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0105 STARLIGHT DRIVE - Health
105 Starlight Road Marstons Mills — A= 100-034 TOWN OF BARNSTABLE LOCATION /p,� Sdz�/ir,�t d7l SEWAGE VILLAGE ASSESSOR'S MAP&PARCEL Z�:I ,-( INSTALLER'S NAME&PHONE NO. �D q 260, SEPTIC TANK CAPACITYjCi LEACHING FACILITY:(type) ("size) NO.OF BEDROOMS . OWNER PERMIT DATE: / Z_ COMPLIANCE DATE: C 2 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) _Feet FURNISHED BY _�� ��/i✓Y✓ 45 3 P�c1G 13 a C,G -3 7.0 No. Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:_L PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for Disposal OpBtem ConstrULtion permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No./ y f-a,/j4y - idr Owner's Name,Address,and Tel.No. AA, As's/e sor�s ap/Parce 1� Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms _�F Lot Size sq.ft. Garbage Grinder(. ) Other Type of Building //l�•,lif j� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3y gpd Design flow provided 31/f gpd Plan Date Number of sheets 1 Revision Date Title Size of Septic Tank r t/.9 C Type of S.A.S. :2 S00!q¢1jO✓t' `acb e:ho -n Description of Soil Nature of Repairs or Alterations(Answer when applicable) tn15 kdj e— .tJC:J box PvV ,q— So 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 Certificate of Compliance has been issued by this Board.of Health. Si Date Application Approved by Date �. Application Disapproved by '" - Date for the following reasons Permit No. :>,� —0 Date Issued a No. V o� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS YesAU application for Misposat *Pstem Construction Permit ApNZ plication for a Permit to Construct( ) Repair(+'Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components r, 3r jotion Address or)yot No.fps t{�✓�'Skut' Owner's Name,Address,and Tel.No. 1/ssor's Map/Parcel �aller's Name,Address,and Tel.No. Designer's Name,Address,and Tel:No.Q �j 1pvU�S/x �j'`f�^'�(�"�l�� �Jl!/,/�Q'•S`©*✓ Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building /��'r,/�ra-J�)� / No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 34* gpd Plan Date 2 -2,11-2 7.- Number of sheets / Revision Date Title / Size of Septic Tank ry .9 ,v C Type of S.A.S. z-$00ig4J/BN 1 FG4 1-4r Fyn' Description of Soil Nature of Repairi or Alterations(Answer when applicable) n 5�G G A/C"uf t/- 0j r-�tJ(� ;2• Soo G�A�nn) l.c-a,(k r s;. f)OO/ n1O,) 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 Certificate of Compliance has been issued by this Board of Health. SigneB lr .~ .-.- Date - ,�-`"` _ Application Approved by -�''-�-k---�,._. Date Application Disapproved by Date for the following reasons Permit No. ng;ic " '""-C " Date Issued ] --------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that�the On-site Sewage Disposal system Constructed( ) Repaired( ►•-y' Upgraded( ) Abandoned( )by �r at I D �i�<,i/i +fit Jl!� /Ur,��}�,,,tS ,/�e(t [ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No,, ' e dated / - Installer , 1 ,/,/'l ?�Io jx) Nc- Designer ,a n j,J AA n.rw #bedrooms Approved design,flow "� r gpd The issuance of this p{ermi/t shall not be construed as a guarantee that the system will ff unnccttiion as desig'ed. Date ��N J i h Inspector, I./ ��J � _Q � - ---- ------- ----- - - -- -- -- --- --- - - - No. � t_ �3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Disposal 6pstem onstruction Permit Permission is hereby granted to Construct`( ) Repair((,/d� Upgrade( ) Abandon( } System located at (�. 7-)ci! ,1C h 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 permit. Date Approved by t '1 Town-of Barnstable Regulatory,Services Thomas IF.Geller,Director Public Health Division ti a6s¢ Thomas-McKean,Director 200 Mato Street, Hyannis,MA 02601 o Off1ce: 50&8624644 Fax; 508-790-6304. Date:s/ � Sewage Permit# Assessor's MapTP reel /GD Installer&Designer Certification Form Designer: C>alf is, r},` Installer: INC Address: W�/ Address: t _ .�}�N/�G was issued a permit to install a ms er). septic system at /p S 2 �44/-DrA,M based on a.design drawn by ( dress) j.. • N!�► + .sated 272 Jfli certify that the septic system referenced above was installed substantially,according to the"design,which may include minor,approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout(if required) was-inspected Iand 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 V? -14tions. plan revision or certified as-built by.dpsigner to follow. Stripout(if rP xted and the soils were found satisfactory. ZN OF M,qs DAVID Installer's Signs ),- tore i t 4 TOWN OF BARNSTABLE LOCATION -- 5—sickI'<`c�Lq��t'l(Je- SEWAGE # YILLAGE,�' '�z� 1"�` U ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Coo 6 a., LEACHING FACILITY: (type) y c (size) NO. OF BEDROOMS BUILDER OR OWNER PERMTTDATE: ! COMPLIANCE DATE Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells`exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ` e v 4 � !1/t � �r � ,� �� � � ��. � ��� TOWN OF BARNSTABLE � �/ •o3g LOCATION/ 0 hi; ��. SEWAGE# VILLAGE,&,Ak d ASSESSOR'S MAP&PARCEL L00 , D 3� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /0-0-0 LEACHING FACILITY:(type) 42 XGe (size) /000 NO.OF BEDROOMS 3 OWNER PERMIT DATE: .;2// /�f COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY x 1 eA-A, o F doS ef 3 s-q .c 100013 Commonwealth of Massachusetts / Title 6 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments .* 105 Starlight Drive Property Address ,Cheryl Sundelin Owner Owner's Name iequiredifo is Marstons Mills, Ma. 02648 2/15/2011 required for , every page. Cityrrown state Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your. Raymond Dumas cursor-do not Name of Inspector use the return key. Dumas Landscape Const. Inc. Company Name -- T � 564 Old Stage Rd. Company Address Centerville, Ma. 02632 �O City/Town State Zip Code 508-778-0249 S 1437 Telephone Number License Number B. Certification I certify that i have personally inspected the sewage disposal system at this address and that the �" u information reported below is true, accurate and complete as of the time of the inspection.The inspection was pel'formed based on my training and experience in the proper function and maintenance of on site c= sewago disposal systems. I am a DEP approved system inspector pursuant to Section 15,340 of Title SJ310 CMR 15.OQO).The system: �.T C,i C J Of£Passes 0 Conditionally Passes Fails > 0 Need§Further Evaluation by the Local Approving Authority r 2/18/2011 In, o s i ature Date F` v� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority.. