HomeMy WebLinkAbout0055 STONE BRIDGE LANE - Health 55 STONE BRIDGE LANE ; LDS
A= 125 006.007 J'S 7` OnS
TOWN OF BARNST LE
LOCka"ION O i G(" SEWAGE #
VILLAGE / ` ASSESSOR'S MAP & LOTA9L( ("7
TAU€R'S NAME&PHONE N0.
SEPTIC TANK CAPACITY Ud
=LEACHING FACILITY: ( ) (size) (n
NO. OF BEDROOMS
BUILDER OR4i�i�
PERMITDATE: COME 1.CF. 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
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TOWbOO& BARNSTABLE
LOCATION JS S ��Dt�c �,�=, y-s c . SEWAGE #
VILI..,AGE /tl ASSESSOR'S MAP & LOT
INSTALLER'S NAME PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) �� (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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COMMONWEALTH OF MASSACHUSETTS
Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
141
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 55 Stonebridge Lane
. Marstons Mills MA 02648
Owner's Name: Bruce Thomas
Owner's Address: Same
Date of Inspection: November 7,2005 Job#05-339
Name of Inspector: PATRICK M. O'CONNELL
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the info` ation reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed sed on m�
training and experience in the proper function and maintenance of on site sewage disposal systems. I' m fft-III,/� >
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syste : ��� � QF/�j4 ,
' •N S
_X_ Passes Cn
Conditionally Passes ? P RIC
Needs Further Evaluation by the Local Approving Authority - M. ,y
Fai '�,
Inspector's Signature: Date: 11/7/05
4F5 INSPJill III E,`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.
Notes and Comments: Observed 16-18"of standing water in leaching pit with no high stains,tank is not in
need of pumping at this time.
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 55 Stonebridge Lane, Marstons Mills
Owner: Bruce Thomas
Date of Inspection: November 7,2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ 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.
Answer yes,no or not determined(Y,N,ND) in the 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
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4
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 55 Stonebridge Lane, Marstons Mills
Owner: Bruce Thomas
Date of Inspection: November 7,2005
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
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Page 4 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 55 Stonebridge Lane, Marstons Mills
Owner: Bruce Thomas
Date of Inspection: November 7,2005
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
_X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS, cesspool or privy is below high ground water elevation.
_X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
—X_ 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. IThis system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.1
_No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
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Page 5ofII
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 55 Stonebridge Lane, Marstons Mills
Owner: Bruce Thomas
Date of Inspection: November 7,2005
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ _ Pumping information was provided by the owner, occupant, or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks
_X_ _ Has the system received normal flows in the previous two week period ?
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection?
_X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up ?
_X_ _ Was the site inspected for signs of break out?
_X_ _ Were all system components, excluding the SAS, located on site ?
_X _ 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?
_X _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems`?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
_X_ _ Existing information. For example, a plan at the Board of Health.
_X_ _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [310 CMR 15.302(3)(b)]
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Page 6 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 55 Stonebridge Lane, Marstons Mills
Owner: Bruce Thomas
Date of Inspection: November 7,2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2003—41,000 gal. 2004—40,000 gal.= 110 gpd.
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records: Tank pumped one year ago.
Source of information: Owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_X_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)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed (if known)and source of information:
1988
Were sewage odors detected when arriving at the site(yes or no): No
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Page 7 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 Stonebridge Lane,Marstons Mills
Owner: Bruce Thomas
Date of Inspection: November 7,2005
BUILDING SEWER: XX (locate on site plan)
Depth below grade: V
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage, etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: V
Material of construction:_X_concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 8.5' long x 5.2' wide— 1000 gal.
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 29"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 13"
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Tees are intact and clear,tank is not in need of pumping at this time. Recommend pumping every
three years.
GREASE TRAP: No (locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
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Page 8 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 Stonebridge Lane, Marstons Mills
Owner: Bruce Thomas
Date of Inspection: November,7,2005
TIGHT or HOLDING TANK: No (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: XX (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.):
No solids or high stains present.
PUMP CHAMBER: No (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
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Page 9 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 Stonebridge Lane,Marstons Mills
Owner: Bruce Thomas
Date of Inspection: November 7,2005
SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X_leaching pits,number: One 6x6 pit.
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.): Observed 16-18"standing water in pit.
