................................................................................................................................................... has been installed in accordance with the provisions of T T 5 of he State Sanitary1ARANTE e as�desc ibed in the application for Disposal Works Construction Permit No.- ...t... _�;_._2_ _---•- dated..... d �� �THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......./z-1 -•---_ ....��- -------------------------- Inspector :r^,��. : ._ :��� ........:.........•----•------>.................. .......... THE COMMONWEALTH OF MASSACHUSETTS i I BOARD OF HEALTH -� OF..................................................... � ....... ............. -•••••......•••.... No._.. ...1............... FEE....... ............... Disposal Works Tonga ru_r#ion Prrmit Permission is hereby granted......; �. a --_-----_ a to Construct ( Kor Repair ( ) an Individual Sewage Disposal ystem , ,� P at No.•. -- _! �. ' i 1 i t _1..1. ................ > ... Street �''! `'�� as shown on the application for Disposal Works Construction Permit _ o.L___.L_J .,;-_l.Dated.......�_.�:_�--,,�-- ... -- . CIA - Board of Health DATE----- '"s ..= ..............•-•-----------------------•-- ` FORM 1255 A. M. SULKIN, INC., BOSTON �� I rr F� N LEGEND ® -- -- EXISTING CONTOUR RpO 46" E - - _ x 100.98 EXISTING SPOT GRADE a Wokgby a, N 28�53 -/JGl-- UNDERHEAD WIRES � 101,06 � G EXISTING GAS SERVICE ,5 00 yy EXISTING WATER SERVICE °off a / `� x 1 ul 0,�0,70 / TEST PIT `9 O / BENCHMARK � � 1 00,98 .� 0( � I 4 LOCUS 1.90 SH D LOCUS MAP 13;.:`;;A 101.04 NOT TO SCALE tt-.. C) TP-1 ' O 4 '00.91 �::2 Lr). 100.98 . \ r. \\ t\ O N.\� 'Q� EXISTING LEACH PIT "::1---10 RECORD AS-BUILT LOCATION t 101.10 CONTRACTOR SHALL LOCATE, `501 _ • � z 101,20 PUMP AND FILL WITH SAND o EXISTING SEPTIC TANK x 100.77 x 1 O O TOP OF TANK, EL.=99.22t 9G W INV.(OUT), EL.=97.89± DECK Benchmark Set 0� o WHITE PAIN TAB.H. COR. 3 . 100.89 101,38 EL.=101.38 (Assumed) o �, x x 10 L 1 � 'ate ^ 00 u x• 100,66 ,Ex�s77NG z x � Oc 100.76 HOUSE (#65) T.0.F.=102.J81 / fence 00 � 101,28 � / 101.41 x 101.2 0 LOT 30 101.33 3 12,559 S.F. Q Map 43 '71 1�1 Parcel 071 W o: _10 .9 a Paved G� 101.03 Driveway -100.78 \ 100,72 l l l _ 79 9-9 o- . " ' �p ' S. S9'`421 iiii� 0 700� _ - 10i 98.49 99.21 edge of pavement 10 GENERAL NOTES: SASSAFRAS LANE 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS. 3, THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING �N �F MASS FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. G o PETER T. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. MCENTEE 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF o CIVIL THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF No. 35109 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. W,TER SUPPLY PROVIDED BY TOWN WATER SERVICE. FF R£6ISTE���EN 8. ii*RE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. OWNER OF RECORD SON, JANE M �• 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS OL OL 4 ~ AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE 65 SASSAFRAS LANE SAS SASNS MILLS, MA 02648 O,Z� DIRECTED BY THE APPROVING AUTHORITIES. 