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.this inspection does not address flow the system will perform in the future under the same or different conditions of use. a t5ins-09M Title 5 Official Inspectioh Form:Subsurface Sewage Dlspo I System•P ge 1 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r` 105 Starlight Drive Property Address Cheryl Sundelin Owner Owner's dame information is required for Marstons Mills, Ma. 02648 , 2/15/2011 every page. City own state Zip Gode Date of Inspedion S. Gertificafipn (coot.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon 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, N©)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 ❑ NO(Explain below): t5ins•09/08 Tile 5 Official inspection Form:subsurface Sewage Disposal System•Pagel 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 Starlight-Drive Property Address Cheryl Sundelin Owner Owner's Name information is Mar tons Mills, Ma. 02648 2/15/2011 required for � every page. Cityrrown State Tip Code pate of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): [� Observation of sewage backup or breakout 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): E] obstruction is removed ❑ Y ❑ N L3 ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): �] broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: 0 Cronditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, Safety or the environment. 1. System will pass unless Board of Health determines in accordance With 310 CMR 16,303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water . ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Oisposgl System-Page 3 of 17 tiS Commonwealth of Massachusetts W.0000 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 Starlight Drive Property Address Cheryl Sundelin Owner Owner's Name information is required for Marstons Mills, Ma. 02648 2/15/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (Cdnt.) 2. System will fall unless the Board of Health(and Public Water Supplier,if any) determines that the system its functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. [] The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 5Q feet or mote 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other-failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all Inspections: Yes No Q ® 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 ❑ ® 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 %day flow t5ins.09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 r, 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 Starlight Drive Property Address Cheryl Sundetin Owner Owner's Name information is required for MarStons Mills, Ma. 02648 2/15/2011 every page. City/Town State Zip Code Date of Inspection B.. Certification (cont.) Yes Na ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: . �] Any portion of the SAS,cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. (] ® Any portion of a cesspool or privy is within a Zone 1 of a public well. [,] ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.- ❑ ED 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 it the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and.the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd 10,000gpd_' ® 'thesysterni fails.I have determined that one or more of the above failure Criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a, design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the System is within 200 feet of a tributary to a surface drinking water supply ❑ 1—I 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 If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the lar9e 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 16.304.The system owner should contact the appropriate regional office of the Department. t5ins•OWS Title 5 Official tnspection PQrm:Subsurface Sewage Disposal System,Page 5 of 17 • e! Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 Starlight Drive Property Address Cheryl Sundelin Owner Owner's Name information is required for Marstons Mills, Ma. 02648 2/15/2011 every page. cityrrown State Zip Code Date of Inspection �. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® [� Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ 0 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) ® Q Was the facility or dwelling inspected for sins of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components,excluding the SAS, located on site? ® Q Were the septic tank manholes uncovered, opened,and the interiorof 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? ® El 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. Forexample, a plan at the Board of Health. ® El approximation in the field(if any of the failure criteria related to,Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Inf6rma'tion Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 examle. . DESIGN flow based on 310 AMR 15.203( P for 110 9Pd x#of bedrooms): 330 t5ins-09/08 Title 5 Official lnspeCeon Form:Subsurface Sewage Disoosal System•Page 6 of 17 r Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 Starlight Drive Property Address Cheryl Sundelin Owner Owner's Name information is required for Marstons Mills, Ma. 02648 2/15/2011 every page. Cityrrown _ State Zip Code Date of Inspection D. System Information Description: ' As built plan on recored was wrong. Located Septic Tank and precast 1000 gallon leach pit with 1 ft. of stone around pit 1 ft of water in pit with no evidence of any hydraulic failure however septic tank rear concrete baffle was bad.Obtained permit to install sanitary tee at outlet and replace old Orangeberg pipe from septic tank to leach pit.Also installed 2 risers on septic tank and 1 riser on leach pit --- Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes 0 No Water meter readings,if available(last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No Oct. 2010 Last date of occupancy: Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 810 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No . Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if available: 2009/47000 gallons 2010/46000 gallons tins•09/08 Tits 5 OffbW MspectiomForn Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 Starlight brive Property Address Cheryl Sundelin Owner Owner's Name information is required for Marstons Mills, Ma. 0264$ 2/15/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Oct.2010 Date Other(describe below): General Information Pumping Records: Source of information: Jan 2011 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System. ED 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 13 Tight tank.Attach a copy of the DEP approval, ❑ Other(describe): No D-Box t5ins•09108 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 Starlight Drive Property Address Cheryl Sundelin Owner Owner's Name information is Marstons Mills, Ma. 02648 2/15/2011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and Source of information: House Built 1973 Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: 4' feet Material of construction: cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: 28 ft across basement feet Comments(on condition of joints, venting, evidence of leakage,etc.): all good Septic Tank(locate on site plan): Depth below grade: ' covers 12"below grade feet Material of construction: ®concrete [] metal ❑fiberglass ❑ polyethylene ❑other(explain-) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: none pumped in Jan. 2010 t5ins•09M Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 • Commonwealth of Massachusexts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 Starlight Drive Property Address Cheryl Sundelin Owner Owner's!dame information o is Marstons Mills, Ma. 02648 2/15/2011 required for every page.. Cityfrown State Zip Code pate of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle none Scum thickness none .Distance from top of scum to top of outlet tee or baffle none Distance from bottom of scum to bottom of outlet tee or baffle none How were dimensions determined? visual Comments(on pumping recommendations, inlet and outlet tee of baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): all good Grease Wrap(locate on site,plan): Depth below grade; feet Material of construction: ❑concrete []metal [l fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 105 Starlight Drive Property Address Cheryl Sundelin Owner Owners Name information is required for Marstons.Mills, Ma. 02648 2/15/2011 every page. CityRown State Zip Code Date of Inspection D. System information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank should be pumped every 2-3 yrs. Tight of Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Matorial of construction: ❑ concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ] No t5ins•09M Title 5 Official hspecSornForm:Subsurface Sewage Disposal System+Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments lug 105 Starlight Drive Property Address Cheryl Sundelin Owner pwne ft Name information is Marstons Mills, Ma. 02648 2/15/2011 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cant.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert no d box 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order. ❑ Yes Q No Comments(note condition of pump chamber,condition of.pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan,excavation not requited): If SAS not located, explain why: t5ins-09/06 Title 5 Pfricial Inspection form:Subsurface SeWage Disposal System•Page 12 of 17 v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 Starlight Drive Property address Ch"I Sundelin Owner Owner's Name information is regpired for Marstons Mills, Ma. 02648 2/15/2011 every page. CityPrown State Zip Code Date of Inspection 1). System Information(coat.) Type: leaching pits number: 1 ❑ leaching chambers number: n leeching gallgries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innoyative/alternative system Typetname of technology: Precast Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): all good 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 t5itts•09l08 Title 5 Official Ittspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 Starlight Drive Property Address Cheryl Sundelin Owner Owner's Name ro 'IS for Marstons Mills, Via. 02648 2/15/2011 every page. City(rown State Zip Code Date of Inspection D. System Information (coat.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): all good Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,Signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 Starlight Drive Property Address Cheryl Sundelin Owner Owner's Name information is required for Ma tons Mills, Ma. 02648 2/15/2011 every page. CityrroWn State Zip Code Date of Inspection D. System Information (cant.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand,sketch in the area below drawing attached separately t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 4 Commonwealth of.Massachusetts Title S. Official Inspection Form gbsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 Starlight Drive Property Address Cheryl Sundelin Owner Owner's Name information is required for Marstons Mills, Ma. 02648 2/15/2011 every page. Citylrow State Zip Code bate of Inspection D. System Information (cons.) Site 1=xam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: Approx 26'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: pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain; used topo map and ground water contour map Checked with local excavators, installers-(attach, documentation) ❑ Accessed I)SGS database-explain: You must describe how you established the high ground water elevation: Elevation(topo)70'-35'ground water mapT36-9'adjustment SDW252 Well=26'to ground wafer Bottom of leach pit 10'deep=16'of separation. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•09= Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 v . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 Starlight Drive Property Address Cheryl Sundelin Owner Owners Name information is required for Marstons Mills, Ma. , 02648 2/15/2011 every page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary:A, B,C, D,or E checked- E Inspection Summary D(System Failure Criteria Applicable to All Systems)completed E System information—rEstimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Forth:Subsurfa6a Sewage Disposal System•Page 17 of 17 • Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 105 Starlight Drive Property Address Cheryl Sundelin Owner Owner's Name information is required for Marstons Mills, Ma. 02648 2/15/2011 every page. cKyrrown state Zip Code. [late of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate where public water supply enters the building.Check one of the boxes below: hand-sketch in the area below drawing attached separately ��Tc�►3N rJ+4't'2 r f r Sy , �{ i t5ins 09M Tits 5 offidal loon Form:Subsurface Sewage Disposal System•Page 16 of 17 -..: --- ---- -- ----- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Lertifitate of compliance THIS IS TO CERTIFY,that the(0 -site Sewage Disposal system Constructed( ) Repaired d,�' Upgraded( ) Abandoned( )by - at fi% 01 h� n c `tr c eId in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ' a t Q 30 dated ;2 Installer rt�,Vli Designer - #bedrooms 7 Approved design flow gPd The issuance of is p rmit shall not be construed as a guarantee that the system wi ctio designed (` Date Inspector ` lop tIVEO COMMONWEALTH OF MASSACHUSETTS JUN 2 1 ?040 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIyRs °tft jaw DEPARTMENT OF F.A VMONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292-6500 '17RU D Y'COXE flocoeenry AAGEO PAUL CELLUCCI Gcwerno! l;G'.ViD ]1.si'PRUHS SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECT1ON FORM C%aauniasioaar PART A C�?11011! Fnipeo"AddAsa: I Qn,✓Se .S t-�i� �`� Nsotra see 0vrosr to )c� (,1Ad'S'�r.b �tl.�l5� �,� Ad**"ofOwoto. J Q.. DMM"of : .s/a 4/00 Notts of,teepees:fR.aea Print) i `l ta1a� , r.5 s- O l 1 aftt a DEr a Inspector pesrauant 153 Of Thb 6 4310 CUR I LOGO) Cwspetey MINOR: c Msng q0eC.�-W&.& el Adtftaea: 5 C►off 6 Cf Teigleoor Nene�w: I c*Mlfy the I have personally I napeea9 the sewage dsposd systsnn at this address and that the Information reported below its t; te, aeesmrta and oomplsts time as of the me of Fnspecdcn. The inapection was partormed based on my training and experience in the mahrttenance of on-aka sewage dspcaf systems. The system: propr►n fuan,ufon and Pass" - -_ Conditionally Posses Noeds Further fEvaluation By the Local Approving Authority _ Feb � �ts*esas►'e ` .i% �J�dG(Q.E. Doe: b The System Inspector shelf subrnh a co,y of tNs Inspection report to the Approving Authorhy ISoard of Health or DEPlwithirn tleIIr,,#1801�dairn of comisisting this inspection. N the systwi is a shared system or has a design flow of 10,000 gpd or peeN►,the Inspector atrtd tfi n eyitenn owner Mall submit the report to the approprieW regional office of the Department of IEnvtronme00 Protection. The original ctor a d i,s st tlm systrrm boner and copes seal to the be r/ar,If sppMr:abla, and the approving aurthority. MOTIFS AND COMMENTS rev:.fsedl 9/2/98 POW Of11 45 PrinMd on lk n i.4 n.,.., SUBSURFACE sIEWAGE DISPOM SYSTEM BIBPECTIOM FOItM PART A Maparty Address: il raSow L�Z Draea �f�(0 IMMECTON SUMMARY: CMok At, a C, dw o A. =YSTIMN PAS: 'Kc— I have not found any Inform Won which Indicates that any of the faiurs conditions described In 310 CMR 15.30:1 exit t Any failure criteria not evaluated e►s indicated below. Ct : B. SYBTW CONDI170MALLY PABt1IN: One or more system comporrlrnts p described In the"Conditional pesa" • on need to be replaced or r completion of the rspieoemewt or repair,as approved by dw Board of N .wiry s stared. 4he /slam, u1M�n Mdieete yes, no,or not delomdried(Y, N.or ND). Describe basis of ation In ate Instances. it"not dete►nNned",empolorn ii,rhy not. The septic tank Is metal,unless the owner or oiler hmi provided the system Inspector with a c CempSance(attached)Mdleatfnp that the tank instsMrd whin twenty �y a•i' C tNlk:at,r of the septic tank.whiMm or not ma1N,Ise (20)years prior to the data of the inspeell.orr or failure Is imminent, The s stem will ,structurally unsound, stows substantial Infiltration or es:ilh. soon, jar-tank y pass Pmdon if the sxiatina septic tank is replaced with a complying 411 ptic;teak as approved by the Board of Health. 3ew"e backup or break o►high stalls water level oblemed In the distribution box is des to broken er obu,n+etrsd sllrelsl or des to a broken, : m uneven distribution box. TMr system will peas Impaction if Iwfth approval oilIM Board'eP MeeMhi. itoken Itipe(s)are replaced bstruction Is►omroved lsMbution box Is kr*VW or replaced The s;re=K pu""more then four times a year due to broken or obstructed pipets). The syn:snn w,ry pass iprovsi of the Board of Health): kroken pipe(sl an replaced c bstructlon is removed ti• revised 9/2/98 2wa> i SUBSURFACE SEWAGE DISPOSAL sysTEM NsPscnow FORM PART A A011TIFICATqu Iessd muse Pr .WW A Owner V,,o Doonal, ep.etl57 C. FURTHER EVALUATION M REQIAIED BY THE BOARD OF HEALTH: Conditions exist width requinr furthar evaluation by the Board of H in order to datemdne If the system Is feiillig to !otm:t tlw, pubk iweld,safety and On rkwironlow. !I) SYSTEM WB.L PASS UNLESS'BOARD OF HEALTH N ACCORDANCE WITH 310 CUR 15.303(1)pii T RAT TW.Ij-rI1TMA M NOT RXACTW)NNO N A I1IMNI IEi1 WHICH WILL PR THE PUBLIC HEALTH AND SAFETY AND THE ENVIFII;IIilIII INT, Cesspool or privy is within 50 feet of surhe water _„_ Ceespoai or priW is within SO feet of a be ring vegetated wetland or a salt marsh. 