CESSPOOLS: No (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 or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: No (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.):
Tiflo ; 1--ti— Pn— All 1;110n0 9
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 Stonebridge Lane, Marstons Mills
Owner: Bruce Thomas
Date of Inspection: November 7,2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
Stonebrid a Lane
Water service
Driveway
# 55
22 22 17 26
35
52
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• Page I 1 of 1 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 Stonebridge Lane, Marstons Mills
Owner: Bruce Thomas
Date of Inspection: November 7,2005
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 12 feet
Please indicate(check)all methods used to determine the high ground water elevation:
_X_Obtained from system design plans on record- If checked,date of design plan reviewed: 6/13/88
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)
_X_Accessed USGS database-explain: USGS topo map and town GIS.
You must describe how you established the high ground water elevation:
Pere test performed on 5/31/88 found no water at 144".Topo map shows property above el.60 and
town groundwater contour map shows water below el.40.
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e0
SUBSURFACE SEWAGE DISPOSAL SYSTEX INSPECTION FORS
Address of property ,j.S s-fov,e b,; ,� �cl, Al GrS�v—s /Lj ,S
Owner's name �(
Date of Inspection Muryu tn r , v
PART A
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner,
Health. occupant, and Board of
. None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A.
The facility or dwelling was inspected for signs of .sewage back-up.
p
VThe site was inspected for signs of breakout.
All system components, excluding the SAS, have been located on the
site.
VI/ The septic tank manholes were uncovered, opened, .and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determine
on existing information or approximated by non-intrusive methods..
based
r
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of' SSDS.,
r Ile
f hVEO
J O N i 1995
fte
SUBSURFACE SEWAGE DISPOSAL SYSTEM -INSPECTION FORK
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
si� number of bedrooms
number of current residents
_ garbage grinder, yes or no,
y,s laundry connected to system, yes or no
V_ seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available: g
OLc vOQ Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
/Y b ✓Jy cn,.�. !� s i !n Tu:i .-t.,.. -.�•i� � Cti ✓ �i 1 /G�47 /,� G� �—
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7
System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
Type of system
_L,/ 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) •
Other (explain)
Approximate age of all components. Date installed, if known. Source of
informatrii
�r h Sir, O
l�o Sewage odors detected when arriving at the site, yes or no
t
. 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
i PART B
SYSTEM INFORMATION continued
SEPTIC TANK:,
(locate on site plan)
depth below grade: 12
0
material of construction: concrete metal FRP other(explain)
dimensions: 5 I X? " X G 1600
sludge depth
J�• distance from top of sludge to bottom of outlet tee or baffle
3" scum thickness
6" distance from top of scum to top of outlet tee or baffle
' distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evi ence �o+f leakage, recommendations for repairs, etc. ) /
f'b✓�J 1 " w(.-k o PaA�e., /ll a e u Gt
4-y 4/c wrs.
DISTRIBUTION BOX: /
(locate on -site plan)
fGue depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leak a into or out of box, recommendation for repairs, etc.)
-�� C-d C-
[/
r
PUMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORH
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits and number k
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
CESSPOOLS (locate on site plan) : A/��
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 (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,_
condition of vegetation, recommendations for maintenance or repairs,etc. )
PRIVY: /v�4
(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, recommendations for maintenance or repairs,etc. )
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK
PART B
SYSTEM INFORMATION Continued
SKETCH OF SEWAGE L=SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
Froh'�
176„
say
I Aix
�Q h
DEPTH TO GROUNDWATER
fj-., depth to groundwater
method of determination or approximation: /✓i c. . l t t > 7' 1 0 /L c/y 6�r
-1 1��-✓N S �. I t �O
1:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM /
PART C
FAILURE CRITERIA -
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
Backup of sewage into facility?
_/ Discharge or ponding of effluent to the surface of the ground or
surface waters?
_I Static liquid level in the distribution box above outlet invert?
N� Liquid depth in cesspool <6" below .invert or available volume< 1/2 da}
flow?
A/ Required pumping 4 times or more in the last year?
number of times pumped
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy: .
below.. the high groundwater elevation?
�L within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
/ y within a Zone' I of a public well?
/Y within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
within 50 feet of a private water supply well?
/LV less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well .water ana1K.
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspectory l j < " `17 S
Company Name �o y �. CA S Sew
Company Address L d 61 j 94 5
Certification Statement .
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
one:
VI
have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector' s Signature s
Date
Original to system owner
Copies to:
Buyer (if applicable)
Approving authority
n J
_ a
TOWN OF BARNSTABLZ
L A1ION �.-6T 5 3 ZLIEBi LD Cog ��WAGE # 1, 5
VILLAOE 467&& /LLS ` ASSESSOR'S MAP.Cz.LOT
�'�IIA1ST LLER'S NAME & PHONE NO.
