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HomeMy WebLinkAbout0075 SASSAFRAS LANE - Health ?5 Sassafras"Lane Marstons Mills F/R A = 043 072. TOWN OF BARNSTABLE t LOCATION 75- �Ci—�Sc�-n><ArgS �- SEWAGE #2004 - og 17 VILLAGE / '� � � f''` ASSESSOR'S MAP & LOT '43 9—?- ,INSTALLER'S NAME&PHONE j'SEPTIC TANK CAPACITY locva C CeSC!15-'. LEACHING FACILITY: (type)50' 0 C4 c�rU j�� (G� (size) NO.OF BEDROOMS 3 BUILDER OR OWNER &e O-M Feb. Z PERMITDATE: �A �©,�04 COMPLIANCE DATE. Separation Distance Between the: Maximum-Adjusted Groundwater Table to the Bottom of Leaching Facility A.�lq Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) N//� Feet Edge of Wetland and Leaching Facility(If any wetlands exist ,lq Feet within 300 feet of leaching facility) —��' Furnished by 6�'1• G e ICI � T�►��r . ze" Je Z = 35' 2 ; zl,L 5 �( (' - 3 ;24,� �, i / B s�T,. vF - G Sc.ss a_-�rz�s �-aA e ()�✓ u No. Fee r THE COMMONWEALTH OFMASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for ;5igo5a1 bpztem Con5tructiou Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. '07S `j(2���c--��'C 5 Owner's Name,Address and Tel.No. [fa Assessor's Map/Parcel 7 S`r„S so— /'� S (�— M 'Z'� r— -7 Pia-t S` S 'i-/t is Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Al. e. /�` r� re �v313. i�P�cP AJo. I'd 5700--775-07435' Lllarlk0o-K ©rf tj.a- 62-6 75 ca'a-te-rVIIle pe of Building: Dwelling No.of Bedrooms . Lot Size i4 J,96 sq.ft. Garbage Grinder( ) Other 'Type of Building No.of Person's Showers( ) Cafeteria( ) Other Fixtures . Design Flow S U gallons per day. Calculated daily flow 3 5- 3 gallons. Plan Date L7 --a t Z3 Sri 4 Number of sheets % Revision Date Title 6rjG 5� Ctvfrt c� a Si' S e Size of Septic Tank Joo � f��e t s %. Type of S.A.S. Ce-t Description of Soil N ture of Repairs or Alter ti)ns(Answer when a plicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed - C E Dater- Z V—d4 Application Approved byA) Date — —0� Application Disapproved for the following reasons Permit No. 12b0 l—u L/7 Date Issued N_. o. Fee !- Entered in computer: THE COMMONWEALTH OAF MASSACHUSETTS ✓ , Yes r PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for �Digogal bpotem Con!5truction Vermit Application for a Permit to Construct( , )Repair( )Upgrade( )Abandon( ) E)Complete System O Individual Components Location Address or Lot No. �'jGj �j�St- fY�S la, Owner's Name,Address and Tel.No. Maa-S1Vns k It(5 DIK'n'n 568 -IfZU- Assessor's Map/Parcel M C� 4 3 ct r �Z so-f r0.S � s -A s /S Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. M. e_ c n re 5�s-38 S q4o� !v r:t(� 4 CZ6 . /03 F RcP iVO. /645 ��/,uou'f�i 2of SUS-775-U73S aracov r or i� &a. 626 75 1 �'cQn f�✓v�/(e ' pe of Building: Dwelling No.of Bedrooms 3 Lot Size 14 g,96 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 C> gallons per day. Calculated daily flow 3 S 3 gallons. Plan Date I-9-6-t4 Z 3 Z.o o:-,4 Number of sheets f Revision Date Title 3 rf� . la ct - ✓' 7 S SScssg_,f r s &a- . Size of Septic Tank /no 6 �,.. � �X ,F . Type of S.A.S. vo awl car-ul(S ' Description of Soil, A sue` Nature of Repairs or Alterations(Answer when applicable) //'!5'{�- �'1�2(.y ch S T. L"k Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boyd,of Health. h Signed 'G'1 A C l l�,C Date/- Application Approved by Date 1 / Application Disapproved for the following r asons `l Permit No. 0CwQ-U L/-7 Date Issued 3� / THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by at F _ g 1 dr has been constructs in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. tau�/-U�/7 dated ! A L/ Installer Designer `-The issuance of this permit shall not be construed as a guarantee that the system wil��`function ,designed. Date !1 U Inspector C1, - - • - - --- No. S.JfN�I' n`I 7 - — ---------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION . BARNSTABLE., MASSACHUSETTS Diopozal bpztem Com6tructfon 3permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at A) o,emu, and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date oQils p 1.! t. Date: I 3 0 U L/ Approved by�I / . f TOWN OF BARNSTABLE LOCATION 75- J`�- 5�->n�OS t� SEWAGE#2004 - 7 VILLAGE M��4� 6'''c� ��� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO;M J_M e Z1T7.1� SEPTIC TANK CAPACITY �._�� car �5 Z� / LEACHING FACILITY: (type,' � (size) '�x��✓ �� � NO.OF BEDROOMS .3 BUILDER OR OWNER 9 PERMITDATE: a0 ,2004 COMPLIANCE DATE: Feb- Zcot4 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ��i9 Feet Private Water Supply Well and Leaching Facility (If any wells exist N Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching faci ty) R Feet Furnished by i"► 74 �''1 Pre- (a e •v M 4. � (I v oLi so ?a FAILED INSPECTION %I r��3 X DATE:- 12119103 PRO-PERTY ADDRESS:_Zj_,�,,,�,��,���,,� �_____ T RECWD JAN ? 2004 ---22648---------------- TOWN OF BARNSTABLE HEALTH DEPT. On the above date, I .inspected the septic system at the above address. This system consists of the following: 1. 1- 7000 gaiion zz/?; .io .tank 2. 1-Di,6t2-iPai-ion &ox 3. 1- 1000 ga.eeon /22eca_3.t .beaching /2.it Based on my inspection, I certify the following conditions: 4. 7h.i-3 .ins a t.LLe dive ZeR.t.io zyz.tem(78 code) 5. 74,e hg-s.t em zz in h ydaauiio �a i eu1ze. 6. A new 1each.ing aizea need. .to ge inz�tai_eed. 7. 12umpead compee.te .sy-3.tem a4 .t.ime 0,1 .in312ec44_0n. SIGNATURE: Zlf AAA Name:_J�_ Macomber Jr. Company: Jose_ph_P. Macomber_& Son, Inc . Address: Box 66 V Centerville, Ma.