21 SYST13A WILL FAIL UNLESS 1 BOARD OF HEALTH IAND PUBLIC WATER SUPPLAM,IF ANY)DETERMBNES,THAT'Til IE SVS1E14 IB F UN1CTWONNG N A THAT PROTIECT><THE PUKJC HEALT1f AND SAFETY AND THE E MMONM ff. The system has sollRic tank and soN absorption system ISOIS)and the SAS is wMdn 100 feet of a surfeM:e wIIter supphr or tributary to a ace water supply. The system ore o se4;1tic tank end solf obserprtion system and"SAS Is within a Zone l of a public watt,se�rpiiIy WON. TM sYa tees•smAlle tank and soil absorption• stem and th-- Y the SAS is w tehin SA feet o4 a vats r Pri water slupp:y wsN. TM cyst has a septic tank and soil absorption system and the SAS is less than 10o feat but S0 fast ai nlo:. from u pdvate abr supply"Nall, unless a WON water s for ooNform anoYei bacteria and volatile organic compounds kw. earls¢hat:the won is N from pok don from that facility end rife presence of ammonia nitrogen and nitrate n N It►ogan Is edusc to or ills than ppm. Method used to detsrmina distoncs (eppr�an not void). 31 OTHER k rev.lsed 9/2/98 PW3of11 SUfid VRFACE SEWAGE DISPOSAL SYSTEM WSPECTHM FORM PART A CM I11117C.ATtDIs Ieandraeodl 0vaser: Dams of s 5, D. SYSTEM FANS: You must"sat*altitar"Yes" or"No" to each of the following: I have determined that one or more of the following fanure concltions exist as desc ad In 310 CMR 16.303. The hasrri for thin determination is idornifkrd below. The Board of Hoslth should be contacted to de rmine what will be necessary to cot-ovt the failure. Yelt No Backup of sewage into focSty or system component due to an oaded or clogged SAS or cesspool. Discharge or pondir:p of affluent to the surface of the grou or surface waters due to an overloaded or oletgp id SAS or cesspool. Static Ifquld level In ifu distribution box above out vent due to an overloaded or clogged SAS or cos:spool Uquid depth In josspool is lose than 6" below or avidlable volume Is lose than 112 day flow. _ — Required pumping neon then 4 times in last year II due to clogged or obstructed p4misl. Number of times pumped Any poe do. of the t tii Absorptlo System, cesspool or privy is below the hi gh groundwater elevation. Any potion of a cee;:epool vy is within 100 feet of a surface water supply or tributary to a wrfse:a water !;uge�y. _ — Any portion of a ca: or privy Is within a zorw I of a public wen. Any portion of a ltpool or privy is within 50 feet of a private water supply wen. Any of a e:esnp W or privy Is lese-then 100 foot but greater Iran 50 foot from a private water sgpPllr e.,�with nu at" water qunnty analysis. If the well has been analyzed to be e,attsch copy of well wutrtr ai;taiyris.lot? cc m bacteria, vsiatne organic compounds,smmonla nkrogon ltrate nitrogen. E. LARGE SVSTM FAS.S: You 1teust indicate sitMr "Yes" or"No" to such of the faliovAV: The following critede apply to ;arge systems in addition to aribria above: The system serves a facility w Rlt a design flow of 1 00 gpd or greater Urge System!and the system Is a significant lvaet 0 pubie MaRlt and safety and tits anvi onntent bet" or man of tlta following conditions a:dst: Yes No the system is wllfeln t00 h •surface drinking velar soppy 'the system h withht t of•tributary to a turfaea drinking water wppy IM system b lol In a nitrogen swwhlw area 4lnterhn Wsgtead Protection Ares=MfPAI or a mapped ZO?Mt I of a glut lie water supply w The owner or operator of any h systs m shall upgrade the system In accordance with 310 CMIt 16.304(2). Please consult tPtio ocM rei,lio gal office of the Deprtmortt for r Irommadon. revised 9/2/98 l%V4 all tt OUSSURFACE SEWAGE ONWOM SYSTEM StISPECTNM FOAM PART S CIECUAT ?��►eoa: L 0,5, `tC Drl V"Q Ohsmw: .J +C,say0 l(', Dar,st& 1 tisee-� Check If the following have been done: You must Indlcew either"Yes"or"No"as to each of the following: X No Pumping k+formetlon was provided by the owner,occupant, or Board of Health. _ None of the system components hove been pumped for at least two weeks and the system has been recG10% mimsi 62w rates during that poHod. Lerge volumes of water have not been introduced Into the system recently or has apart of this; Inspection. _ As built plans have kinan obtained and examined. Nob if they We not evadable with NIA. _ The facility or dwoIRigq was inspected for signs of*swage backup. _ The system does nol:receive non-sanitary or indwtrial wests Now. The site was inspswtid for signs of breakout. AN system componsius,excluding the Soil Abeorpdon System,haw been located on the alb. _ The•optic tank manholes were uncovered,opened,and tM interior of the septic tank was Inspected for conch ion of befflee or to",material of a:mswuction,dimensions,depth of liquid.depth of sludge,depth of scum. The sire and location of the Soil Absorption System on*.a sib has been determined based on: _ Existing information. t-or example.Plan at S.O.H. — Determined Determined In the Nel d(if any of the failure eriterle related to Part C Is at issue,approximation of dkttanco is ur,!,cceptuoio) 11 g.so21a1(bl) The facility owner(arid occupants,if dlfforent from owner)were provided with information on the proper imdm:jamoe of SubSurhoe Disposal ilystams. rev :aed 9/2/98 ryrs,�tl SUBSURFACE SEWAGE D000SAL:YBTEM WSPECTION FORA! PART C SYSTEM 0~11AATIM Prapmty L d Data of Za / W /� COM Design Ilow:_,Q,M.p.d./bodroorn. Number of bedrooms(designl:� Number of bedrooms(ectuall:4 Tavel DEBION flo*= Number of aw►ont residents Garbage grhrdsr tiros or not: Laurufry(sopme"system} (yes or no):O, If yes, separate Inspection required Laundry system InspeoW jpa or no) seatronal use(yes or no): t� Water nrster rsadlrope,N Is p ag(last-two yew's use(gpd): Bump es Pump(y or reol.