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HomeMy WebLinkAbout0050 SHAMMAS LANE - Health 50 Shammas l LU:_h e�.` Marstons Mills / A=065-004-008 7 _r Commonwealth of Massachusetts 0 4, 00? �� :• Title 5 Official Inspection Form + 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .� � 50 Shammas Lane V� Property Address Richard and Vanessa Gumbert Owner Owner's Name information is Marstons Mills MA 02648 08/21/2020 required for every page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. Rivers End Road Co � Company,Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 08/25/2020 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. '.Singp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............. /% 50 Shammas Lane u Property Address Richard and Vanessa Gumbert Owner Owner's Name information is required for every Marstons Mills MA 02648 08/21/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 4 bedroom home has an H-10 1500 gallon septic tank with an H-10 D-Box feeding 3 leaching chambers with stone. At the time of the inspection no visible failure criteria was found. 2) 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): t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:SubSLrface Sewage Disposal System-Page 2 of 18 II�__ Commonwealth of Massachusetts �v Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Shammas Lane Property Address Richard and Vanessa Gumbert Owner Owner's Name information is required for every Marstons Mills MA 02648 08/21/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form h= I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t 50 Shammas Lane Property Address Richard and Vanessa Gumbert Owner Owner's Name information is required for every Marstons Mi Is MA 02648 08/21/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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 Supp Y. ❑ 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts �- - e Title 5 Official Inspection Form Ii; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Shammas Lane V Property Address Richard and Vanessa Gumbert Owner Owner's Name information is required for every Marstons Mills MA 02648 08/21/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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. i 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form <iii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 50 Shammas Lane Property Address Richard and Vanessa Gumbert Owner Owner's Name information is required for every Marstons Mills MA 02648 08/21/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 I i f Commonwealth of Massachusetts Title 5 Official Inspection Form + 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 50 Shammas Lane Property Address Richard and Vanessa Gumbert Owner Owner's Name information is required for every Marstons Mills MA 02648 08/21/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 plus GPD Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d town water 9 ( Y 9 (gP ))� Detail: In 2019-7000 gallons were used and in 2018-1000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 50 Shammas Lane Property Address Richard and Vanessa Gumbert Owner Owner's Name information is required for every Marstons Mills MA 02648 08/21/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 50 Shammas Lane Property Address Richard and Vanessa Gumbert Owner Owner's Name information is required for every Marstons Mills MA 02648 08/21/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DE approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 8/26/2013 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): " Depth below grade: 21feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments on condition of joints venting, evidence of leakage, etc.): Water was flushed and came freely. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts �n ,(,A Title 5 Official Inspection Form + 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Shammas Lane u— Property Address Richard and Vanessa Gumbert Owner Owner's Name information is required for every Marstons Mills MA 02648 08/21/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-10 1500 gallon Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 50 Shammas Lane a Property Address Richard and Vanessa Gumbert Owner Owner's Name information is required for every Marstons Mills MA 02648 08/21/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Dis tance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts �d =. a Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Shammas Lane Property Address Richard and Vanessa Gumbert Owner Owner's Name information is required for every Marstons Mills MA 02648 08/21/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. r t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V � 50 Shammas Lane Property Address Richard and Vanessa Gumbert Owner Owner's Name information is required for every Marstons Mills MA 02648 08/21/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ii Title 5 Official Inspection Form pia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Shammas Lane Property Address Richard and Vanessa Gumbert Owner Owner's Name information is required for every Marstons Mills MA 02648 08/21/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsu-face Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . � 50 Shammas Lane u� Property Address Richard and Vanessa Gumbert Owner Owner's Name information is Marstons Mills MA 02648 08/21/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsu-face Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Shammas Lane Property Address Richard and Vanessa Gumbert Owner Owner's Name information is Marstons Mills required for every MA 02648 08/21/2020 page. CltyrFown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 **As-Built from the installer attac hed On next page** t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Assessing�As=Built Cards https://townofbamstable.us/Departments/Assessing/Property_Valu... TOWN OF BABSTABLE J p hW mmG s LOCATION.r S s H SEWAGE#� Wd,AGE IIIS ASSESSOR'S MAP&PARCEL"'W` INSTALLER'S NAME&PHONE NO, SEPPICANK CAPACITY /SGD 1EACHLNG FACUM:(ty el NO,Of BEDROOMS 7 OWNER P14, PEWDA1E; COMPLIANCEDATE; ' Sepamtionl)6s�ceBetwe®t�: MaaimomAdugdGrmmdwatarTiletobBottomofLachmgFac24 Feet hate Plater Sgpty We0 and Leaching Facility gang As exist on skorwifin200fe¢toflexhiagfacik) —Fed Edge ofWetlaadaodLeac4Fdty(If existwifhin 300fedofl ) Fe EURNISf1ID '! i l 1 of 1 8/20/2020, 8:33 PM Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 50 Shammas Lane Property Address Richard and Vanessa Gumbert Owner Owner's Name information is Marstons Mills MA 02648 08/21/2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit. i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 F Commonwealth of Massachusetts �n Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Shammas Lane Property Address Richard and Vanessa Gumbert Owner Owner's Name information is required for every Marstons Mills MA 02648 08/21/2020 page. City/Town State Zip Code Date of Inspection E. Report 'Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: t 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached 'r For 15:, Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLF LOCATION,'S]Q I S I-la~,,&5" /w SEWAGE# VILSAGE �� /��/g ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. & �° SEPTIC TANK CAPACITY LEACHING FACILITY.(type) NO.OF BEDROOMS �f OWNER PERMIT DATE: 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 Facilityan �tlands�exist ithin 300 feet of leachi ity) Feet FURNISHED Y 75- 3 v /g� No. go I� J�5 Fee �" - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftpliCatlon for lBisposal *pStrm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 50 5460Ain49 1h, Owner's ,Name,Address,and Tel.No. Assessor'sMap/Parcel ® Gv -oel " �IC61IGrd Vol rF Installer's Name,Address,and Tel.No.