-02632-0066 rcv" yL ABLE Phone:-- 508-775-3338 ------------------- THIS CERTIFICATION DOES NOT CONSTITUTI*.A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. a Tanks-Cesspools-Leachfieids Pumped & installed i Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775.6412 • r a i - COMMONWEALTH OF MASSACHUSETTS ugEXECUTIVE OFFICE'OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION.FORM—NOT.FOR,VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PARTA CERTIFICATION Property Address: .Z 5 —�—r—4 fd 3-5 fd� �rcfL�— Owner's Name: Owner's Address: Date of Inspection: Z� Name of Inspector: (please print) o,6 P 12h 1. Ng r_om&ea aa. Company Name: �a_ P_ ft r_omP.ez 9 Son Inc. Mailing Address: gnx 66026 32 Cen eay.c e, azz. Telephone Number: 5 0 8-7 7 5-3 3 3 8 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system.at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15340.of Title 5(310 CMR 15000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Dater . a r The system inspector shall s mit a copy of this inspection repo to the Approving Authority(Board of Health or DEP)within 30 days of co pleting this inspection.If.the system s.s skated syste,m or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This-report,only.descr-ibes:conditions at the time of inspection and under-tile conditions of,use at-that time.This inspection does not address:how the system will perform in the future under he same or different conditions of use. 4 Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1) OFFICIAL INSPECTION FON RM — N 0 T F 0 R I.'U i",2TM SUBSURFACE SEWAGE y'oy. I PAR,T A CERTIFICATION NoWnutd) Property Address: 7*5 TnAAa4aa,-(wing Na A A f a n A, 01 ZIA, Mq Owner: Date of Inspe- Inspection Summary: Check A,B,C,D or J,,j p A. System Passes: no I have not round any information which indkovs th�jt —3 3 10 I .ML, TT 03 or in 3 10 C?Yfk 15304 exist, Any Mu CORN no "Mand a Mand be Comments: e C B. System Conditionally Passes: One or more systern components as described in Pass" section need to be kc, or repaNd The systern Von compkKon of Ac r,VacN;iWw or ,repah, V WrOved by iha Board Answer yes, no or not determined (Y,Nj4�,,) 6"-'r the Il:itdcanskes, "Pow. 'rhe set ptic tank is metal -,-nd over 2r) j,tntrsf'LL 'nctal or no ) is unsound, MY% subwakl irinintion or MazKon or is System -xii! plzs inspection ir'j)e Knig UK is replacad with a compohg wp& twk e'j 8! `A ri.iai sc-�dr pass in,mion sit Is ��Ir- t I ly s o d, riot Wng wid Ua Cubficme orC0M,H, ;CC to tvj is ks5 M,iri 20 j, of 5,,waQt backup or out 1 in th KNOwn Vv dw to yoUn oboucad pipty)or due to bmhn scund or uumn 'w"x. syslcrn will pass in.-Pec(ion ilr(wiun o;Fjoard o(Hc-aj0)): are :.Cj)18C":j obs(roction IS ;(:rnovcd disti ibudon lcdor rcpl-nec! N T) cxp 1 i.�in: no T')-, systt!ri rcquir-.-,J1 rou.m.ping mare On 4 Inn a you Ae to bmken Or obaNcH Thr. pa'..-s ap"-'roN''-.d ')F'G". 11"o"trd o T NrD x P 1:1 i r-.,: Page 3 of 11 OFFICIAL INS°PECTION FORM.:-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONTORM PART:A , . CERTIFICATION(continued) Property Address: 75 Sazza�2az Lane Owner:. aft Date of Insp ction: I :"/z o,/0-R C. Further Evaluation is Required by the Board of Health: Conditions.exist whichaequire further.evaluationby.the Board-.of Healthdri order.:to.determine ifthe 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: Q 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 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 asurface 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. UO The system has a septic tank and SAS and the-SAS is less thar�100 feet.but 50 feet or<more fioni a private water supply.well".Method used to determine distanceyl "This system passes if the well water analysis.,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure.criteria are triggered.'A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL,INSPECTION FORM—NOT-FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM:WSFECTION,FORM : PART A CERTIFICATION(continued) ' Property Address: 75 S a z z a z a s (,�;ap- Owner: 41, R b1 Z 494 Date of Inspection: �� D. System Failure.Criteria applicable to all systems:. You must indicate"yes":or"no"to.each:of the:following.-for all inspections: No _ Backup of sewage.into facility or system component.duelo overloaded.or clogged SAS.or cesspool Discharge.or:.ponding.of eflluent.to the surface of.the.gr!.ound or;surface:waters due to an:overloaded or s clogged SAS or cesspool V _ Static liquid level m the distribution box above outlet invert due to.-an overloaded or clogged SAS or / cesspool 4:0®0 4 , ✓ Liquid depth in cesspool is less than.6"below invert or available.volume is less than'14..day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. .Any portion of cesspool or privy is within 100 feet of a surface water supply,or tributary to a surface water supply. Any portion of-a-cesspool-or privy ris'within a-Zone i,of apublic well.., Any portion of a cesspool or privy is within.50 feet of a private water supply well. Any portion of a cesspool or-privy is less.than 100 feet but greater.:than.50.feet from a private water supply well with no acceptable water quality.analysis. [This system...passes:if the well water:analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates:that the.well is free from pollution•,fr..om:-that facility:and.the presence of;ammonia nitrogen and nitrate nitrogen is equal to or.less than 5.ppm,provided that no other failure criteria are triggered:A copy of the analysis must be attached:to.this form.] (Yes/No)The system fail .J have determined thavone or;:more of the-Above failurc: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 10,00.0 gpd to 15;000 gpd. 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) yes no the system is within 400 fe o a surface drinking water supply- the system is within 200 feet of a� `butary-to a surface drinking water supply _ 1the system is located in a nitrogen sensitive area.Onterim 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 asignificant 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. 