SEC TANK CAPACITY I�do GILL•
r1 4 1 PIT (size) GIK
LEAoHING FACILITY:(type) '(
NOS OF BEDROOMS 3 PRIVATE WELL O UBLIC WA
� BUILDER OR OWNER
DATE*. PERMIT ISSUED:
'T
DALE'. COLIPLIANCE ISSUED:
VARIANCE GRANTED: Yes No l
.......; .. ..'. .
y
Ise tZ�
TGWN OF BARNSTABLE
LOCATION 5 --9Tat4g7"3f-�i7 66 WEWAGE # ° IJE2
VILLAGE H J7 S /GLS ASSESSOR'S MAP & LOT .
INSTALLER'S NA24B & PHONE NO.
1O SEPTIC TANK CAPACITY f ODD C1 Alt
�d
TEACHING FACILITY:(type Lew ?t`f (size)
NO. OF BEDROOMS -3 PRIVATE WELL O=PUBLICT
0 BUILDER OR OWNER 6(LEA 3 Afilms
DATE PERMIT ISSUED: "?o
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
47-
12
f lit I
k
1 � f
s
THE COMMONWEALTH OF MASSACHUSETTS
BOAR` D OF HEALTH
�c?.c ✓. .............0F.. ...........................
ApplirFatiun for Disposal Work.5 Tome rurtiun thrutit
Application is hereby made for a Permit to Construct (,Je) or Repair ( ) an Individual Sewage Disposal
System at:
.....................................................
Location-Address or Lot No.
........ ...Realty...T-r.ust............................ 765_..Falmouth Rd..._ Hyannis.,..:??A...02601
Owner Address
�.YIAI✓�1 i�it/ ........_.
Installer Address
d Type of Building Size Lot__o -9.4!_.....Sq. feet
aDwelling—No. of Bedrooms.._..._..._.vim...............................Expansion Attic ( ) Garbage Grinder Wc,)
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures .._..._..
W Design Flow...... „S`......................•_.gallons per person per day. Total daily flow_____�Z ........... gallons.
WSeptic Tank—Liquid capacity/?O� ;��e.gallons Length_,&' . Width.-*". Diameter________________ Depth-57B w
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area........-----------sq. ft.
Seepage Pit No........ Diameter.._.....5;;�!__..... Depth below inlet.=%_a..;?.... Total leaching area... Z.sq, ft.
1 Z Other Distribution box (JO Dosing tank ( ) J
Percolation Test Results Performed by.. � �:_.��� i�'..-���)�"._ _1i Date.....-�1--- �,/ E_.......
j Test Pit No. 1.......L......minutes per inch Depth of Test Pit---- '...... Depth to ground water....114/ ----------
f Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -----•••----••••-•---•------••-•--•-•-----•--- .....................................................------••------•------------•-•--••----•------
Description of Soil---� - ��`� e�% �j -_ — ' ��¢"._ ......
� ._ _C ,�' ZC.___.SE:.. s�!E� �� „ '_Z " c c��.. Cam.?!�P .S
V
V Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------------------
--------
-------------------------------------------------------------------------•-•----------------•--••-•-----••--------...------------•-•----••------•-•---------------•-•-••---•----•--•---••-------•--•-•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has iss by he board f health.
- ./,�j
` Date
Application Approved BY ��c, ._ .. --- ------... .
J v Date
Application Disapproved for the following reasons:.............................................................. ................................................
--••----••-•••---•.............•••----•-•-•----•----•••••---...---••-----•••--•--•-•••-......••••---.......----•-••-••---•-•-•-•-----------••-----••-----------••-•••••••------------••••-••-----..._..•.
Date
PermitNo.------. �....................... Issued.......................................................
Date
Fss.. .. .:
THE COMMONWEALTH OF MASSACHUSETTS
I BOAR® OF HEALTH
Noce . .................OF..%,..?�`���.�;.c� . ....................................
Appliration for Uwvasal Works Tontrurtion r mlt
Application is hereby made for a Permit to Construct (k or Repair ( ) an Individual wa osal
System at:
-----••------•----.... +
- ... �. . .......---•-------•------.---•-
-•-•
Location-Address or Lot No.
........Q3P-r-:-G!G 6.-•1...Pt4XCj1.0U.er--Tl?r.�xe't:.................•--------- 7.hS..Falmrau;.h__R�t...�_..�i annis�.._.1`a..A fill
Own Address
Installer Address
UType of Building Size Lot..._✓.,t"', .....Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Gri der (,t/�
Other—T e of Building No. of persons............................ Showers
Pk YP g p ( ) — Cafet ria ( )
Q' Other fixtures --------•_-_ (••---
- --..__...-• ----- -----
W Design Flow........_' 7 .........................gallons per person per day. Total daily fl ow-___.4': 4- ?-
WSeptic Tank—Liquid capacity!'`t.p.gallons Length Width.4�� .. Diameter---------------- De
x Disposal Trench—No..................... Width....................
Total Length.................... Total leaching area........--.........sq. ft.
Seepage Pit No ------------ Diameter........ " ------- Depth below ..... Total leaching area....... ...Z.sq. ft.
Other Distribution box (jO Dosing tank ( )
Percolation Test Results Performed by. =t .! c ?t°'..`���?1' _. �.�'cPC Date.....=4Z�.I -------
a` Test Pit No. 1...._�_._...minutes per inch Depth of Test Pit....Z��'.__._. Depth to ground water-___�./....
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.-_-______-__r ._____
._....._..--•--•-•......_...--•------•----•.............................•------.....--------•----------•--•-•------•---------•---_..............--`r'
D Description of Soil... „ �'dr? >" �• y - ._� ::_-� I," .etc. - _ c�- 1.sJ:S�-
�Syr,�,/
►�+ �Tr an R"C?t !r S+e�_.._.xo.s o ii1rC'may c a r�f T ....... .?re.`Y: es r w ...............
UNature of Repairs or Alterations—Answer when applicable.__.._.......................................................................................... t
i
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Ti:IE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...................................................................................... ................................
Date
ApplicationApproved By-----•------...... -- - -----------•3--...----- •.•_.--•-----•........................... Date
Application Disapproved for the following reasons:................................................................................................................
-•.........................................................•--•--••-------•----••------.....-•------...•---•---------•----••_...-•-•----........_•----•--------•.......................................
Date
Permit No............ -¢ ' j --••--•-----•----• Issued...................Daatete................................
�•-r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.................................................................................
Tntifiratr of Contplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by------•-•------..__—�.........----------
..� •- =
J � /�� Installer
at.-----•------ ------ -• - - -•-- i ......../,-e4a ....••------
has been installed in accordance with the Of I 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...---------- da.ted_...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE t
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH /
r OF................... :.. F z �. r 1��1..........•--••-........ 5 .
No.......�... _��<- � `.'''.i.�..�...`.. , .:,. �.. �,._., FEE.__... -.��.-•-----
✓> Disposal Works Tonitrttrtion .andt
Permission is hereby granted................
`"5 N .....................................................
to Nonstruct ( Repair ( ) an Indivldual Sewag Disposal System
at _.o..................... . .....(..... ( -- �sZ--- ------•----•--•--•-------•-----•-=•---•-•--•••-•-•-
� . J ''Z Street r
as shown ?n the application for Disposal Works Cvonstructiofi Permit �._.1��
.................
oard of Health 1
DATE... ...V
l
FORM''1255 HOBSJS & WARREN, INC., PUBLISHERS
-
-
. DETAIL: �A SIN PIT DETAI
DATA. ATEs INDICATES SEPTIC TANK DETAIL.. 1000. GALLON � fl1STRIBUTiON BOX C G L : REVISIONS:Iii SOIL TEST PITt
/� V OBSERVED NOT TO SCALE NOT TO SCALE -NOT TO SCALE I>Q twrE
)0LO /�p TTEEST� 9ROUNDwATER
ROTES:L SEPTIC TANK SHALL 8E STEEL 4. RLET AND OUTLET TEES TO SE CM IM OR 21 a NO. OF OUTLETS: OR PAVEMENT .