� Lent dew of occamtey: Typo of establishment: Dealgn flow: old (iesecl on 1fi.a Basis of design fbw Oressetrap present:(yes or no}_ kodustr(al Waste Meldkeg Tank present- Mort-Mgt ry waste dischemed to Tide 5 system:(yes or no)_ Water realer readings,If Last data of occupancy: —_ --— OTHM:IDescr(beI `.set date of ocou Y.— OEiifElltAL MOIIAEATION PUB#PBIG 1wr nand rca of Infer on: System�rmped as pat of Inqectlon:(yes or noj=Gol 11T—If yes. volume punned: _gWons Reason for pumping: TYM:OF BYSTEfM _ 1leptic tardt/dkttAbutlon box/so I absorption system ^_ Shvis cesspool Overflow cesspool ivy Shand system(yes o nol (If,rem,attach previous Ing;s ram m records,.(f eny) 1/A Technology eta.Attach copy of up to date operation and mebw1murce contract Tight Tank Copy of DEP Approval OtMr rr�� APPRIOINATR AGE of all comporerns, late Installed Of known)and source of enformstbn. C1 MaroOs oders detected when arriving at the site:(yes or no) revised 9/2/.98 f �er>tt SUBSURFACE SEWAGE DWOzAL S1rsTEM RUPECT7CIN FORM PART C SYSTEM SPORNATKPI loon entsam Prgroelt► t J 5 bo 1fJ I C, 5 � (Locate on oft tbnl Depth below a"�•, u MatndM of oonstruotlon: oast iron_640 PVC_other iexpisin) Dhnowe fr privats w supply wail or auction Rns Diarnawater . Cortirnants:(condition of joMta,venting,evidence of leakage,etc.) SIt�"t1C TANL . llocas on alto plan! Depth below g►sdsc�i Material of construction:--Lccncrste,_,metal_FRwOass ,_Polyethyierq,_.other(explain) If took le metal,Rst"e_ is age corArmad by Certificate of Compllenee__(yss/Nal Dimension: Sluilse depth. Dletanee from top of sludge to bottom c.f outlet tee or baffle Semi Raekneas:_� 1t Distance from top of scum totop of outlet tee or baffle:•_ �( Distance from bottom of scum t of outlet tss a affle:V Yew dimensions were dstarrnlm Camttoftts: (mcomm,andstlon for pumping,Dart of inlet end ou teas or belles,depth of lig l ovol in rel n to`f outlet vgrt.sng e i inr 'itti, evidence of took"is,m.) ``�. ', %. — cti OIIEI+iE TRAP: � .—.�. .�.—.,_..�. fioeate on of plan) Not below Veda: Material of eonstructlon:_concrete_in&W_Fibo►glass sPolpethylsns_ sr(sxplsin) Ditnensfans: Scum thickness Diatmas from top of scum to top of ou*rt WeZ-b D(starroe from bettors of scum to boom of oDeis,sf last pumping: Comments: frocorovider msndatlon fa pumplrtg,cortdltla►of inlepthh of Ilauld level in rotation to outlet Invert,stnrctur�l)neegelttr, evidsrroa of ledcage,etc.) revised 9/2/98 hys7of11 SUBSURFACE SEWAGE DISPOSAL SySI M arISPECTION FORM PART C SYSTEM f Faft ATIDN(eonswedl owMw: tj -6-60 w Dover of bMpOction:'5 }31-10L,lO TI9(Iflr OR MOLOW TANK: (Tan It must be pumped pZtwtime asf, Inspection) flocate on site plan) Depth', ore isMatarlal of construction:_concrete metal _ oyetylene_other(axpMn) Dbyminslans- Capacity: . wilam Design now: gamons/day Ala n present Alsr+n+level: Ahirm In w order:Yoe_ No_ Data of previous pumpirp: cornhttsrst.: icondition of Inlet too,condl n of Hann and float switches,etc.) zz AV 4 DI01t11MUsi01M SOIC� (locale on sore plan) Daplh of liquid level above ounat Invert: e�e n Comma ts: (notr.If level end �rfbuti aqua➢,V4denc*of solids carryover,evidence fee apo i r out of bo ate.) -was _sue t P Lie tl�- KMP frl+A�eel• (locste on site plani Punprs in worlft order:(Yes or No)—_ Alen"In workMS order fYes or No)— Comnants: (note Condition of pump chamber, nd'Jon of pumps and appurtenances,etc.) r , , revised 9/2/98 rsprtefu all "nUiACE BEtillAQE DMNML SYISTM NiPECTIfM FORM PART C r SYSTM MFOWAATWN fewOnwed) Daft of b6owdeor Ong A�OI�N.YO4®I ffiAf�l:. (locate on alto plan,N Possible; excevetirri not required,location may be appromJmated by non-Intrusive methods) N not located,explain: Type. -Wm**M phs. ;L lewd"chonbas,raimba:_,_ . Ieaahk gaflon(a,number:_ IeeohIng trenches,number,lsnlith leashing flolds,nurnnber,dmenuione overflow oaaspooi,number:®._ Ahonativo systenn: Name of Technology: Comments: (note condition of sail,signs of hydraulik-190ure,level of pending, damp soil,condition of vegetation, etc.) CEitiPOD A: (lacew on rite pion) Numbu and configuration: . 'Ispth4op of)lrpdd to Inlet Invent' wh of some lava: Oep th of scum layer: Mow Mons of cesspool: Materials of conaouctlon: Mdcarfan of groundwater Inflow(cesspool must rd as part of inspection)�_ _ry Cenwnomts: (note condition of soil, gns of hydraulic %Uwe,lento of pending, condition of vegetation, etc.) FiN01Y: (laceto on of plan) Materials of oons"ucdon: Dimensions: Depth of SON& 01 � Csxnwaanta: (acts condition of loll;signs of h hgurs,level of pending,condition of wrgetatisn, etc.) i a - revised 9/2/98 # Pw9of11 { r IuUURFACE BE1NAGE DOWOBAL sYKTEM NSFECTKOIII FORM PART C SYSTEM NMFOVMATKHII Iearet nMOO hawaaA�.a. 1 o�' �CL� oarrrr: ,� o W t C_7 _ SKM:M OF UWAGE DGPAL SYKTUM, inoDuds tbs to at last two permanent reference landmarks or bsnchmsrke locate sin wale within 100' (Locate where public water supply comes into house) � ( revised 9/2/98 ftr10d11 ` v A SEWAGE DISPOSAL SYSTEM NSPECTBDIi FOAM PART C SYSTEM MNOIMOATION loatetirandl Ik Owner: Dole ad btap.atl, S MACS Aepon nerve SON Type— -- Tydcal depth to groundwater —. USOS Date webeks visited Obeewallon Walls*hooked Groundwater depth. Shallow_ Moderate _peep SITE IMAM Sbpe Surface wear Check CeNar Shallow woft -� ! Esdmrroed Depth to Groundwater It PI Indicate all the methods used to 6vtsrmine High Groundwater Elevation: Obtained from Design plans on rocaord AObserved Sits (Abutting property,aboometion hole, basement sump eI f IDeterrrMned from local conditions Chocked with local Board of health INvocked FEMA Maps (Chocked pumping records Checked local exeavators, kustsilers Used USGS Ante Describe hOw you established the High Groundwater Elevation. (UM be compleKedl r • 1 revised 9/2/98 p44w11of31 No. g—G 0 3 Y Fee U U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitation for Bisposal *pBtem ConstrUttion 3permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System dividual Components Location Address or Lot No. �����. Owner's Name Address,and Tel.No. rq,\� `r- L `S Assessor's Map/Parcel U�\ Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms�� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) t 