4 r Page 5of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE:SEWAGE;IIiISPOSAL SYSTEM:INSPEC`PION FORM PART CHEC1G IST Property Address: 75 Sazza 2n.t fnno 17a2z.toa,3 .I UAV MA, . Owner: Urn n 7 i r n n Date of Inspection: z y o i0 a Check if the following have-been done.You must indicate"yes"or"no"*as-to each..of the:following: Yes 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 thsinspection? Were as built plans of the system obtained and examined?(If they were.not availabl.e`note 98 N/A) _ Was the facility or dwelling inspected for signs of sewage back up? - Was the site inspected for signs of break out? _ Were all system components;4cluding the SAS,located on site? Were the septic tank manholes uncovere'd,-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.depth4scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil.Absorption System(SAS)on the site.has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)) 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL;SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION Property Address: 75 S a,3,i a.fin a i fan o Owner: N o ga n_1-)iYnn Date of Inspection: FLOW CONDITIONS RESIDENTIAL .� Number of bedrooms(design) - Number of bedrooms(actual): DESIGN flow based on 310 CNIR 15.203 (for example: l 10 gpd x#of bedrooms): ( , Number of current residents: Does residence have a garbage grinder(yes orno):1LQ Is laundry on a separate sewage.system(yes or no):Jt/O [if yes separate inspe:.ction required]. . Laundry system inspected--(yes or no): Q� Seasonal use: (yes or no): Water meter readings, if available(last 2 years usage(gpd)): CQ= pQ J n Sump pump(yes or no):M Last date of occupanc4.RE COMMERCIALM UST1R'AL Type of estabJ hment: Design flow(b:se�on 31.0 CMR 15.203): d Basis.ofdesi6'how(seats/perso s/sgft,etc.):, Grease trap present(yes or no): Industrial waste holding tank present(yes or no):U Non-sanitary waste discharged to th T•tle 5 system(yes or no): Water meter readings,if available- Last date of occupancy/use: OTHER(describe): 'W GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for 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) F Innovative/Alternative.technology. ach a copy of the current operation and maintenance contract(to be obtained from systSji owner) Tight tank Attach a copy of the D approval �Other(describe):tit Approxi =atj components,date installed(if known)and source of information: r� Were sewage odors detected when arriving at the site.(yes or no) `y 6 Page 7 of I 1 OFFICIAL.I.i SFE,CT-ION-FORM. NOT FOR VOLUNTARY ASSESSMENTS UB SS-? ItF4kCE $EW4kQZ I)ISPOSAL SYSTEM ITISPEC'TION FORM PART C SYSTEM INFORMATION(continued) Pro-0myMdreSss �775 c/- Owner: Np- xnn Date of Inspertlors: 1.2419103 R BUILDING SEWER(locate on site plat) DePthholowgrade: 24" -640j21)c fli/2e �,E. z<.ings Mtteritls;ofconstrvctivn: cast (ron ,,,,,_40PVC,,,,,othar(e�tplttin): e 13y,6tem. Distance kbm.privow water supply well or suction Iirre: Comments(vti condltivn of joltlts,venting,e.vJdooca of le: age;c.tc.)i .iz .vented thabugh the 2oo� ventz SEPTIC TANKS �(locate on site plan) 1,000 ga Leon.6 D4pch below grade: Mitcriil.of construction:—concrete„metal,,,_rt-barglass_,_polyethylene. I.f iunc is snarl ilst ale; is age confirms., by a tier lficate U`(ompltanoc(yes or no); (attAch a copy of certificate) "+ ,i tn4ro �Dimensions: fn Z�g f , � �),Q_ Slud.gc depth: „e�L Qist4ncc from top of sludge to.bottom of outici tcc or baffle: t Scwn thickness:. ,,,, Distance from top of scum to top of outlet tee or baffle: Distance.0om.bottom of sctun to bottom or outlet tee or b fl—v How were dimensions determined; 4 R U)6 -tit), Comm.cot;.(:on.pumpin.g re.co.rr mcndatoons, inlet ano oit ei tee or baffle.condition,structural integrity,liquid levels as rcliW.to ouki invert, cvi:dcncs of.lealtagc,ate); ,sound and zhowz noe v.idence 'ol- —Peal e* gei GREASE TRAP: (locate on site plan Depthbclow grads: , Materitl of c struction:Aconcrcta „mFusl ,fibcrglas' � palyethylcne „other (explain), D.tmen:Iona; Scum thickness: Distance b om top o warn to top of outlet(cc-or baffle: 111 Di;sunce from bottom of. um to bonom of outlet tee or baffle: Date of last ptun,ptpg: Comments(on pumping recotnmondaiigns, inlet anc!outlet tee or baffle condition, structm. I Integriry, liquid levels as teltied 10 outicl invert, evidence o s:ge,etc,); r Page 8 of 1 I OFFICIAL INSPECTION.FORM—NOT FOR VOLIUNTAR St fBS>�1RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ENTS PART C SYSTEM INFORMATION(continued) Property Address: _ 75 Sazza,paaz Lane Owner: Date of Insp ction; TIGHT or HOLDING TANK: &,(tam must be pumped at time of inspe'ction)(locate on site plan) Depth below Bade:= _ Material of construction: concrete ,metal 4—fiberglass polyethylene other(explain). Dimensions: Capacity: gallons Design Flow:, gallons/day Alarm present( es or no): Alarm level: Alamo working.order(yes or no): Date of last pumping: kA Comments(condition of alarm and float switches,etc.): hoiding tank ate not /22e,6ent. DISTRIBUTION BOX: (tf present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): at.ion Pox haz one ea;telta-e.:7he2e iz evidence o� zoiiclz vidence o zea age into o"Z ou PUMP CHAMBER:R-Q—(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): e,*z 1.3 not ae,3ent. e, 8 Page 9 of 11 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued), Property Address: 75 Sazza�e2az. Lane Naz.3tonz Ni. iaz, Na. Owner: 17egan Dixon Date of Inspection: 12/19/0 3 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not,located explain why: L0.C6L 66b� 464-79ege 1 Ty Pe leaching pits,number:L leaching chambers,number:Q leaching galleries,number:_g::)- leaching trenches,number,length: o leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: 71 f-P o f)„¢ (7 Rr-0 4 0) Comments(note condition of soil,signs of hydraulic failure,.level of ponding,damp soil,condition of vegetation, etc.): Loamy 3ard Lo POn_eu 4Jno Arind- fen a h !,a9' 7Q Z� dam12 vegeia;6 ion .ins no2ma.P. CESSPOOLS:&Vicesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: -�� Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of by laulic failure,level of ponding,condition of vegetation,etc.): PRIVY: ,(locate on site plan) Materials of constru tion: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition,of vegetation,etc.): paivu .iz not ,fino,svnf 9 Page 10 of I 1 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION;FORM PART C SYSTEM INFORMATION(continued) Property Address: 75 Sa-3-3uZ2a.6 Lane NnnAfnnA M;I/0< 4a Owner: /y oo q i a it b-9/b Date of Inspection:T / SKETCH OF SEWAGE-DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. �. . o 10 I Page I I of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued). Property Address: 75 Sazzaeaaz Lane. Owoer: �ggetra L1 jam» Date of lospectioo: 12,4p'lp4 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicaic (check)all methods used to determine the high ground water elevation: OObuined [Tom system design plans on record - If checked, date of design plan reviewed: NA US Observed site(abutting property/observation hole within 150 feet of SAS) CO Checked with local Board of Health-explain: A14 Checked with local excavators, installers. (attach documentation) C.� cccssed USGS database-explain: _h ID•llinwn.-ga2nhtae—ee. ma. u- You must describe how you established the high ground water ele atlon: . used:Gah2et 9 Nietez. 12/16/94G2ound wtaelt e�evation� a&ove zea level d,3ed:I1S avat.ion we.�.� data. une used:7e rhnlna,P_ Pu.P_.P_et.in 92-000- 1 R a e nnua 2anggT7 d-- ,.,�i•f on o'Po un4.r_an4 2anua2u 1992 Leaching Pit :cc( Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore,the vertical.separation distance between the bonom of the leaching pit and the adjusted groundwater table is feet. C� 11 f I m a .1ri—.-n— rrr.—mr•nrrrt:v-n'ra*r.rn.r:•.•rr•rr•o:*:'mrsr:rrn nrn^:•srra+•�c*ra�'t .T�17^T*'..�•. TOWN OF Barnstable [BOARD OF HEALTH SUIISURFACE SEWAGE DI Sr'OSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I ....T••,••,•.t—�.:1'��!T.T1.�1'11:TT1 T+{TTT\TT•T'7TtTt'1""11/7'T•Y1:'�r`f"1+1n'RZTfi[TTNmRiSA-RT"� RRI I•RRT'RPi\TTTT.'RTi••r.�.•T'T•�• •�•.^ -TYPE OR PRINT CI,EARLY- PROPERTY INSPECTED STREET ADDRESS 75 Sa,3.6a P1ta-s Lane ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME L 40 PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME JoSeph P. Macomber V ton Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 street TOMn or city stet• t I P COMPANY TELEPHONE ( 508 ) 775-33-38 FAX ( 508 ) 790-1578 CERTIFICATION, STATEMENT I certify that I have personally inspected the sewage disposaj system nt this nddress and that the information reported is true , accurate , and Vomplete as of the time of <inspection, The inspection was performed and any recoininendaLions regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 , 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . .'Y Sy:st:em FAILED The inspection which I have con 0cted h.as found that the system fails to Protect the Public health and the environment in accordance with Title 5 , 310 CMR 15 : 303 , as specifically noted on PART C - FAILURE CRITERIA of this i;:� on. form ' - Inspector Signature . Ihate ne copy of this c .ification must be provided to the OWNER, the BUYER ( where applicable ) nd the .DOnRD OF HEALTH, * If the inspection FAILED , the owner or operator ahall upgrada ' the eyetem within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CHR 16 . 306 . partd . doc 116 No... Z.1.... ' Fmc.......Z.— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH l� ll ....................OF....��.r3..gni �4h�l .............................................. for Disposal Works Tonstrurtion Prruti# Application is hereby made for a Permit to Construct (f/) or Repair ( ) an Individual Sewage Disposal System at: .............5a ss a4r a s avu �l%� G�. ��c a-/- 3 I _v .vl c$$hon•Address ... •.. ....or Lot No. .......................................... •. • t'.sl�'a:_7 i. ........................... Owner Address Installer Address Type of Building Size Lot... Z.!^�( �......Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic (tom Garbage Grinder (1 O) 04 Other—Type yp of Building .. �..................... No. of persons............................ Showers ( ) 7— Cafeteria ( ) 4ES a Other fixtures .................. d ---------------------------------------------- W Design Flow.....-.6...............................gallons per person per day. Total daily flow...=} d.._........_...._......._......gallons. WSeptic Tank—Liquid ca.pacitylo4©...gallons Length..bt'_-+'.-. Width.+"'.(a.... Diameter................ Depth............. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No------.............. Diameter..1 ........... Depth below inlet....G.............. Total leaching area.2D5?__ sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 4 Percolation Test Results Performed by..�l'R? LA? ...................................... Date....—..Z... g a Test Pit No. 1...?.........minutes per inch Depth of Test Pit... Z........... Depth to ground water...IVQ............. GL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ....................•-------................................................----.........._•----............•... ............ ..........----•----------- O Description of Soil.J.-J..._.7.BiP./R4.ft...= �.�r.�2 e.l,e--3 6.ems/a � 7v12- �Y1e •Sav►9�........................... x VW ..............•--•-----------••-•---------------------------•-•------. -. - --------------------------------•.........................----------•--•-. ------------------------ •------ ------------------------------------------------•------------------...------•--•--......------------------------------------------------------------..............-•-----------•--•-••-----•-•---••-••-- UNature of Repairs or Alterations—Answer when applicable............................................................................................... ••---......