5 f oovER
REINFORCED CONCRETE. -3CHEQ 40 PVC. TEES TO OE CENTERED 'UNDER
�ROIDaHT TO fiflt�H GRADE
TP TP 'MANHOLE ICOYER --1--- NOTES! w` ` r -
TP �.. t. SEPTIC TANK TO WITHSTAND,H-Ib tAADPIB
. .. �-- � L :GIST. BOX TO WITHSTAND H.-f0 LOADING
GRD L.lo3. flRD. EL._ .'�D.IEL. ORD. E UNLESS UNDER PAVEMENT;bFtrns OR
• W. L. OW. EL•. TRAVELED wAYS•wHEREtN H-tt7 LOADING 1 UNLESS t►'NOER PAVEMENTS DRIVES OR ! EO ate• FILL
J TRAVELED MAYS WHERE114 H-tO LOADING
- - PRECAST
SHALL'APPLY, _ N 1 GIST. 1 SHALL APPLY '• _ -
000 o t= o 0C3
• TOP � SL/8 3. ALL PIPE COIINECTION9 AND CONCRETE eeaNMOLt p+�se
seou�T TO s7�eN MAIe[ '1 BOX t. PROVIDE INLET TEE OR BAFFLE WHERE SLOPE OF - o
CONSTRUCTION TO BE WATERTIGHT I INLET PIPE EXCEEDS 0.08 FT./FL OR IN ��� PIPE- e
1 1 PUMPED SYSTEM. d
W.(o, 71 tram. L---r ----i o a o d o n n a NOTE:
- 3. FIRST TWO FEET OF PIPE OUT OF DIST. 100 0- GALLON GENERAL NOTES: .
PERG $'-6N LEACHING PIT TO
oevtR BOX TO BE LAID LEVEL. �d l a n o s� t� c o 0 0 WITHSTAND H-10 LOADING '
3 .. ...;- .. ,...• • •: , L THIS PLAN 15 FOR DESKiN AND '
(4AL.____— .. .• . .. PLAN VEW .•. .v UNLESS UNDER/ REMOVEABLE • PRECAST M_�' :6 , CONSTRUCTION OF THE SEWAGE {
• `Q PAVEMENT,DRIVE E OR
n *°e+o+►L M►TER t�tt COVER • ' TRAVELED WAY WHEREIN ` DISPOSAL FACILITY ONLY
3/4 TO Iv a n n a v •a. o n a
'LEACHING PIT' '.+• o H-20 LOADING SHALL 2 ALL CdNSTRUCTION METHODS AND
'
ILO 14u5 67 SHED APPLY MATERIALS SHALL "CONFORM TO AItLSS.
... -..:.:•'�'.� STONE
Sq,c/D ¢' RAVL�L 1 PROVIDE �.. . •..:•:.. v on o s= ado
1 i "LET TEE MfA HT : ' � (n°tines? � - DE.O.E..TITLES AND LOCAL HOARD
SatitE /it/E 1 JOINTS hrP) .1 - r; _`1 Ir +° a o o iO o v o c o OF HEALTH 'REGULATIONS. . .
- 1 PRECAST Ir '::_ 4e-cr sm. OYTILET 5-$ - jr 1[[
7
$EPTIC h �_ LteMO pErTM TEE. 4" INLET M=T[� — .ij i i I:, o o p a o ,c� coo , 3. ALL PIPES LOCATED UNDER PAVEMENT
i TANk' i !0 }L�1 I 4"OUTLET 1 •;� r , OR TRAVELED WAY SHALL EE
/ITED�UM is �. ( 4-- - e SCHEDULE 40 OR EQUAL.
1 j 1 i�. ? 2 / 4. ALL UNSUITABLE MATE RAL (TOPSOIL,
CoAIC.TE L -------- -- -- - - -- - :.� ••�JJ ':i:::,. . c�:c: • . i� :::=.1;;:- :�:•: ':i� flIA SUBSOIL-, CLAY) ENCOUNTERED BELOW
SOTTM ON LEVEL STAKE SAME d.:0 _ � o.r o^o �L�� , 101 DIM. THE INVERT OF THE LEACH PIT TO
CROSS-SECTION '� Jv o BASE BE REMOVED FOR A DISTANCE OF
PLAN VIEW CROSS-SECTION VIEW 10'• AROUND AND REPLACED WITH
CROSS-SECTION CLEAN COARSE SAND.
o
DATE: DATE:. DATE: DATE: INVERT ELEVATIONS,
•
5-31-88
TEST BY: TEST BY: ,
9Y• d
TEST BY:
TEST ,
STEPHEN HAMS INVERT AT OU1lD1NG
WITNESSED BY: 1NiTNES3Ea BY: W1TTiE88ED 8Y: WITNESSED BY:
INVERT AT SEPTIC TANK(in)
IG -
INVERT AT SEPTIC TANK(out)
JE DUNNING
RRY
PERC. RATE: PERC. RATE: PERC.RATE: PERC. RATE:
• INVERT AT UIST. SOXtin)
< 3 M1�!lIkCH fd1IN./INCH 111MJMCH MMlINCH
INVERT AT .DIST. 'BOX(out) 6 /45
/ 2
IN
VERT
VE RT A LEACHING
6
TI
� 1 .