��p0 11-77 d/7 Designer's Name,Address,and Tel.No. d� �o di LG �. �c I '� Type of Building: / Dwelling No.of Bedrooms /7 Lot Size lilqq sq.ft. Garbage Grinder( ) Other Type of Building j?pS jG e(.t No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) © gpd Design flow provided gpd Plan Date j0-1 /ir—1_3 Number of sheets 1 Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enviro tal Code d not to ac the system in operation until a Certificate of Compliance has been issued by this Boar H Ith. Sign Date Application Approved by Date ' Application Disapproved by Date for the following reasons Permit No. arLP( "J ' 3 Date Issued r r ----------------------------------------- ------------------------------------- - No. df /� Q �€ „ Fee I`� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for bisposar 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 50 50a V4 IfG S t A• Owner's Name,Address,and Tel.No. "Assessor's Map/Parcel Installer's Name,Address,and Tel.No.���� 11-77 Cl 7 • Designer's Name,Address,and Tel.No...-- — �g Type of Building: Dwelling No.of Bedrooms `y Lot Size , L sq.ft. Garbage Grinder( ) Other Type of Building 1?es id eo t No.of Persons Showers( ) Cafeteria( ) Other Fixtures lit I Design Flow(min.required) '"! I D gpd Design flow provided gpd Plan Date 7—13 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S7VL:--ple Nature of Repairs or Alterations(Answer when applicable) (5:: 1 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 y1th. fatal Code d not to face the system in operation until a Certificate of Compliance has been issued by this Board of Sign // Date Application Approved by (v/ Date �' r Application Disapproved by Date for the following reasons Permit No. gC)13 " `7j ;k-- 5 Date Issued --------------------------------------------------------------------------------------------------------------------------------------- TH E 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 S D 0 iM( )G�S to . has been constructed in accordance r with the provisions of Title 5 and the for Disposal System Construction Permit No. �3 / dated r r Installer lz,4jw EJC( j n G [�� Designer _ #bedrooms Approved design LJ gpd The issuance of this permit shall not be,construed as a guarantee that the system will function as designed. Date ^n 11 Inspector _ ------------------ --------------------------------------------------------------------------------------------------------------------- No. -- ®( J —3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS disposal *pstem Construction 3pPrmit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this pe i Date 1-3 Approved by NOTE LEGEND EXISTING LEACH PITS ARE TO BE PUMPED. EXISTING O �� REMLOVE ALAPSEL L CONTAMINAND FILLED AR REMOVED. TED OILS IN THE ISOO GAL O AREA e 54494 of ,ao VICINITY OF THE PROPOSED LEACHING SEPTIC TANK 1 GALLERY AND REPLACE WITH CLEAN ASSR MAP 65 Pa 4-8 MEDIUM SAND PER TITLE S. • EXISTING 1 GAR . LEACH PIT G R TEST OT D-BOX O P!T ® OWED HYDRANT Q EXISTING MINIMAL STONE CONTOUR GRADING PROPOSED DRIVEWAY THIS Is a 108 ®® COLOR ���QOGy �I PLAN \ 77(oG__� O� USEFO�OR PLAN ONLY INSTALLATION �� 109.PNID� FULL DETAIL IS BEST VIEWED IN FULL COLOR 4 O Oph s Olop O ' 'ail,f 3,Lq'Z � _�51 A W �P �Q� P`' 09 SCALE: 1 in = 20 ft 0 20 40 � V 0 1O 20 LOT V �34. �Fa'�Q'�y� AREA = 54494 sf +- `I �i AREA _V � BENCH MARK pp so. 0, s BENCH NI�UARK PAINT SPOT ON ��2a 18 CONCRETE PAD #' m ELEVATION = 108.66 vqn/� P4� BARNSTABLE GIS DATUM V F L O P R O F 0 L TOP OF FOUNDATION RAISE COVERS TO WITHIN ALL PIPE TO BE SCH. 40 PVC EL = 109.91 +— b in OF FINAL GRADE AND TO PITCH AT 1/8 In/ft