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 Certificate of Compliance has been issued by this Boar ealth. Si Date Application Approved by Date - Application Disapproved by Date for the following reasons Permit No. { ( - 0 3� Date Issued 2 No. a fl (( Fee U U TH COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION- TOWN--OF BARNSTABLE, MASSACHUSETTS 01pplicatlon for VepoBal 6pstem Constructions permit Application for a Permit to Construct( ) Repair(✓Upgrade( ) Abandon( ) ❑Complete System Q, dividual Components Location Address or Lot No. ` S �' V �'r R Owner's Name Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. ^ Designer's Name,Address,and Tel.No. WO Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd i I Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. i Description of Soil i Nature of Repairs or Alterations(Answer when applicable) QQ C)t G,(� L_,-Gj X., %or- 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 Certificate of Compliance has been issued by this Boar ealth. Signe Date �( Application Approved by \ iv. f Date a ( // Application Disapproved by Date for the following reasons w Permit No. G ( I Date Issued 2 nor - - - - - - --- -- -- - -- ---------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS f Certificate of Compliance THIS IS TO CERTIFY,that the Own-site Sewage Disposal system Constructed( ) Repaired Q/< Upgraded( ) Abandoned( )by at (\A G,r�hks%An AnsirulciAd in accordance with the provisions,of Title 5 and the for Disposal System Construction Permit No. ►I -�; r dated 2 J Installer �s CQ� ACC c c r.^y� Designer E #bedrooms Approved design flow gpd k The issuance of hi rmit shall not be construed as a guarantee that the system wil If7tio as designed j Date -2_ ✓ s 7_// Inspectorcr _ -... ------------ ---------------------------------------.- . No. a 6 �� J n )A Fee _bo - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction 3permlt Permission is hereby granted to Construct( ) Repairs Upgrade( ) Abandon( ) System located at nS SkG.r�..� \n ``U ��5 Mt 1k3 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 IF DateIA roved b A2JJr Pp Y G No.._._ Fimic.... .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ow� .-------OF............J-1f ...................................... Appliratiuu -fur Diopotial Works Cnuuutrurttuu Vrruid Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: Location•Ad ess or Lot No. c=z`r--------- /...� ------------------------ ----•------•--•-----•---------•---•----........ Owner Address.---•-------- ...`Tdf. Go.!l.G -------- ---------------------------------------- Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.._..................................Expansion Attic ( ) Garbage Grinder ( ) o`k., Other—Type of Building ______________------_-____ No. of persons.--------------------------- Showers ( ) — Cafeteria ( ) o' Other fixtures ---------------- -----•--__-_-_ _ _ W Design Flow..--------- .......................gallons per person per day. Total daily flow--------3,n.4_.....__.___-------------gallons. WSeptic Tank—Liquid capacity_/ZO-gallons Length---------------- Width................ Diameter__._...._-._--_ Depth---------------- x Disposal Trench—No--------------------- Width--------------------- Total Length-_---------_.--_--- Total leaching area.-------------------sq. ft. Seepage Pit -------------------- Depth below inlet_______:___-:-_-_-- Total leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) �-' Percolation Test Results Performed by------------- ........................................................ Date------------------------------------.... Test Pit No. 1----------------minutes per inch Depth of Test Pit..------------------ Depth to ground water-----------_::_--_. Li, Test Pit No. 2................minutes per inch Depth of Test Pit-_---_-._.____--_- Depth to ground water--.-..---.-.--------__. a ---•-------------------------•--------------------•--------------..........------.-- .. -•------•-------------------.... Description of Soil oS } . �SP/yOL i l.� -----� ,P :G--iC'r------x W ------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ VNature 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been isol 4bbyhe b and of ealth. Signed . - � 7 .3 Date Application Approved B f`� Q ' = lctS = Date Application D' pprove .for tl ollowing re sons:- . . . •- ----•---- -- ... . - .............................. Date Permit No..-------- _ Issued ...�q -7 3--•---- � Date 9 i r� ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ... .......OF...... f.: .: rif ii' f ter ................................ Apphration -fur Uiipuual lVarkii Towitrurttuu Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 1117 !� ------------------------------------------------•------.... -----------------•---- Location-Address l� or Lot No. Own�r am Address W t!!1 . c . r. .... .. .r�..... .x Installer Address QType of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms----_. ------------------ - _Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building -------------------_------ No. of persons_--..___------_-__-_-__.--__ Showers ( ) — Cafeteria ( ) w Other fixtures ------------------------------ d -------------------------------------------- WDesign Flow---------- >.. . ....:..................gallons per person per day. Total daily flow-------- _ ".._................... ... WSeptic Tank—Liquid capacitv."*(f°_2� gallons Length---------------- Width................ Diameter---------------- Depth--.----._-.----- x Disposal Trench—No____________________ Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No... A4—-::° Diameter-------------------- Depth below inlet.................... Total leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------- ---------------•----•----•---•--.........._...................... Date........................................ a Test Pit No. 1-----------_____minutes per inch Depth of Test Pit-------------------- Depth to ground water..