•---•................••--..........----......_................................--••----•---...•---........----------------•-•-----•-••-................................----•-••--•---...--.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Com ' nce has bee issued by the board of heal . s y Si ed... ---- R...._. . ....• = - Qr.... /... Date Application Approved By-----.•. .......... Date Application Disapproved for the following reasons:.............................................................................................................._ ....----••--•-•-•---•---------•..............................................•-••---------...--------••-----------------...---•-•----........---••-----------------------------•---•------•------------- .�l�.----- --. ...------•-•...............--•--------------'-•---------------^- Issued ^----,ate Permit No ----... Date No..R . �6d f Fmc. l- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' ......................OF... CO.t ahN....•----•--••----------•-•-••---............... Appliraation for Disposal Works Tonstrnr#iun rami# Application is hereby made for a Permit to Construct (IP") or Repair ( ) an Individual Sewage Disposal System at: -•.............._...........--_--.---.-............. ...- .............................. ................ ... ---- ...-•--.................................................... Location-Address or Lot No. Owner Address W ....................... .... . ..._.._..... Installer Address ©. Type of Building Size Lot.. 0...... feet Dwelling—No. of Bedrooms............................................Expansion Attic (F--) Garbage Grinder 60) p,l Other—Type of Building .A�............... No. of persons............................ Showers ( ) — Cafeteria ( ) GaOther fixtures --------------------------------•--•---------- W Design Flow.:...5.6................................gallons per person per day. Total Bail,y flow_.�:��..................................gallons. WSeptic Tank—Liquid'capacity/ _...gallons Length._8.!!+._.. WidthA.'.Z.... Diameter................ Depth-.-----.--_. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No____ _______________ Diameter../Q............ Depth below inlet....(9.............. Total leaching area.a:`�..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by..&/ ?lgkC-4-1 6' ....................................... Date...7/� ............... Test Pit No. I...4..........minutes per inch Depth of Test Pit..!.��........... Depth to ground water_.0�r�............. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.... ........... --------------------------------------------------------•-----------------...----._.._........--••-•...................................... ODescription of Soil.,f";.- ?? ¢ m_..... I•Z .. --...' ...y............................................ .U ....... •--•------------------ ------•--•--------------.---.--- VW •-•-••-•--••.............•-•-------•----•-•--•-•••-••-•------•-------•-------------••-•.._........-•---••------••--•-------••••-•--•----•-•-....•--•-•-----•••---•--•-•-••-:..--•--.....-----•--•---.--- Nature of Repairs or Alterations—Answer when applicable................................... ........................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI,1 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..--1-...-•-------•--••-••---•-•--••--•••-••-•-•------------------------•-•-•-•----. Date Application Approved By------ ' ._. :��i *4 4�...... . Date Application Disapproved for they f ollowing reasons---------------------------------------------•--...------------•-----------------------------------...---------- .............................................. :..................................................•........------.........--•-----------------------------.....------------------------------------ Date 3/ Permit No.. .............•---.... Issued.................. ..._...------................. Daatete i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH lAVAI......................OF....G .�?{. ! .� ..- ................................................ Ta if irab of TomphFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (✓) or Repaired ( ) by-•-•----------------•-----------------•---------.----------------•--•----------------•------------- ----------------------------•--------------------------------•-------------•-•-•--------------- . Installer -- ------•--------•-------•---------•----•----•----.....-•-----------------------••-------------•-•---------•-•----•--•--- has been installed in accordance with the provisions o 1 TIME 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permif No..�!`-���r�._.... � ?� -- -- dated. ,� ..................... THE ISSUANCE OF THIS CERTIFICATE{SHALL NOT BE CO UE® AS ARANTEE THAT THE 51fSTEkoI 1N/I FUNCTION SATISFACTORY: DATEIf D f 9---------------------------------------------------- Inspector-- ....... ...... . ........................... ......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,- tlr ...........................................OF............-•----------........-------------•-------------------------------........ 7--....._., No...,.. FEE........................ Disposal Workii Twunotrnrfinn amit Permissionis hereby granted---........................................................................................................................................... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo................................................................................................................................................................................................ street as shown on the application for Disposal Works Construction Permit No..C._.f.::.! Dated.._/�_/ j''_----------------- -•••••..............................