MIN 108.0 3 ft ���S���G fn USE H-20 __ MAX H 20 105.50 RATED UNITS EXISTING 1500 GALLON PRECAST SEPTIC TANK EXISTING 6 in 104.63 DRYWELL + EXISTING SEE DETAIL ON BACK 104.80 STONE 104.50 ���� ABS®RPTO®N BASE SYSTEM —SEE DETAIL O EXISTING 6 in STONE BASE 29 ft o) 5 ft ON BACK u5 b) 12 ft 102.50 NO GROUNDWATER MOTTLING OBSERVED; 96.71 LOCUS tH OF�SS,f �� OF,pgssf N o DADVID CyG DADVID cyG� �Gp-TFcy SE AGSYSE DISPLOSAL AN 00 Q COUGHANOWR OUGHANOWR H -TO SERVE EXISTING DWELLING No. 1083 No. 461 h RACE RICHARD & VANESSA LANE 'PFGISTER�C gPPR0�0 v GUMBERT Q 2 NOT C S sOl[ EV Off' y` OWNER(S) OF RECORD TO Q /� �RON��l� 50 SHAMMAS LANE SCALE °Q 7�- MARSTONS MILLS. MA O 4 v rev S t t?1 20 ( -L 43 TRIANGLE CIRCLE PROPERTY ADDRESS MARSTONS MILLS. MA THIS PLAN IS INTENDED SOLELY FOR INSTALLATION OF THE SEPTIC SYSTEM SANDWICH MA 02563 AUGUST 17. 2013 C DEPICTED ON IT.FOR ANY OTHER CHANGES TO THE PROPERTY INCLUDING 508 364-0894 L O C MAP PLACEMENT OF ADDITIONS.SHEDS.FENCES OR SWIMMING POOLS.OWNER SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. FCC 112 _vs, ETE-3735 SOIL TEST LOG p DATE OF TEST: AUGUST 14. 2013 D C�S fO N C A L C U L A T M N S SOIL EVALUATOR: DAVID D. COUGHANOWR. LSE*461 DESIGN FLOW: 4 BEDROOMS X 110 GPD = 440 GPD WITNESSED BY: DONNA MIORANDI. HEALTH DEPT. SEPTIC TANK: 440 GPD X 2 DAYS = 880 GALLONS NO 1500 GALLON SETIC TAN IF IN TEST PIT 1 P RCGUND AT064 1nI— 2 MIN/NCHATERTNEC SOILS SOUNDUSEI NG STIR CTURAL CONDITION.IF NOTKINSTALL NEW 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DISTRIBUTION BOX: USE 3 OUTLET H-20 D-BOX. FEn ONCHES) H0FlZ NJ TEXTURE (MUNSELD MOTIM 10821 SOIL ABSORBTION SYSTEM: INSTALL A 33.5 ft x 12.5 ft x 2 ft 0-8 FILL LEACHING GALLERY AS DEPICTED BELOW 8-12 A SANDY LOAM 10 YR 4/3 NONE FRIABLE Abot = (33.5 x 12.5 ) = 418.75 sf Asdw = ( 33.5 + 33.5 + 12.5 + 12.5 ) x 2 = 184.0 sf 12-38 B LOAMY SAND 1E YR 5/6 NONE FRIABLE Atot = 602.75 sf 105.04 Vt 0.74 x 602.75 = 446.03 GPD 38-138 C MEDIUM SAND 10 YR 5/4 NONE LOOSE 9671 INSTALL A 32.5 ft x 12.5 ft x 2 ft GALLERY AS CONFIGURED NO GROUNDWATER ENCOUNTERED BELOW - Vt = 446.03 GPD > 330 GPD REQUIRED TEST PIT 2 2 MIN/INCH IN C SOILS ELEVATION DISTRIBUTION LOX DBE3 HO-20Y DEPTH SOIL USDA SOIL SOIL CCN_CN1 SOIL OTHER DIMENSIONS PIPES EXITING D-BOX TO RUN LEVEL FEET) (INCHES) HOFIQON TEXTURE (MUNSELL) MOTHM AND DETAIL FOR 2 FEET BEFORE PITCHING DOWN 0-5 FILL 5-10 A LOAMY SAND 10 YR 3/2 NONE FRIABLE ID-36 B LOAMY SAND 10 YR 5/6 NONE FRIABLE S14��NO LETO 12 In 8. 104.95 36-120 C MEDIUM SAND 10 YR 5/4 NONE LOOSE MIN 8 97.95 c FROM � - = � TANK w I SO O N L. AS \ l0 6 In STONE BASE 21 to 2 CROSS SECTION VIEW 1500 GALLON SEPTIC TANK SOILS ABSORPTION DIMENSIONS AND DETAIL S YS T EM CONSTRUCTION DETAIL USE EXISTING 1500 GALLON TANK USE SHOREY PRECAST 500 GALLON LEACHING DRYWELL NOT TAI in PER TO DUNIT 33.5 ft SCALE C� ��. M r 5 f t— Lo L14 0 8 in . 0 � w _ m - - STONE 0 4 ft 8.5 ft 8.5 ft 8.5 ft 4 ft i 10 ft_ 5 �� 500 GALLON DRYWELL 6 in [DIMENSIONS & DETAIL INSTALL ONE INSPECTION ^ RISER TO WITHIN THREE INLET CENTER OUTLET INCHES INDICATE F FI LOCH IONS COVER COVER COVER ON AS-BUILT 0,3 IN DROP 36 -♦ I� FLOW LINE oo* c in BUILDING 10 In 14 TO ���-] o,pao i USE In D-BOX oo�000i �� RATED 48 in UNITS LIQUID GAS 6 LEVEL BAFFLE 102 in INSTALLER MAY SUBSTITUTE AN APPROVED GEOTEXT/LE FABRIC IN PLACE OF THE 2 in. PEASTONE LAYER SPECIFIED. 6 in STONE BASE CROSS SECTION VIEW 2 In PEASTONE Ar 2 In PE45TOAE I SEPARATION BETWEEN INLET AND 7EFJFEl"OUTLET TEES NO LESS THAN 28 14 in To V 314 In T [26 LIOUID DEPTH In 1-b2 In GRAVE i/2 in GRAVE n CROSS SECTION VIEW 46 in 58 In 46 in 150 in NOTES 1) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. SEWAGE DISPOSAL SYSTEM PLAN 2) ALL M SSAACHUSET SS TITLED5SSEPTIC MCODE F(310 ICMRUIb)REOUIREMENTS PAGE 2 OF 2 3) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM. RICHARD & VANESSA GUMBERT 4) EC IXTURESE&NVIARO IANCESNMENTALAND BIANNUAL COMMENDS PUMP NGAION OF OF SEPTIC LOW ANK.OW 50 SHAMMAS LANE 5) SEPTIC DO NOTNK MAY NOT DESIGNED TO PARK'OR DRIVE VEHICLES OVERHSTAND SEPTIC TANK. LOADING. MARSTONS MILLS. MA 6) SEPTIC TANKS TO BE INSTALLED- 'LEVEL AND TRUE TO GRADE ON A LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED & ON TO WHICH SIX AUGUST 17. 