-.--_---._-.-.--.-__.. Gia Test Pit No. 2.... .........minutes per inch Depth of Test Pit____________________ Depth to ground water--..-.-..----_---__--_ i ------ ------ Description of Soil. ----------- -------- -------- ----•--- ------•------•---.----------------- ._... -....;.. c, ------------------•---------------------- •••-----•------•••--••-•••••-•-------•-•••••-•-----•-------•--------------------------•-•-•-•-••-•------------ 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 Article XI 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...: .. `""x ' j' .-;' t mow. .,. -- " Date - _.—..._._. { Application Approved By--v : .%.... .. .............. .. . fT ------ �/ ---------- Application Disapp o ed for the ol`wing reasons:___ - e- di_(.-Z ......................... •-•-- -------- f ----•------ � Date /y -- w. Permit No. ==' 69 - ;----•-----•-• Issued `= ................... w Date /;7,3 THE COMMONW LTH OF MASSACHUSETTS BOARD OF HEALTH r f 7. ip srl..." 011rrtif irate of TumvRaurr THIS IS TO CERTIFY, That the Individ Al Sewage Disposal System constructed ( -j"'or Repaired ( ) by-•-•----- -•�) 3 -�...1 i _a fk T =' w ''------ ------------_ -- ----- -----------------. f Id7 aller 1 0 at r� p x � F. _ /F r _ ?' _ _ . • -• r� -•-•---•---_------- -------- i r ;- r_d -- -:_ �a s.. — ..: t has been installed. in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..................:...................... dated---------------_................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM L UNCTION SATISFACTORY. DATE--- `�� � � --- InspAASSACHUSETTS ----,� L"` THE COMMONWEALTH OF BOARD OF,- HEALTH -: f; f `. ............. O F.... 3i as 4�� f / . ... ..... No..... -_........ FEE. 6................. . Permission i�;hereby granted__... Qn f {`'..- __._ ....... ...... . . ....... ...._........ s. f r d to.Construct ( ') or Repair. ( ) A&Individual Sewage Disposal System: , atNo.% �`.rG ��+ t€'�Y• 4' - ff�' "�r ` N r4_!_!' jet 7!: ....e.2.................................................... Street as shown on the application for Disposal Works Construction Permit No..................... Dated--__ _.,"�._._73__.___..__.::...._ Board of Health DATE-------------------------------------------------------------------------------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS ASSESSORS MAP 1 TEST HOLE LOGS 1) The installation shall comply with the State Environmental Code Title V and Town of a Board of Health Regulations. �c ,A . \ PARCEL: SOIL EVACUATOR: �'l� 2) The septic system as proposed on this plan shall not be installed until a licensed town t ' � — �C� installer receives approval and an installation permit from the applicable town. REFERENCE: � t (.� C5b1�, - ` WITNESS: N, 3) Prior to installation,the installer shall verify the location of utilities,sewer inverts, T -2 LG0 "FV 2-9 ` m �� DATE: �1 sewer lines and existing septic components prior to installation. 4) All gravity sewer piping is to be 4 inch schedule 40 PVC at 1/8"per foot. The first 2 ii PERCOLATION RATE: '�" ,t feet out of the distribution box shall be level. All piping connections to be glued. -' � ��. I 5) This septic design plan is not to be utilized for property line determination or for any T.H.#1 ELEV. _70`6 .HXZ ELEV. 1 DD other purpose other than the proposed septic system installation. LOCATION MAP 6) All Title V components are to meet Title V specifications. ' ? 7) Parking shall be prohibited over Title V components unless components are H2O t' D 431 I �{ ( loaded. to 1 � 8) The existing leaching or cesspools shall be pumped and filled with material per Ttle V Ind i(e abandonment procedures. Leaching and cesspool(s)and contaminated soils within moo the proposed SAS shall be removed and replaced with clean sand per Title V Y►' oo specifications. -i -- 9) Septic components are to be 1('from a water service line.Sewer lines crossing a lo7 1--1 j water line shall be sleeved with an appropriately sized schedule 40 PVC with ends / _- N� 4 �} �� ()1D grouted. The water service line or the septic line can be sleeved with the sleeve being a distance of 10'on both sides of crossing the line. \ �1 ✓ 10)If a garbage grinder exists in the structure,it is to be removed if the septic system is not designed to accommodate a garbage grinder. 11)The installer is responsible for care of excavation around all utilities on the property SEPTIC SYSTEM DESIGN U and protecting the structural integrity of all structures during the installation process S EM CALCULATIONS - of the septic is system. FLOW ESTIMATE: 12)This plan only represents that a septic system can be installed on the property a BEDROOMS AT �10 GAL/DAY/BDRM= ��0 GAL,/DAY meeting Title V requirements. 13)The property owner shall review design criteria to approve the total number of SEPTIC TANK: bedrooms and design flow. Installation of the septic system as proposed and receipt p GAL/DAYJBDRM X 2 DAYS= GALLONS of payment for the'design shall be deemed approval of the design criteria by the f f ••��,,, property owner or agent of. y� USE I 0t) GALLON SEPTIC TANK(EXI�5T 14)The validity of this plan shall expire with t ' ( � � t11 p p h he expiration of the town installation perrrnit (GARBAGE GRINDER IS PROHIBITED) issued for this plan or the validity of this plan shall expire on the expiration of the C!a ` 10, J SOIL A850RPTION SYSTEM: Certificate of Compliance issued for the installation of the proposed system on this \ i c1 _,! • r�J U` 2 "' t5f�► C� � plan. SIDEWALL AREA: G��- '�' t; r . Z- �' = 11 P�-� k Q max: 1� N , BOTTOM AREA: c3 7C j ( 7+ j'� c'�1 DAViD� �y No.?OSS r G ! esA st >> � a SEPTIC SYSTEM SECTION 1 I A&D BENCHMARKIb„ w � � `+ W ul to too 10 6 9� TOP OF FOUNDATION J� ,�� Z►� 14 ELE 0 t1q5 �,7� (D ATUM ASSUMED) �5 ��� 6,.STONE BASE � h �s/'r 11C1 H2O D-BOX I ;� i.-- _ �Z5x IZ.'c �l 6"STONE BASE OR COMPACTED BASE WATER TEST FOR LEVELNESSr� I aCC) GALLONS ----- SEPTIC TANK SITE AND SEWAGE PLAN 0 LOCATION:— !� ���� g PREPARED: .SCALE: � , DATE: F I �