10. IT .SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING PROPOSED SEPTIC SYSTEM UPGRADE PLAN CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS 65 SASSAFRAS LANE, MARSTONS MILLS, MA IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). Prepared for: Joey's Septic Service, 81 Cammett Rd, Marstons Mills, MA 02648 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE Engineering by: SCALE DRAWN JOB. NO. INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL. 1"=20' P.T.M. 191-09 13, SUBJECT SITE LIES WITHIN A ZONE II (IWPA). Engineering Works, Inc. 14. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. (508) 477-5313 7/19/09 P.T.M. 1 Of 2 r NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL:97.5 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D-B PROPOSED S.A.S.OX PROVIDE ONE ACCESS MANHOLE TO WITHIN 3" INSTALL RISERS & COVERS OVER INLET INSTALL WATERTIGHT RISER & OF FINISH GRADE FOR INSPECTION PURPOSES T.O.F. AND SET TO 6" OF FINISH GRADE. COVER SET TO 6" OF GRADE PROVIDE ACCESS TO GRADE OVER OUTLET COVER EXISTING F.G. EL.=101.1 t F.G. EL: 101.0f F.G. EL: 101.Ot f /MAINTAIN 2% GRADE (MIN.) OVER S.A.S. L = 16' L = 5'(MAX.) ® S=1% (MIN.) ® S=1% (MIN.) 4"SCH40 PVC 4"SCH40 PVC 6- 10"1 ° Be S Ba ta' s aBaaamaa EXISTING 48' LIQUID mmaaaaa LEVEL ADD 4' 5.2' 4' GAS DAPPLE INV.=97.27 PROPOSED INV.=97.10 INV.=97.89t D-BOX EFFECTIVE WIDTH = 13.2' EXISTING INV.=97.00 EXISTING SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS SURROUNDED WITH STONE AS SHOWN H-10 RATED TOP CONC. ELEV.=97.8 BREAKOUT ELEV.=97.5 INV. ELEV.=97.00 Baar23.0' eases mamm amain ease NOTES: BOTTOM ELEV.=95.00 3' 2 X 8.5'=17.0' 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INVERTS, PRIOR TO INSTALLATION. 5' MIN. ABOVE BOTTOM OF EFFECTIVE LENGTH = 2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE T.P. EXCAVATION OR G.W. LEACHING SYSTEM SECTION ON A MECHANICALLY COMPACTED SIX INCH CRUSHED NO GROUNDWATER, EL.=90.0 STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). — 3) INSTALL INLET & OUTLET TEES AS REQUIRED. 4) CONTRACTOR SHALL INSPECT EFFLUENT FILTER ON 3/4" TO 1-1/2' DOUBLE OUTLET TEE AND REPLACE IF NECESSARY. WASHED STONE 3- LAYER OF 1/8" TO 1/2" f DOUBLE WASHED STONE SEPTIC SYSTEM PROFILE (OR APPROVED FILTER FABRIC) N.T.S. SOIL LOG (3) 5" DIA.OUTLETS 15 5" 16" 2- DATE: AUGUST 25, 2009 (REF#12,678) � SOIL EVALUATOR: PETER McENTEE PE, SE (SE#1542) WITNESS: DAVID STANTON R.S. HEALTH AGENT 12"- s ELEV. TP—1 DEPTH, ELEv. TP—2 DEPTH 15.5" u 11 101.0 FILL. ' 101.0 FILL 0 6O 100.3 A g" 100.3 A ' 8,. o SANDY LOAM SANDY LOAM 2" 99.8 10YR 4/2 14" 99 8 10YR 4/2 14 H-10 LOADING " 6 B D-BOX SANDY LOAM SANDY LOAM � ' 10YR 5/4 10YR 5/4 97.8 38" 97.2 46" N.T.S. C1 48" C1 PERC 60" M-C SAND M-C SAND 2.5Y 6/4 2.5Y 6/4 ®® ® 0 ®®®NEEEEEUEEEE 33" r- 90.0 132" .90.0 132" N Z ®®®®®® ® ®®®® ' PERC RATE <2 MIN/IN. ("C" HORIZON)NO GROUNDWATER ENCOUNTERED 102" 4" KNOCKOUT DESIGN CRITERIA 20" DIA. COVER NUMBER OF BEDROOMS: 3 BEDROOMS 4" KNOCKOUT / 4" KNOCKOUT 62" SOIL TEXTURAL CLASS: CLASS 1 0 DESIGN PERCOLATION RATE: <2 MIN/IN DAILY FLOW: 330 G.P.D. 4" KNOCKOUT DESIGN FLOW: 330 G.P.D. GARBAGE GRINDER: NO EXISTING SEPTIC TANK: 1000\GALLON CAPACITY 500 GALLON CAPACITY, H-10 LOADING LEACHING AREA REQUIRED: (330) = 445.9 S.F. CHAMBERS .74 N.T.S. USE 2-500 GALLON LEACHING CHAMBERS IN SERIES PROPOSED SEPTIC SYSTEM UPGRADE PLAN SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES 65 SASSAFRAS LANE, MARSTONS MILLS, MA SIDEWALL AREA: 2(13.2' + 23.0') X 2 = 144.8 S.F. BOTTOM AREA: 13.2' x 23.0' = 303.6 S.F. Prepared for: Joey's Septic Service, 81 Cammett Rd, Marstons Mills, MA 02648 TOTAL AREA:..............................................................448.4 S.F. Engineering by: SCALE DRAWN JOB. NO. NTS P.T.M. 191-09 Engineering Works, Inc. DESIGN FLOW PROVIDED: 0.74(448.4) = 331.8 G.P.D. 