2013 1 ETE-3735 INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING. 8/17/2020 ShowAsbuilt(2200x1700) JU �h�iI1A7�r,5 TOWN OF B/ARNSTABLE LOCATION, ,�jA QI SI�A/YaYi�S /N SEWAGE 41 VILLAGE /�'1, f//1 II S ASSESSOR'S MAP&PARCEL — — INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /SGD LEACHING FACILITY:(type) 3—5?,0 0143!J/h(e�ij) NO.OF BEDROOMS �/ OWNER 4LU PERMIT DATE: 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 an Hands exist within 300 feet of teat ity) Feet FURNISHED 3i5Y J n v\1I �11 Q 3 7 https:Hitsq Idb.town.barnstable.ma.us:8431 i Home/ShowAsbui It?mp=065004008&sq=2 Town of Barnstable yoFIME l � Regulatory Services Richard V. Scali, Interim Director 7ARNSTABLE, > Public Health Division C+p i63q• �`� Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Diesi2ner Certification Form t ssessor's 1Ma \Parcel Date: �Iu� U, � 3 Sewage Permit# P / 3 Designer: 7OLu,t� covor oAHdwr Installer: 'Qgi X (-,q Xle-1, Address; -Th G( (P �'�r Address: �( �=�'!© �"C C Su 4 W� c� A A O25On G3 Zia was issued a permit to install a (date) (installer) ,!11 septic system at �V '"5 �h based on a design drawn by • (address) �(4 �u A 0 w i( dated (designer) 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. Strip out (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. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructe 1'ance with the terms of the IAA approval letters (if applicable) ESN of Mgssq DAVID cyGN o D. COUGHANOWIR N staller's Signature) No. 1093 STER�� Ztae,ipe14, ip)atu_,,) NlTARIPNAffix Designer's Stamp Here)( , PLEASE RETURN TO BARNSTABLE PUBLIC HEM BOTH SIRS . CERTIFICA TE IA OF COMTLNCE WILL NOT BE ISSUED UN ALTH DIVISION. BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HE THANK YOU. ' 'QASeptic\Designer Certification Form Rev 8-14-13.doc Town of Barnstable P# ' r+� Department of Regulatory Services 17 Public Health Division ts►rwarewu ' Date mass Y: a639 �9i 200 Main Street,Hyannis;6 02601t1 �rED y►p'l A � t�n ^' Date Scheduled— . _v Time . . Fee.Fd. .o ' 1 Soil u ° ability Assessmentfor ,S Pw e .Dzsp C Performed B �-/4� 4 ��� d Y: �� { GIN Witnessed By LOCATION& GENERAL INFORMATION Location Address �+� Owner's Name R4 1D 4 AkSSA m4l?_,S%O� 1q) [mil AddressIOGtSs=� CsL(�►'l 'j ,rye,``__' _ M� sp� )nA D�Assessor's Map/Parcel: E W ®o —()� Engineer's Name b9 NEW CONSTRUCTION REP AIIt t Telephonv# P �t e Land Use Slopes(96) : t d r 'Surface Stones iyd iyo A ' p V Distances from:< Open Water Body l o o 4t P.ossilile.WeLArea.+ [D� ft Drinking Water Well (.�6�- ft. .� ^ Drainage Way 50 + ft Property Line `J g Y p Y ��� ft Other ft �1J SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands f.n proximity to holes) ZE C_ LA vE10 Parent material(geologic) 1 A (q' V+w-1 S Depth to Bedrock n e Depth to Groundwater. Standing Water in Hole: he_ (� Weeping from Pit Face h 0 he Estimated Seasonal High Groundwater 4-0 { �+ T�0� s v r f 4ce DETERMINATION FOR SEASONAL IIIGH WATER TABLE Method Used: (461411 n6 nlhg O %3 g Depth Observed standing in obs.hole: "� In. Depth to soil mottles: In. t a Tp" Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level. Adj.factor..,-,m,a Adj.Groundwater Uvel PERCOLATION TEST bate% is 1t3 xim0 �d 4 M Observation / Hole# Q. Time at h" N` A Depth of Pere 6 ` r1 y Time at 6" l� Start Pre-soak Time @ O -G0 Time(9"-6") N/A End Pre-soak d 100 f 2m p P, Rate Min./luch Site Suitability Assessment: Site Passed Site Failed: 1y 0 Additional Testing