•------••--••••----•••----------•--•-•...--•-----........•----_...._ Board of Health DATE................................................................................ FORM 1255 A. M. SULKIN, INC., BOSTON Ui COMMONWEALTH OF NiASSAC' HI 'SETTS : ExECL•TIVE OFFICE OF F—INNIRONMENTAL AFFAIRS.. DEPARTMENT OF E'��'IR01:�IE\TAL PROTECTION ONE WINTER STREET. BOSTON. 1IA 02105 Fl?-_S_•�:CMG ��,` I A wZLLIANt F.WELD -;. . _ �� TRL }'CG?= Gaveztc' _ �2. ARGEO PALL CELLL CCI aD v� DAVID=B S'TRI. Lt.Gavcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORI+�I 1 co Corr issiarr 4 c1 PART A �� ' ! --}�•J� CERTIFICATION '8 5 Property Address; "Is S��SAF�'s�iS Lt-., AfsTOW,MIIIS Address of Own*&: �Tj�yyt� C7 hq`tZo� Date of Inspection: ak-, l01(;6 02e`A$ :(If different) Name of Inspector: 1 am a DEP ap roved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) Company Name: / o 04-"e E,1 J- ef-7 M P" p M 4'--f Mailing Address: 2 n / ,=,< e-'37P!�4 . L lf51 o H I57- C=1 2E9�-q Telephone Number: f$'GT_ CERTIFICATION STATEMENT cent) that I have pe•sonall ir.spec:ed the sewage disposal system a; this address and that the information recored be!o,,% is true. accura:e and comolete a: of the time of inspec c The inspec:;cn was pe^crmer base--' on my training and experience in the proper funalcr arc maintenance of.on•s,te sewage d;sposa: s}•stems. The systerr.: Passes . _ Conc!t,cnai:% Passes '.eec; Furhe- E-,-a!uaror• Sy the Local Approving Authority — Fa..- r Inspector's Signatu : LULD Date: sae S�se^ Insv.,o• shai' sabrtit a copy of this inspec�on reocr, to the Apurcving Authority within th;ry (301 days of completing this inspecocr.. It the system is a sharer syszern o• has a des-S-t no,,,. of 10.000 gx or greater, the inspecor and the syste-.. owner sha'I subr--;t the re^,o^ tc the aporopriate reg,onat a rce of the De;a-meat of Envirenmenta' Protector. The crig-na! should be- se-it tc the syste- e--� and copes to the buyer. if applicable. and the ap.-roving autherin INSPECTION SUMMARY: Check A, E, C, or D. Al SYSTEM PASSES: 1 have not found any information which indicates that the system vieiates any of the failure criteria as definer ir, 310 C.MFc Any failure criteria not evaluated are indicated below. . COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass- section need to be replaced or repairer. The system), ucC completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no. or not determined (Y, N. or NDt. Describe basis of determination in all instances. If 'not determined', explain why net. The septic tank is metal, unless the owner or opeator 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. c the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltranon, or tz-> failure is imminent. The system will pass inspe^.ion if the existing septic tank is replaced with a conforming septic crk w approved by the Board of Health. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . ..PART A CERTIFICATION (continued) Property Addrass: Owner: Date of Inspection: BJ SYSTEM CONDITIONALLY PA55E5 tconun,,!,d Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(w;,h approval of the Board of Health). Describe observations: 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 pats inspection if twith approval of the Board of Health): broken pipets: are replaced obstruction is removed C) FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require furthe•evaluation by the Board of Health in order to determine if the iystem is failing to prate- the public health, saier•and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETER.MINE5 THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. Cesspool or pri%ti is within 50 feet of a surface water Cesspoo! or privy is within 50 feet o:a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (A!vD PUBLIC WATER SUPPLIER, IF APPROPRIATFi DETERMINES THA' THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFEETY AND THE ENVIRONMENT: The systern has a septic tank and soil absorption system (SAS, and the StiS is within 100 feet to a surface water supply or tributan• 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 supn'y we!I. The system has a septic tank and soil absorption system and the SAS is within 50 fee! of a private water supply Weil. The system has a septic tank and sail absorption system and the SAS is less than. 100 feet but 50 feet or more from a private water supply well, unless a we!I water analysis for coliform bacteria and volatile organic compounds indicates tha the we!I is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to c' less than 5 ppm. Method used to determine distance (approximation not valid). 3) _ OTHER (reviaad 04J25/3- ) logo 2 of 10 t i 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 "►vo' as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined 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 necessam, 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. Sta:ic liquid levei 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 1/2 day flov. Reouired pumping more than 4 times in the last year NOT due to clogged or obstructea pipes . Number o'times pumped _. Anv poriton of the Soil Aosorpt�on System, cesspool or privy is below the high groundwater eievanor. Am por;on of a cesspool or privy ,s within 100 feet of a surface water supply or tributa-v to a surface water supply. And portion of a cesspoo: or pri.ti• is w,thin a Zone I of a public well. An,. po^io-• of a cesspool or pn%-v is within 50 feet of a private water supply well Am- por,,or. o`a cesspool or prey is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quahr\ anaIN-sis. If the well has been analyzed to be acceptable, attach cope of well water analysis for cohiorm bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate ether "Yes` or "No" as to each of the following. The