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. (508) 477-5313 7/19/09 P.T.M. 2 Of 2 �y. AL g. rcr aFfOIA04rm 3'-RISER coAvwrE co v9" COAMaR1 W GOWN EL 9 0' 4"•al &* 40 PVC //:' PII�'!E-•+A/IL AST ';�•; • .: — {{ _1 PvTcH//S"P!Q FT ;!� sti�• S/e" to I/!` y •• drA4E' A#vwr INVERT. ., Pl�iGi1 ST EL 86.12' NVE7PT < •i; Awdltp OPEN SPACE s�rnc rAMr Q. 85.96 a.. 85.7 �. ar ivvmr 1000 6AL ;� o {? .L4" to /Lam" TT ri o EL ,$S.3Z ~AL�85.86 �_ ;� cD wS MAL 1 ' t� EL 81.5 0 5.0' �---- 10.0' 4.0' 55.0-0-' P!i OFIL OF — ELEV= 77.5' I / 9 0.5 tin GfPloUW WA UR U" 90. SEPTIC SYSTEM LOT 30 SOIL LOG DArF 7/28/86 tirmw P5959 GENERAL NOTES rEsr Aw" 90.0 EL. .$�.�' ELALL PIPE SCHEDULE 40 PVC R 0=Z— TOP/LOAM L 0 T ' 31 . -.� 2-4' CLAY DESIGN DA TA 90.0 Lo MAAMR OF BEWOOW 3 330 TOTAL FLOW GPD 80 UOM LEAC"M AREA 8 131 SGt FT. 16.0' SVE LEAC"W AREA sot FT. 10 GARBA GE DISPOSAL hare"* 209 O SO.- 44 4-12' MED.SAl� TOTAL LEACtAW AREA LESS 2 wai PROPOSED ODELEV-77.S' PfRCLtA TrAM RATE HOUSE NO WA T&W iJX00VTlER16D LOCATION CAL Cl"r I R2 = 3.14 (25) = 78SF (1) = 78 GPD 2 11 RH =131 (2.5) = 329 GPD _ N TOTAL = 407 GPD NOTE: TOWN WATER IS AVAILABLE 89.5 . .. ' -z : ` io W w � W SITE PLAN OF LAND 3 LOCATED IN BARNSTABLE o �� 5 MARSTONS MILLS ) ,� •s 8°� R=640.00 v 79.98 90.0 PREPARED FOR GAS LINE GAS LINE 89 SMITH 8JIM 8 •5 EXISTING E.T.W. =vAl of PROPOSE_ E•T�_ — _ 88.0 END OF PAVEMENT NAL � PAUL ryc Sgti �� l v ME.AI7HEW NO.32098 I a JQHN s 9FG/STEREO JACOBt ' `iNA( >ANosJ SASSAFRAS LANE No.8,4 1"SEA liN ( 50'- WIDE LAYOUT) _ 1 RES. ZONE: RF FLOOD ZONE: C ~YA NKEE SUR VE Y CONSUL rA N rS PLAN REF:448/88 0 20 40 60 143 ROUTE' 149 fP.O. BOX 2ww SCALE. I'� = Zo� l ,li0�l1lCS WLLSo MA. 02648 DATE: 4/20/89 JOB # 1142- 30 E _ AL 9 0 rcr arf>oramnON 3'-RISER CoAcwrr coMTS CONOMW CO"N 90' 4"sch*" 40 P'vC srarE /Vvmr /WE7PT NVE7PT ;.'1.'• a, P11RErAsr EL 86� 3E"77r TAW EL 85.96 EL. 85.7 < it; v Py OPEN SPACEEL l000 cAc. N"�15.136 NVEyPT M p W4A.9" EL R5,5 • MAE 10' "� �--- 10.0' 4.0' '�� 55•D�f PROFILE G OF ELEV= 77.5' I 9 0.5 AV aQa" WA TER rABLf SEPTIC SYSTEM LOT 30 SOIL LOG rE 7/28/86 M,wR P5959 GENERAL NO TES rEsr m" 90.0 - EL. 89.5 ALALL PIPE SCHEDULE 40 PVC ffr R °- ' =/LOAM L. 0 T 3 �° 2-41 CLAY DESIGN DA TA 90.0 `r _ LO AK#*MR OF MWOOA6 3 - 330 -� TOTAL FLOW GPd O MUM LEAC"M AREA 78 SCt SO FT 16.0; _ Z ME LE4C7,W AREA NO sox ,hcr "o CAA10' 44 _ 4-12' MEMSAND TTO UL L A 209 s0. fr. i OSE(� ' ADM"70V RA rE LESS 2 PROP ELEV-77.5 HOUSE _ NO WATM MV=Wr� _ LOCATION ��C� CAL Cl"nay _ N R2 a 3.14 (25) = 78SF (1) = 78 GPD __2_ll_..RH =131 (2.5) = 329 GPD TQT4( = 407 GPD NOTE: TOWN WATER IS AVAILABLE 89.5 / - W SITE PLAN OF LAND 3 LOCATED IN BARNSTABLE MARSTONS MILLS ) R=640.00 79.98 90.o PREPARED FOR ..................... GAS LINE GAS LINE 8 89.0 JIM SMITH 8.5 EXISTING E.T.W. PROPOSED •T.w _ 88.0 END OF PAVEMENT AL i `N of �qc Jq� PAUL ti I CL IT JOHN I �' MERITNEW y JACOBt •o No. 32093 �e �o No. 814 4�� �''�s���FGISTER�SJ�a`` SASSAFRAS LANE �� aaL ,ANo ( 50'- WIDE LAYOUT) EALj�°� RES. ZONE: RF FLOOD ZONE: C ~YANKEE SURVEY CONSUL rANrS PLAN REF:448/88 0 r 20 40 60 m3 ROUTE m.9 ip,,a BOX mm " SCALE: 1 = 20' tMRSrOW AMLS, AM. 026449 DATE: 4/20/89 JOB # 1142- 30