Needed(Y/N) 0 Original:'Pub►ic 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. •1, Barnstable Conservation Division at least one(1)week prior to beginning. �5: Q:\sEPrlCU'ERCFORM.DOC DEEP OBSERVATION DOLE LOG Hole# I Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA);- (Munsell) Mottling (Stnticture,Stones,Boulders. onsistency,%Graven 56 12 A S�uOY LdAM! to-�R ¢�3 l3o�►e F60161e LoPKY SMir, to �{.t�s/6 Fri able. 3$'-138 C_ MED ' SAU>) 10 �P— s/4 Loose DEEP OBSERVATION HOLE LOG Hole# 2 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsisten %Gravel) aLaAt'%� SwuD lo4z 1/7 None Frigble ►0 3� �3 joAM SBUD 10 5A Fristble 36- L zo C M ED S ANA (0 K SA t, Loo s e DEEP OBSERVATION DOLE LOG Mole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%Gravel) DEEP OBSERVATION DOLE LOG .S Bole# Depth from Soil Horizon Soil,Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency, �r. Flood Insurance Rate Map: _ Above 500 year floodboundary No— Yes ._ Within 500 year boundary No Yes Within 100 year flood boundary No;V Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for..the soil absorption system? e S If not,what is the depth of naturally occurring pervious material?_._._--- Certification I certify that on NOV r 1915 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent t the requir training,expertise and experience described in 3 10 CMR 15.017. � t�oF,ttgss Signature �- LSF Date u `� , ZD� ��°`� DAVID o D. � " COUGHANOWR 0 Q:W EPT10PERCPORM.DOC E VA L V P� TOWN OF BARNSTABLE LOC " .ON �3'T" �� ZAJ SEWAGE # �O0 VILLAGE/9h -AXS &/GG-5 ASSESSOR'S MAP Si LOT INSTALLER'S NAME & PHONE NO. 900 ��'y�'� %AF— SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 40a Pi7—,S (size) '2- /C NO. OF BEDROOMS- 'y PRIVATE WELL OR IC WATER BUILDER OR OWNER 1-0­ , A..JMOE J` C''&y f DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No CID 37' F f 2 -LSD 6L No... � Fss..����..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i .►nl_n�.................OF... A 2 ..(..�.�LX....---.....-----........------------ , ppliration for Uispoii al Works Tontrnrtion Vamit Application is hereby made for a Permit to Construct (1/5'or Repair ( ) an Individual Sewage Disposal System at: ...�.of..�!_.M.A.S....ghY.-.........�A. 'oNs..... .+...�.� -'.. 7 ................ - Location-Address, or ..:l �1TnP3 �wner . Address i&�Wc,-7 - !Y.. ! Rl � ..............•. Installer Address ,�yd UType of Building Size Lot..._Jr..4).�711....Sq. feet ., Dwelling—No. of Bedrooms._14"No. .................Expansion Attic ( ) Garbage Grinder p, Other—Type of Building __... of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures __________________________________ W Design Flow..................%5.7 .............._.gallons per person per day. Total d�il flow_........___. ..............__.._gal�ons`� W Septic Tank—Liquid capacitylXlO�allons Length./.Q..�... Width. .. ..... Diameter................ llepth__ .. .. Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area---4,7.Q3.°_Z-sq. ft. 0 Seepage Pit No--------- Diameter._... ..... Depth below inlet_......`.a._......... Total leaching area... -.0jc�nz ft. Z Other Distribution box Dosing tank aPercolation Test Results Performed by.-.__.?_..�v.�'l.!J1.j................... Date_. -.c ./p__�g8 Test Pit No. 1....._. _._minutes per inch Depth of Test Pit..,- .______ Depth to ground water.___.___.-'.._...____. Lf Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --- . ............................................---•••--••-•--------•..........................-•---„........................................ Description of Soil . `� o Lo P\t."'- ................a6--- « -- . 