ioliow,rg criteria appiv to largo systems in addition to the criteria above: The system serves a facilm with a design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to public hea!th and safer 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. freviaad 04/25/97) Page 3 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:`Zip 5'�S" {2.t�S Owner:dt Date of Inspection:6Z 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 normal flow rates during that period. Large volumes of water have not been introduced into the system recenth or as part of this inspection. As built plans have been ootamed and examined. Note if they are not available with NIA. The fac:l1r, or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. The site %%as inspected for signs of breakout. All system components, excluding the Sod .ADsorption System, have been located on the site. _ The septic tank manholes µere uncovered. opened. and the interior of the septic tank was inspected for condition of` baffies or tees. materia' o' construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption Svstem on the site has been determined based on: _ The iac,1w, ov-ne• tano occupants. if difteren: from oµ•neri were provided with information on the proper maintenance of Sub-Surface Disposal Svstem. Existing information. Ex. Plan at B.O.H. _ Determined in the field cif am of the failure'Criteria related to Part C is at issue, approximation of distance is unacceptable [15.302.3):bi? (revised 04/25/57) Page 4 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.`t PART C SYSTEM INFORMATION Property Address:—75 G OwnenQ 11`�(L,l� Date of Ihspection:Z'ZgWF3 '"�''(( FLOW CONDITIONS RESIDENTIAL: Design ilow 7S,%O .p.d./bedroom for S.4�S Number of bedrooms 0'9 Number o'current residents Garbage g•,.der (yes or no): Laundry co-•-ected to syste ( s or nol Seasonal use ryes or no.. Water meter readings. if ava fable (last two i2• year usage igpol: Sump Pump lves or no,: Lac: date of occupancy , t�oj COMMER6 4L'INDL'STRIAL• Type of establishment Design fio%%- t ahons/da% Grease trap present. tees or no_ Industrial \Taste Holding Tani; present. wes or no ':on-sanitan %%aste discharged to the Tane 5 system. ;res or no %%ater meter readings, if availabie Las:Pa;e o; o :upanc� OTHER: Describe Last care of occuoanc. GENERAL INFORMATION PUMPING RECORDS and source of information System pumped as par, of inspection: (ves or no._ If yes, volume pumped t allons Reason for pumping TYPE OF SYSTEM Septic tank/distribution boVsoil absorption system Single cesspool Overflow cesspool Prnoy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site. (yes or no) (revised 04/25/9'7) Page 5 of 20 SUBSURFACE SE`6VAGE DISPOSAL SYSTEM INSPECTION FORM ', PART C SYSTEM INFORMATION (continued) Property Address: 1,�5 eA's Owner: (� - Date of Inspection: BUILDING SEWER:. (Locate on site plant Depth below grade. Material of construction: _cast iron _ 40 PVC _other (explain) Distance from private water supply well or suction li-t Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site All Depth below grade q Material of construa'on: -,concrete _meta _Fioergia- _Polyethvlene _othertexplain If tank is metal. Ifs: age Is age confirmec o� Ce-t:f,ca,,e of Compuance _(l es.;No Dimensions ,'boo g y- Sludge depth 8"[ Distance from top o: s?udee to borom of outie: tee o, ba^ie Scum thickness I- dl I( Distance from to of scum to top of outlet tee or ba^ie l 1 p fl Distance from bottom of scurn to bo-o-n o,outlet tee e, bai'.e Now dimensions were determined Comments. trecommenciation for pumping. condition o. inle and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc. eowto 14 GREASE TRAP: (locate on site plan) Depth below grade. Material of construction: _concrete _metal Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: ~- Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of i:filet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.,- (revived 04/25.17) Page 6 of 10 T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properh Address O%ner: Date of Inspection: I�� 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: Capacm: galions Design flow. galionsda, Alarm level Alarm in working order _ Yes, _ No Date of previous pumping Comments (condition of inlet tee. condition o- warm and float switches. etc.) DISTRIBUTION BOX: (locate on site pa- Depth of liquid level aoove outie: in% Comments J to to a lei• I d distrU oua'. e�•Idence ' olids carrvov `yid nce of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plan. \ Pumps in working order: (Yes or No' Alarms in working order (lees or No. Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Pag• 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION_FORM .PART C _ SYSTEM INFORMATION (continued) Property dd( -ss: Owner: G Date of Inspeaion:9'"7(J SOIL ABSORPTION SYSTEM (SAS):_ky.'� (locate on site.plan, if possible, exca�a on not required, but maybe approximated by non-intrusive methodsi If not determined to be present, explain: Type .. ._. � leaching pits. number. _v p leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dirnension.s overflow cesspool, number Alternative system Name of Technologv Comments. to to condition of soli s!gr.s of hydraulic failure, le i of ponding, condition of vegetate ete.t (21C �J ey L CESSPOOLS. (locate on site plan Number and configura'-on Depth-top of liquid to inlet Inver Depth of solids layer Depth of scum layer. Dimensions of cesspool Materials of constructior Indication of groundwate- inflow• tcesspool must be pumpeC as par, of inspection} Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) VY:4b - (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.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert,. Add ess:ZdS 5 ` �� Owner:13 -� Date of Inepection �])1'��� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reverences landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) IS At A�o Z_ 25 e fl3, 33� �. (revised 04'25/5") + )page 9 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C "-T �q SYSTEM INFORMATION (continued) Property Addres-• `S `"'r'—� ' ". % Owner: D #VC14— Date of Inspecuon:��C� � 1 Depth to Groundw•aterUFeet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abunrng property, observation hole, basement sump etc.) Determine it from local conditions Cnec'K �+rth Iota! Board o• nevtr Check FEMA Maps Check pumping records Check local eacavarors. installers l se L 5CS Da-.a Describe m you, o oras no,.. %o:: estab!*he tner igh Groundwater Elevation. (Must be completed: 41 f(Z 96- trevaiad 04,2519 Page 10 of 10 L� 5 v F CVl- a rA up I Pf�OF I Lam: NOT TO SCALE TE6T i10LE LOG 2"LAYER Or'5/S"PEA5TONE rtRsr PIPE LENGTH OVER g/.+"-1 V7 POUPLE DATE: ✓vGr zs /yf /' sT97 �. m u/RCEDY COVERS To w�THM To DE 5ET LEVEL TOP roLwAr�:�v wAsHEP wore i" Or MNKhED GRADE. rOR MM- 2' TEST 15Y: —A w�ti ,eo MNl6H 69AM WfrNE55: PERORATE: c Z,�i v�i✓cs� CL f�.jR�iT+41.�2/aS �i✓i Q• AQr A" PY TOP ® EL R/• AL7 / 4" PVG - a LaCCJS 877 8 0 /RG,Zo 3� h/-2o i race/ T C S a� WTOM ® EL 'S Z o // ' 87 Z5 ► IN Un.�erTM MIT 7 83.Oo 94r, o, 3 A41 .w ate.3/ SEPARATION g Boa 6AL1.ON A47,A*z8S �z G,o' SEPTIC TAW • _cx. 57. A,, srorE DASE 77• s vpa r-oc T..00 i 1�1/ i✓0 ram: >j�C .SAS 2�i�-1o�/�A���''/���'✓/Oc�S -��r./L�. /z r DESIGN DATA a " s PA LY FLOW: (3)f5EPROOMS x 119 6PD= 8 330 6PP u) G S SEPT r,TANK: 35'o6PP x200% nC-RP 7,Sys sg `X'S'6ALLON PRECAST SEPT C TANK 3� USE%vn� Y LEA6111 - FAGILFY: _<av 0 i9C ��►?lt/c '�Z USE: (�J8 z ' o .- �y I Ise W/y'o,= sTo,V � moo. sf CAPACITY: ?l S�°tio ,,AA► 13O TOM: 3' x Z5'X rya zoo, s //l4 22 a GENERAL NOT- P Z o 7'W ���2c (` TOTAL: -7 S 3, o O CONTRACTOR TO 13E RESPONSDLE FOR THE LOCATONOF ALL UTLfFES, ABOVE ANP UNPERC-7ROUNP,PR 09 TO ANY EXGAVAT ON OR CONSTRUCT ON. 2. SEPTC SYSTEM TO rE NSTALLEP N GOMPLWNCE WITF130 GMR 1500:TITLE V ,I i H6 PLAN r>P,dT I O�E USCJ GK r rZ(l`LK i 7 _►�i-✓L i Ef�ivia'vr;i v 4. ALL PI5TURf5EP AREAS TO I3E LOAMEP AND SEEDED fl 5. CONTRACTOR TO PROVPE U f10UR NOTGE FOR ANY REG?UREP WeEGTONS G� p / � O ACTE2nri9T/!/� 1 TE �EVVAaE PLAN LOCAT ION: rJS -S�sS �f��?S ,+'�,eS7�✓S i'�/G Gs G� PREPARED FOR: /t-1 ��/ ,�/�.'�•`,/ SCALE: DRAWN DY: 4 N OF Mq - <�sTEvr-nlw. s� J�'� NUvfoo �o PATE: `� � RUMBA -• /�, �! ^' ` •�. NOr y , AjWELLER & Ae�06/ IATEe 1645 FALMOUTM RP ^- SUITE 46 GENTERVILLE, MA 02(o32 TEL.: (508) T75-6 135 � FAX: (505) - 75-075q PROFESSIONAL ENGINEERS & LANP SURVEYORS 4L 9._ rw orrocmAlmw 1.0'-RISER COAQWrE COVr M C AA2%W COPU 89.7' 4"s cokt# * 40 PIAC N A rE- pe E �3�:52' #&vrr /yV> r .'.; sT r spAEL IsiEPorAW EL. $$1SL &. 87.9' o <0 G. NVERr �•Ez. .fi�.. 2 er 'e `° o �90.5 10.0'� 3.0' �-20' ._ 6.0' A 8.0' 4.0' 101.50 !-ROFIL E OF ELEV.= 77.5 Mo GROU o WATER Ti4" SEP TIC SYSTEM LOT 31 SOIL LOG 90.0 DAyE7128/86 Nor p5997 GENERAL NO TES q r"r A4" ALL STRUCTURES H2O LOADING IF IN DRIVEWAY. t1') 'EL. 89•8 ALL PIPE SCHEDULE 40 PVC O EL ._ 0-3' T/L/S REMOVE ALL UNSUITABLE MATERIAL FOR 10' IN ALL `�— DIRECTIONS IN COMPLIANCE WITH 310 CMR-14:02 O, DESIGN DA TA � LOT 3 0 3-6' CLAY At#49ER OFLOT 32 44A 3 PROPOSED TOTAL J20W 330 Gpp c0 HOUSE cv BOTTOM LEA a" AREA 50 Sot Fr. LOCATION 04 WE LEAC"M ARE4 150 so FT. No sox •. . G4 RBA 6-12' MED. SAND T LEA� 200 SO. fT 17. 17.0 CO ELEV=77.5' PERCt"TAN RATEHOUSE NO wArw exow mo crat.cu�rT 1000 gal. CORNER R =50F (I) - 50 GPD BOTTOM 2-1f'RI-1 _ 150172 (2.5Y^ 375 GPD SIDE TOTAL a 425 GPD W o 4v NOTE: TOWN WATER IS AVAILABLE. Z ir t- n. . O w O• L.. R 3 co SITE PLAN OF LAND �� LOCATED ]N BARNSTABLE. d' ���� =640 iGO.43 GAS LINE GAS LINE ( MARSTONS MILLS 40 _ 89.0 g.0 _ PREPARED FOR 8 8g,5� _-____ 88.5 EXISTING E.T.W. OPOSED E.T.W. _ .—. — � - pR — — S• 87.5. 88. � END OF PAVEMENT JIM SMIT SASSAFRAS LANE14 OF ftxx Q. J HN COBI z 50-WIDE LAYOUT Ma 3�oae " �o No.814 - E SS���0� otiw f o� SURVE'A ALTH . RES. ZONE. RF YA NKEE SUR VE Y C0NisuL rA N Ts FLOOD ZONE: c o Zo 40 60 143 ROUTE 14.%9 (too Oe BOX 265) PLAN REF 448/88 MARSITONS ACLImSo MAo 02648 , SCALE: I" 20' DATE: 4/21/89 JOB # 1142 - 31 IL 9.r rep arrothimrxw 1.01-RISER carp coves CoNcmTr Qot" 89.7' IL 4"tdhd* 40 PVC a •• PrE-.4Aft ACST •: {{• • • . < Sraw (^, 'IVK:RP 1PIrVJ�T :� '•: PAST EN SP /�, � 52 s�rac rAnr� Ez. :_ 67 9' < :}; �►�' ovvD?T 1000 GAL. jvmrEI. �$. Q $8.06' NVDPT ,,� co o WS 90 5 Q 5 — a.. raw 1--.10 i N• , 9 C5 10.0'� 3.0' � 20' --1-- 6.0' '� 101.50 Is 8.0' 4.0' PROFIL E VF .. ELEV.= 77.5' AV GR01W WA M? TA6LE SEPTIC SYSTEM LOT 31 SOIL L o G 90.0 A4rE 7/28/86 .P5997 GENERAL NO TES TIsP H t ALL STRUCTURES H2O LOADING IF IN DRIVEWAY. Q. 89.5' IL ALL PIPE SCHEDULE 40 PVC 0-3' T/L/S � REMOVE .ALL UNSUITABLE MATERIAL FOR 10' IN ALL DIRECTIONS IN COMPLIANCE WITH 310 CMR-14:02 DESIGN DA TA LOT 32 *0) 44 LOT 30 3-6' CLAY -,J OF � 3 PROPOSED HOUSE Qo N CIRD TOTAL FLOW 5030 S T LOCATION N BOTTOM LEA AREASM LEA QW#V AREA CA 4 ------ RBAGE D�SAL NO O hcarewo • f-12' MED. SAND 200_ S* FT. 17.0 4? TOTAL LEA AREA LF1qs '2 17. ELEV=77.5' PERCt" W RATE HOUSE NO wArm e+cmwmmv I000 gal.,CORNER CALCt"rAMA$ M 'R-R =50F (1) = 50 GPD BOTTOM 2-H-RH = I5OF2 (2 5)zo 375 QPD _ SIDE _..� TOTAL,= 425Z,GPD O I N NOTE: TOWN WATER IS AVAILABLE. LJJ WR ) 50"ITE rOm'LA N 0%F LAN D" (( Q of � LOCA i ��Eu IN BAKN5TAbE L �0• ��m =6 60.43 GAS LINE GAS LINE MAKZi I VN5 MILLZ43 � 89.0 5 _ 89.flEP PROPOSED E.T.W. _ 8' _..._ — 88.5 EXISTING E.T.W. a JOa!�N 87.5 88. t J�►c081 1B8.0 }�-- END OF PAVEMENT �o� No.814JIM t03 M I T H Q ���K'EA 0%5`&A5bAF a Kmft ASOF& LANE �F N At, a Y ( 50 WIDE LAYOUT ) Q '� No,32M S5� '�FA 1M !►! N SURD RES. ZONE: RF YAIVr%EE SURV& )r CONSUL /V I ly FLOOD ZONE: C o 20 40 60 Rourcow 14,,o& el ,a sox 143 265) PLAN REF, 448/88 MARSTONS KILIA fdAe 02646 SCALE: 1" = 20' DATE: 4/21/89 JOB # 1142 - 31