P T _—Z
DATUM.
/000te
BOTTOM OF LEACHING PIT 56-.60
U.S.G.S. MAXIMUM GROUND
VERTICAL DATUIN: N.G.V.D. WATER ELEVATION
OBSERVED GROUNDWATER
BENCH MARK USED: ELEVATIONM28RA DISK M.H.B. ROUTE 28 EL. 61 .76 N.G.V.D. O , -
$�rz� E ,�
Z NE D. R.F
SETBACKS ( OPEN SPACE) :
FRONT : 30' I R-sZ.so. 1
SIDE : 15'
�I
• I I �
REAR: 15'
b
- DRITERIA
o ESIGN C
T
I 171 3 9G S. F 1 d l DESIGN ..FLOW: - -
_ Lcv-r 1
/ ti �
o. 40 <_.
+ A C . '� l 3 BEDROOMS AT 110 GP.BlD 330 GP.D. ® !
_ ,
/ 1 NO GARBAGE
NOTES.
_ GRINDER �
- L o-r �}-
23 The BSC Group
i . FOR PROPERTY LINE INFORMATION. SEE . PLAN � ' � I j � REQUIRED SEPTIC TANK: '
RECORDED AT THE BARNSTABLE REGISTRY OF DEEDS.
PLAN BOOK 447 PAGE 44. I /
i I cQ j 330 X 150 % 495 GAL. �o
2. THE TOPOGRAPHIC INFORMATION SHOWN WAS I PR�p�s ¢',c22 d 6 I SEPTIC TANK PROVIDED: = 1000 GAL.
i ♦ O
OBTAINED BY AN ON THE GROUND SURVEY. I + ` zed c- 1 SIZE OF LEACH Ca Cod Surveyf
LEACHING FACLIITY REQUIRED:
Corlsuttants •
3 I
3. UNDERGROUND UTILITIES WERE COMPILED FROM AVAILABLE � l � 0 � � ALL/ _ � OESK�1 PERC.RATE: � 3 MNINCa -
RECORDED PLANS OF UTILITY. COMPANIES AND PUBLIC AGENCIES QvO•F �� �4 l _ 3236MainStreet
AND ARE APPROXIMATE ONLY. BEFORE CONSTRUCTION CALL
4� •`' o. ` � it 330 G. P. D. CAPACITY Rou'te6A -
'DIG SAFE' 1-800-322-4844. \
_ Barnstable Village MA
\\ `. /000 � 02630
s; ,
617 362 8133
o
5 S¢E OF LEACHING FACLITY PROVIDED: PROJECT TITLE:
W/Z' sToA/E EL-�3.l0 6' DEEP X WDIAM. PIT W/2' STONE
PIT* _ SEWAGE DISPOSAL
S_IDEWALL - 178 S F X 2.0 356 G PD
1 SYSTEM DESIGN
BOTTOM 79 S F. X 0 83= 65 G.P.D.
F
VA OF,y,� TOTAL: 257 S.F 421 G.P.D.
LOT 5
o RENBICK m -- 421 G.P.D. > 330 G. P. D. :. OK ` STONE BRIDGE LN.
c� CHAPMAN cn
• ,o 'A No. 27654,0 &Z IN
/ LOCUS PLAN: - ;" 2oe3�
STERN
-_. . '�
�SS'ONAI'�N�'\ '
� ' OPEt1 � 1 i ,
(tea col / 5PPtcE (�4
Y; "TONS MILLS MA.
1 f
V
D TE PROFESSIONAL NGINEER -C1 ILL
I '4sy �. Locus k 7r�1�1r`� r.�J.�r. '�
s
PREPARED FOR-
Pomp
• �S/W NAZI- v .. i
_ 1
NICHOLAS FRANCO
"LN,D
OF - Pouf � .
DATE: DUNE 13 1988 '
o� C. y�
� FRANK �. - F k ���•
do e ° °� COMP./DESIGN: :S.A.A. L.t•f
WHITING
H
No. 29669 P q
y�cISTI ° ��< �•' ��p T CHECK: C.F.W.
AZ. .0
�. PLAN VIEW DRAWN: T.A.M.
� 8a � SCALE: 1'= 20' i ,o ' FIELD:
D TE- PROFESSIONAL LAN SURVEYOIR R.E.G./T.A.W.
FILE NO:
mmmmmoi
FEET
DWG.NO: 1336-5 SHEET -
• 0 10 20 40 60 .
JOB NO:3.3047.0 I OF '. 1
I