61.....5�4�._.. U ------------------------------ ------------------------------------------------------- ----------------------------------- •-------------------------------------------------------- --------- --W ---- ----------- -------- -------------•---•--••-------•----------•••-------------••-•--•-•-•••---------••••-••-----•-------------------------------••--•••-----•-•••--••--•-•-•-----•-••---------- UNature of Repairs or Alterations—Answer when applicable............................................................................................... -•------•-•--------------•----------------•----•----------•------------------------•---•---------...--------------------------------------------------•-----------------------------•--..........----•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT s.;"• 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i sued by the ar of h 7 Si ned � -- ­Amj/ �� Datt Application Approved By•-•-••---•---•----••-••••. - --------------------- ..........•--•• --•--�* s-�- ----- Date Application Disapproved for the following reasons:-------•----------------------------------------------------------------------------------------••------------•- Date Permit No.......... I o- Issued-----.....� G-� ---••-•--•--...... ate b. Jam/ 7��� �. ✓ Sufic:" ! a� Z. SCALE . . ,/. -, �. . . DATE ", ��,87 G��7j✓G LoT '�`/' PLAN REFERENCE . . .. ..... . . . . . . . ..T. . IV Ii \ '0 0,' by v v 2 1 � 1 JW Lo7- / -J' o� L6 PEA loll kA -A OF s p!' ELLEY No. 26100 ��= �'/ � 5� on 'L ✓ } TOP OF FOUNDATION CONCRETE COVER ° CONCRETE COVERS • �rmr 7n�r i "0 4"CAST IRON 12"MAX. 12"MAX. ' OR SCHEDULE 40 e P.V.C. PIPE 4��SCHEDULE 40 PV.C.(ONLY) PIPE - MIN. LEACH ' PITCH 1/4"PER.FT. PITCH 1/4"PER.FT. PIT PRECAST LEACHING o A INVERT o d`, PIT OR o EL„!�?•6/„ INVERT INVERT SEPTIC TANK i,s DIST. o �► j= '• EQUIV. BOX ' . ,.o INVERT /.4�,� GAL INVERT - INVERT o w w 0 '• 3/4°TO I I/2' ELXEL e'.' �. WASHED w STONE DIA--A ��vco.vrtxsv PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE �Z'�'/ SOIL LOG WITNESSED BY : DATED� 3� � 4. TIME. . . .. . . . . . . s BOARD OF HEALTH .. . . : .� .5... TEST HOLE I TEST HOLE 2 J/-h�! T-9�of3! . . . . . ENGINEER ELEV. .!0¢: T?. . ELEV. .. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . Tr d DESIGN DATA : 3c L2 101,4, NUMBER OF BEDROOMS TOTAL ESTIMATED FLOW GALLONS/DAY BOTTOM LEACHING AREA . SO.FT. /PIT/C,D SIDE LEACHING AREA . . .'/ A SQ.FT./ PIT/47/ C,PZI, GARBAGE DISPOSAL -1V0A14.(50% AREA INCREASE) TOTAL LEACHING AREA . 40 3., Z. SQ.FT i44'' �Z,yt SLR PERCOLATION RATE LW. 77Y90�7W9. MIN/INCH — — LEACHING AREA PER PERCOLATION RATE �3 . SQ.FT-A op ./V .WATER ENCOUNTERED NUMBER OF LEACHING PITS Two-. / /7' .1N��� APPROVED BOARD OF HEALTH DATE . . . . . . . . AGENT OR INSPECTOROF — -- �T �7 ED+^ LEY Syiq i yiy�s L/-�1✓�. "' 0. 26100 o l 7ST £ Llit���J� PETITIONER No..9�Q.o F.Es� 7 :e.J......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH P /J............OF......................./L1V 'T7_(��f................. Applira#iou for Diiipoii al Works Tomitrnrtiun runfit Application is hereby made for a Permit to Construct ( (er or Repair ( ) an Individual Sewage Disposal System at: Location-Addressl �•� o Lot Owner ,�. Address • n- llLSH PEt ,Wa ...... ... Q f..._._.G k.�1= ---------`-------------•--•----.......--•--..................... � Installer Address Q Type of Building Size Lot___�'�-%.- `f•--------Sq. feet Dwelling—No. of Bedrooms____..._.4`..............................Expansion Attic ( ) Garbage Grinder (,y, aOther—Type of Building ............7�..__..... No. of persons............................ Showers ( ) —'Cafeteria ( ) Otherfixtures -----•----•---------------•---------------------------.-•--•••••-•-••-••------•-••-••----•......••-•••-••-•------•---••-•----•...........--------•--•• W Design Flow............. 5............_..._...•..gallons per person per day. Total daily flow._._.........`. ......gallons. G: Septic Tank—Liquid*capacity�'a�..gallons Length./ '� Width_`� .....~.. Diameter. .....�r_. Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area__(od1_3�....sq. ft. Seepage Pit No...... Diameter.... ------- Depth below inlet......5.`........ Total leaching area_ ?3L? ...sq. ft. Z Other Distribution box ( ) Dosing tank ) `" Percolation Test Results Performed by____________________ C.�?.l�t...__..._..__....._._.._......_.. Date........................................ ,aa Test Pit No. 1.� ____...minutes per inch Depth of Test Pit-__�`f 5/...�... Depth to ground water...l�� -------- Test (% Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------------------------------- ---------------------- -........ -•-•••------- -•------- ----------- ..................... --.----------- .---------- >. D Description of Soil ®'��_.....-• 't 75 PSD!Z,. x ........................................... �' . •-•----------��: ,�a7"a• W •••••-••-•------------------------•-----•--•--••-•------------••-•-••••--••••--.........--••-•.--••----••-•----------------------••----------•--••••----•-•------••-----•----•-•-•-•--•-•-------•-••-•- UNature of Repairs or Alterations—Answer when applicable............................................................................................... --•----------------------------------------------•-•----•--•------------------------.....................---....-------------------------------------------------------------------•-•-•-•----......•-•• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance-with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place t /e5 stem in operation until a Certificate of Compliance has been i ,ed by the b and Signed-------- .. ...................... ................................•----- ..---•-•- ApplicationApproved By.................... -•-....---• ...................................•-------- = -�//�— � 1/Za Application Disapproved for the following reasons-----------------------------------•-------------------...---•-------------•--•---------......a•.------........-- ••-•-•--•--------------••••••----•...--•--•----------••-------•-••------••••-•--•••-------------•••......-----•-------•-••••-••-•••-----•-•-----••-•----------•-•••--•-•--...............---••-••------- Date Permit No....... _`..�c7.�.................. Issued....._- ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................O F..................................................................................... C-5rdif ira r of Tnntpliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Installer at.......•--------•----••-•-•••-•-•••••••--•--------------•--------••-----------------•••---• --•-----•--�l�-A;f/5----------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._ ---- _-'____- ---- - ---------- da.ted_ -�` s'25-----------------•------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A G AR NTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................ ...................... Inspector....-----............. .......)0........................................... THE COMMONWEALTH OF MASSACHUSETTS I BOARD OF HEALTH .............OF..................................................................................... No.... —too FEE.......... �J .... Raponttl nrkn �nnn rttr#i�an rrnti# Permission is hereby granted-----•---� -. t-T " � �s= i------•-•-----------------------•-•-•-••---------------------------..----- to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No........ rr Lt>`�---.r..�.....,� .3.-� ka-� {?l+•f'l`"{i -•Street-----••-•-•---•-•-••-•-•-•--••......................•----•-•--...--------....... as shown on the application for Disposal Works ConstruggtdigjL Permit No.5� :7.1_oLnL Dated-•_.'j,j.q/k--_--._.-.----- .-•-•-----•---------------------------------------••---------........---•--• - �:.-1 - //o Board of Health DATE.. .....-•----------•......••--•------------------------------•------...... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS