HomeMy WebLinkAbout0059 STONE BRIDGE LANE - Health 59 Stone Bridge Lane
Marstons Mills F
A = 125 006008
Commonwealth of Massachusetts
µ3 Title 5 Official Inspection Form
hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Stone Bridge Ln -
Property Address iI
Linda Ford r
Owner Owner's Name ;y -
information is ,.
required for every Marstons Mills ✓ MA 02648 4-17=.-1.`._9
page. City/Town State Zip Code Date of'I:nspection
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.
A. Inspector Information
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code'
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that) am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed
above; the information reported below is true, accurate and complete as of the time of my inspection; and
the inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that
the system:
1. ' ® •Passes .
T; 2. ❑ Conditionally Passes
4: -
3. ,.0 Needs Further,Evaluation by the Local Approving Authority
4. ❑ Fails
4-17-19
nspector's Signature Date
The system inspector shall submit a copy of this inspection rep
ort to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc-rev.7126f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
rvi o� Title 5 Official Inspection Form
I�r'
I,I ws
161 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Stone Bridge Ln
Property Address
Linda Ford
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-17-19
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:,,.
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y El ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i 0111 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,�.T,;;•;> 59 Stone Bridge Ln
Property Address
Linda Ford
Owner Owner's Name
information is Marstons Mills MA 02648 4-17-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms aired.
are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ ' broken pipe(s) are replaced ❑ Y ❑N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑N ❑ ND (Explain below):
' ❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below):
❑ obstruction is removed ❑Y El ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
''the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
w.�
rr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r11. > 59 Stone Bridge Ln
Property Address
Linda Ford
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-17-19
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within'50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
[]The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
[]The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
rI ;. Title 5 Official Inspection Form
i PI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments :
a I'vlF
�r
59 Stone Bridge Ln
Property Address
Linda Ford
Owner Owner's Name
information is Marstons Mills MA 02648 4-17-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No -
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 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.
5). Large Systems:To be considered a large system the system must serve a facility with a design
' flow of 10,000 gpd to 15,000 gpd.
J". a r For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
cam° Commonwealth of Massachusetts
ra Title 5 Official Inspection Form
w I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 9 p Y rY
59 Stone Bridge Ln
Property Address
Linda Ford -
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-17-19
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Wasthe facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i �► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Stone Bridge Ln
Property Address
Linda Ford
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-17-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 4-2019
Date
f
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
59 Stone Bridge Ln
.rY.
Property Address
Linda Ford
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-17-19
City/Town/Town State Zip Code Date of Inspection
page. Y P P
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: -
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
rl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
A
59 Stone Bridge Ln
Property Address
Linda Ford
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-17-19
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Tank 1980's with new field in 2003
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 24"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
i-.I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
>
Jsj
:. > 59 Stone Bridge Ln
Property Address
Linda Ford
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-17-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 18"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 gal
Sludge depth:
12"
Distance from top of sludge to bottom of outlet tee or baffle
20"
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
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
r� �� Title 5 Official Inspection Form
Ir
i W2
p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Stone Bridge Ln
Property Address
Linda Ford
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-17-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth.below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
+ Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight.or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a <,
r_ ? 59 Stone Bridge Ln
Property Address
Linda Ford
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-17-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
.Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from field.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i i,l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Stone Bridge Ln
Property Address
Linda Ford
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-17-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
' ❑ leaching pits number:
® leaching chambers number: 2-500's
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
T e/yp name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
--i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Stone Bridge Ln
Property Address
Linda Ford
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-17-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach chambers in good condition with water level and stain line at 6"off bottom of chamber.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
I�
Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
W
59 Stone Bridge Ln
Property Address
Linda Ford
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-17-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
w
p Subsurface Sewage Disposal System Form Not for Voluntary Assessments
59 Stone Bridge Ln
Property Address
Linda Ford
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-17-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 1 00 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
Dvck
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t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
w� p Title 5 Official Inspection Form
hl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Stone Bridge Ln
Property Address
Linda Ford
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 4-17-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
® Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a ��•
59 Stone Bridge Ln
J-
Property Address
Linda Ford
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-17-19
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspecbon Form:Subsurface Sewage Disposal System-Page 18 of 18
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No. 11 U,3— 2�3 Fee J t/
p THE COMMONWEALTH OF MASSA6HUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Migogar OpMem Congtructfon Permit
Application for a Permit to Construct( )RepairUpgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot �No. Owner's Name,Address an �
d Tel.No. 15 0 • D• S 8S2
5'9 stonc B-►dqe. c.�., IH �� ns Atan£po,,y Lt4m
Assessor's Map/Parcel l S oo �Q® 15c, C"�6L—ZO1 Ln- M-K,Its t4h 026"
Installer's Name,Address,and Tel.No.r�� Designer's Name,Address d Tel.No.
•5.13eu f lc cctpa (:Ons-4 l.C/�lay) Down 1�1�1�
P. 6?-% - vo re zkdaLt,rnA 0226 *9 tA d rYnW+ A 024
e �
Type of Building: esid£nC-p—
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures ,®
Design Flow 3a® gallons per day. Calculated daily flow -I gallons.
Plan Date ' (D umber of sheets Revision Date
Title
Size of Septic Tank 1000 Type of S.A.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure t06 nstruction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Tr e of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued y t is Board of Health.
Signed A Date
Application Approved by Date
Application Disapprov for a following easons
Permit No. 20D Z-a 7-7 Date Issued ( -/°l_03
No ()C): 7 3 '� t t {t Fee �V
r ' t
COMMONWEALTH OF MASS/A USETTS Entered in computer: .
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
a
01ppYication for Miop'ogar &pgtem Qtongtruction Permit
Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) O Complete System El Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No. 15 U�'t74' v O 2
S't Ston� I iC�q�- Cn ./ IH 1�1� (IS laY1 �.'Potty LA'1Z.
-
Assessor's Map/Parcel /o-1 5- 00 ..GO 15cj aohA. bf I A T,
1 n I' ,�/1'1 I HA Oa+g
Installer's Name,Address,and Tel.No. $ "� Designer's Name,Address d Tel.No.l'1 ��1 1 �'1
.S e.v i IcicC�.tC� o r)Skru ck i 0 h Down Gap2 Eng i near al,,l nc .
P.o-T5o�( (02.S - _Fore_ tkd0 A l m p 02-0-1 q39 �1�`Ut- , d mdtkj 14 w.(01 T
Type of Building: eSiderX.c.
Dwelling No.of Bedrooms _ Lot Size &6(V3 sq.ft. Garbage Grinder' )
Other f Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 32>0 gallons per day. Calculated daily flow ) T gallons.
Plan Date (U ' (D ' umber of sheets I Revision Date
Title '57 S 1
' Size of Septic Tank I ()0U Type of S.A. a 50n QQ dona 5
Description of Soil see-Ran '
• k
Nature of Repairs or Alterations`(Answer when applicable)
Date last inspected: /
Agreement: /
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title�of the Environmental Code and not to place the system in operatiowuntil a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed / / Date
Application Approved by IX i !_ - Date
Application Disap!� ed for the following reasons
c Permit No. 2 00?-0 7 3 Date Issued (o -/ 7-0 7
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( )
Abandoned( by t`
at ✓1-e �; M� has been constructed in accordance
with the provisions of Title 5 d the for Disposal System Construction Permit No.20o 3-a ;73 dated 1'0-/.?-0
Installer Re v,l"C_C. Designer co R
The issuance oft s perm' shall not be construed as a guarantee that the system wi i e
Date 6 Inspector
-----------------------------------------
No. o oo�—X 73 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Misspogaf *p!5tem Construction Vermit
Permission is hereby ra ed to Construct(p )Repair( )Upg ade( )Abandon( )
System located, S kie �( �G ,, AA. m �S
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Co stru tion must be completed within three years of the date of thisspperT .
1ate:_ I `/ 03 Approved by
TOWN OF BARNSTABLE
LOCATION a1 t�`3 l_C L" � - SEWAGE #q
VILLAGE �f -- �� l'f`.�bi ASSESSOR'S MAP.& LOT )
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) :3�Q % (size) X a
NO. OF BEDROOMS 3
BUILDER OR OWNER L---J+2
PERMITDATE: o3 COMPLIANCE DATE: 3
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
YV
OR fu
�. �. 2
3
ell
COMMONWEALTH OF MASSACHUSETTS
9
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a
DEPARTMENT OF ENVIRONMENTAL PROTECTION
4 MAP
V
FAILED INSPECTION PARCEL •�c'7 (9�p��
LOT
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION RECEIVED
Property Address: 59 Stonebridge Lane MAR 2 5 2003
Marstons Mills MA 02648
Owner's Name: Alan and Polly Lutz TOWN OF BARNSTABLE
Owner's Address: Same HEALTH DEPT.
Date of Inspection: March 10,2003
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 information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
X_ Fails
I 1I
Inspector's Signature: , Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments Leaching pit in hydraulic failure.
""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: 59 Stonebrid a Lane Marstons Mills
g
Owner: Alan and Polly Lutz
Date of Inspection: March 10,2003
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.
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 exfltration 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:
Page 3 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 59 Stonebridge Lane,Marstons Mills
Owner: Alan and Polly Lutz
Date of Inspection: March 10,2003
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:
Page 4 of 1 l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 59 Stonebridge Lane,Marstons Mills
Owner: Alan and Polly Lutz
Date of Inspection: March 10,2003
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''/z 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. [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.]
—Yes_(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.
A
Page 5of11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 59 Stonebridge Lane,Marstons Mills
Owner: Alan and Polly Lutz
Date of Inspection: March 10,2003
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)]
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 59 Stonebridge Lane,Marstons Mills
Owner: Alan and Polly Lutz
Date of Inspection: March 10,2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330
Number of current residents:4
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)):2001-51,000 gal. 2002-57,000 gal=148 gpd
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIALANDUSTRIAL
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 was pumped Dec.2001
Source of information: Homeowner
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:
Compliance date 6/12/90.
Were sewage odors detected when arriving at the site(yes or no): No
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 Stonebridge Lane,Marstons Mills
Owner: Alan and Polly Lutz
Date of Inspection: March 10,2003
BUILDING SEWER X (locate on site plan)
Depth below grade: 16"
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line:26'
Comments(on condition of joints,venting,evidence of leakage,etc.):
Pipe in good condition,no leaks.
SEPTIC TANK: X (locate on site plan)
Depth below grade: 1'
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: S'long x 5.2'wide -1000 gal.
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle:26"
Scum thickness: I"
Distance from top of scum to top of outlet tee or baffle: 2"
Distance from bottom of scum to bottom of outlet tee or baffle:30"
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.): Baffles intact.Liquid level 6"above outlet invert.
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.):
Page 8 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 Stonebridge Lane,Marstons Mills
Owner: Alan and Polly Lutz
Date of Inspection: March 10,2003
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: X (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: 8"
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.): Some solids carryover
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.):
n
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 Stonebridge Lane,Marstons Mills
Owner: Alan and Polly Lutz
Date of Inspection: March 10,2003
SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X leaching pits,number: 1
^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.):
No ponding or excessive vegetation Pit is not leaching.
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.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 Stonebridge Lane,Marstons Mills
Owner: Alan and Polly Lutz
Date of Inspection: March 10,2003
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.
�rq
G
` Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 Stonebridge Lane,Marstons Mills
Owner: Alan and Polly Lutz
Date of Inspection: March 10,2003
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 20 feet.
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
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:
Groundwater contour map shows water at el.40 Lot above el.60. Bottom of leaching pit 8'
below grade leaving more than 12'separation.
h
No.(J_ L. j l 0, Fps..............................
THE COMMONWEALTH OF MASSACHUSETT$ t
BOAR® OF HEALTH
1 ?Gv ................OF. i 1 5;F77�------------.
Appliration for Disposal Works Toustrnrtiun Prrutit
Application is hereby made for a Permit to Construct (/C) or Repair ( ) an Individual Sewage Disposal
System at:
........................oL®.T-----....'.................................................
Location-Address or Lot No.
Capricorn._Re d,ty,__ 'zu t............................... ... ........Hy.anni-a,.MA..II26.01
Owner Address
Installer Address
U Type of Building Size Lot...e-1 _.G,aB,3_____Sq. feet
Dwelling—No. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder (416)
'a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures -•----------------•-----------------------------------.................
W Design Flow............5. ......................gallons per person per day. Total daily flow__ a......_..__.........__gallons.
WSeptic Tank—Liquid'capacityNsg?�.gallons Length.e l_.. Width--,59`=/e1."_ Diameter________________ Depth_ '*
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area_-_____-..-_-_-_---sq. ft.
Seepage Pit No.......e.----------- Diameter-----4.......... Depth below inlet.4.4.��.... Total leaching area. �.Z....sq. ft.
Z Other Distribution box Dosing tank ( )
aPercolation Test Results Performed by. �..��� f....4?, .. !�'c.... Date..—` �......_._..
14 Test Pit No. L=.....Z.....minutes per inch Depth of Test Pit...tZ. Depth to ground`.water_-__�!f..........
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground w'ater........................
Ix .................................)...........................................................................................................................
Description of Soil._0P�4.N... ..�- � .s. c�� .,�_... _:
W .. ry .-•------------------------------------------------------------------------------------------------------- _______
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 iITLEZ 5 of e State Sanitary Code—The undersigned further agrees not to place the system in
opeoftion untiG,a rlyfi ompliance has en issue by the board of lth.
�19ne _ ._.. . ... .. __`_2_ �
Date
e�)�Application Approved By-• • ... -••............. ..... a----- ..... --•......... . •. .................................=------
Date
Application Disapproved for the following reasons -------------------------••-------------•------------•------•------•-----------------.......................
Permit No.._�... /
.1--------- ---------------------• Issued.---------•---------------------•--•--... Date------
Date
`'✓ ` _./
No....-------•---.. a c7 Fps.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....-......................................OFF,....�......-------....----........----------....................................
Applirtttion for Uiip.asal Works Cnnnilrurtiun 1hrutit
Application is hereby made for a Permit to Construct �X) or Repair ( ) an Individual Sewage Disposal
Swtem at:
�... c.fir ".t „„ri'C% ;_.e;.?/� �%' l4Sr?sr�rr 5__i%"� ..................... .'rrl ..... � ' ........ -- - .....--
Location-Address or Lot No.
-Capricorn...Read,ty...'�. .J;_______________________________ ___7.fa5--- ..Ii�annis�---MA.._II2601
i Owner Address
Installer Address
Type of Building Size feet
Dwelling—No. of Bedrooms.........�.�................................Expansion Attic ( ) Garbage Grinder (41,-:,)
WOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ..----------•-• ••---••-•-••-------•.......................•--••--••-•-•----•-----------•---------------•--........•----•---........._........------
W Design Flow..................... ......................gallons per person per day. Total daily flow....... -- .............gallons.
WSeptic Tank—Liquid*capacity e..gallons Length.:.� .`�.. Width. Z/c�' . Diameter................ Depth_4._`e.
x Disposal Trench—No..................... Width............ Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter..... ........... Depth below.inlet. 4,,7.... Total leaching area.-='--:9.7....sq. ft.
Z Other Distribution box (,k ) Dosing tank ( )
Percolation Test Results Performed by.d5C.. °` 'r-' '"_ f �_ __✓ .___._ Date._ ................
Test Pit No. 1___... -_-_-minutes per inch Depth of Test Pit-_-e��......._.. Depth to ground water-----
%----_-__------
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ................................-•............................................................................................................................
O Description of Soil__ %�c~, - -_'' �rr�3 '�I�G• Ct ' '' �yt' r�_ ='' '' = �'.
V ...• ......->cr4�.._G_ ...l. .. .� ' '>. ----.r''J• '' " _... r'tr°y"._C e4�.....
U 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 TiTL E 5 of e State Sanitary Code— The undersigned further agrees not to place the system in
op ion until.a- er ifi ompliance has been issued by the board of health.
Signed .' . ...... ......&
Date
Application Approved By... . ... ... e •--•-
'
Date
Application Disapproved for the following reason -----------------------------------------------------•---•--------------------•---------...--•-••......_•-----
Date
-------------------------••-------•-••------•---------••------------------------------------------------------------------------------
''
a../,,
PermitNo.- :-� --------•--. Issued-------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
OOA.R.�.. . .OF HEALTH
Zr—
............. VO
". .. ...............'
Tntift-raly of Toutph anrr
T I T CE IF ha t!!! i u Sewage D``i��posal Syste constructed ( or Repaired ( )
by---- ....
nst Ier
fi ` �iof � - .............................................
at jhr �/ Ia
1 ------------------------------------------
has been installed in accordance with the provisions of TIT � �of�Thac� ate Sanitary Code as described in the
application for Disposal Works Construction Permit No...._��r!_..�.__._.._.. dated---- ----_______________________•--------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS RUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F E TH /
r-,
7C r?i � o Er c..1
I � r
N -16
OF.. .......... ... FEE....:......-...........
Disposal nr D Trrn tr ion rrmit -r
Permission i hereby granted............ ••...--•-•••••. ....-- . . . --------.------..wzc/rr t
ual Sewage Disposal System - -to Construct or Re air an dived �. " ; f!F 11
at No.- ' .
}} = =
/Street (7 n )
40
=J / . ./,'..
as shown on the application for Disposal Works Construction Permit No _ r�t� Dated.._...., _..,,f !I. .V
Board of Health
DATE..
t
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
�'i • ;- .-.wt., .tin_=:jam :roxiuz-�.: ..,,ram.—..--v".r; ,. :. _.____._.. .....<-r..w„v�._..
_ �otc
ATES
pp''�� � . SST IT A VIO,c ,,_��
l3 NOT TO SC tE �70T TO >BCAIL .
+os:sERYEo NOT TO SCALE
8T GROUNDWATER NQ DATE
4. OLET AND WTLET TEEB TO SIE CAST BION OR n 5 IMANFIOLE COVER LnAM G SEEO
_ NOTES. L SEPTIC TANK SHALL EE STEEL _ �+---- 2I NO. OF OUTLETS: -BROUGHT TO"1113H 6"OE OR PAVEMENT
REINFORCED CONCRETE. TCHEM 40 PVC. TEES TO •E CENTERED UNDER 1
TP TP - NOTES: / `-
TP H-Ib LAADINB 1MANHOLE COVER
TP 2. SEPTIC TANK TO WITHSTAND_ t---�--f---9 L DIST. BOX TO WITHSTAND HAO LOADING 2"MIN.OF VB"' a
GR D.rEL.—$
:ORD. EL. -URD.£L. G71RD. EL. UNLESS UNDER PAVEMENT,bRty 8 OR r
GW. EL-. TRAVELED WAYS wHEREtN H_!O LOADING I 1 UNLESS V•NDER PAVEMENT,DRIVES OR I ED �" FILL
- - SMALL'APPLY.
J PREGAST ' TRAVELED WAYS WHEREIN H-20 LOAD4140
- n 1 DIST. 1 SHALL APPLY.
I5
�c
3. ALL PIPE CONNECTIONS AND CONCRETE WANMOL[IO V R :. •". ,�
T 1� SU."�3 r , �RotFWT To FNEW 0RAo[ "1 I Box � 4 2. PROVIDE P&ET TEE OR BAFFLE WHERE BUDPE OF - o ♦ -
• •AP CONSTRUCTION TO B!.:WATERTlGHT. t c n t� Qn a a o ob
SO/L . INLET PIPE EXCEEDS 0.06 FT./FL OR i'N PVC INLET PIPE o
.. ' • --- . 4 - t•.
n 1 t PUMPED SYSTEM. d o ss o I= o c� a a a
24 � '•�
3. FIRST TWO FEET OF PIPE OUT OF DIST
IV�Ep/U/V( I u - t�str[R -I000 GALLON b LEACHING PIT To GENERAL NOTES:
BOX TO BE LAID LEVEL. s !>�(j WITHSTAND H-10 LOADING TO - 8 6 . . .. ...•;• .. o 0 o e� e� e�'-ey o a
., •. . ••':' .. .•_• .• PLAN VEW + �' ;•. . o / i. THIS PLAN IS FOR DESIGN AND
C d RSE REMOVEABLE ,. 41• "• � o 0 0 � a .� o �
PAVEMENT DRIVE OR
� - PRECAST • �.• � UNLESS UNDER
CONSTRUCTION OF THE SEWAGE
SA�t/D II troRMAL MaaTfIt LAML COVER 3/4 TO 1•a/2 o o • . TRAVELED WAY WHEREIN DISPOSAL FACILITY ONLY.
+ r DOUBLE -1.16ZHING VIT ,'o -
=- --- -- -- •- -1 �••5.67/ �. H 20 LOADING SHALL
W/TI� r e Ir c� WASHED �. 2 ALL CONSTRUCTION METHODS AND
o., 14 o a o e_, o a c n o O► APPLY.
1 1 1 o PROVIDE •:. �.r:•:. :::: ;:. : ::::••.-.•:.:•'aL' STONE MATERIALS SHALL-CONFORM TO,AIASS.
W
O.E.G.E. TITL
E AND LOCAL A
1 80 RD_
ML[T T[[ 4 .. MIA H'T �: . .. . ._: � tn0liMs? i
4 1 1
• JOITNETRS�'�G •. o 0 0 � O to o 0 0
_ I R (�I 1 1.; '1 .. ,. I_ ,.- .• � 1 OF HEALTH 'REGULATIONS.
�7/l/E$ /R[tAAT � •. �.d•tNN. t4trTl[T 5 40r*' - -
,1 SEPTIC h I II _
/.8 _ t.�oelotr[►TN T[[ 4 INLET oNo [-s 1.. 3. ALL PIPES LOCATED UNDER PAVEMENT
c 1 1 O t3 O O O G a a
8T 7 1 TARK I 4 10 _ / ' N �/ r
ME /U/t�( I , •. ;�L�1 a I 4 OUTLET 1 e o . OR TRAVELED WAY SHALL 8E
1 ' ! I }I-- ( 'y:: _ ' ' SCHEDULE 40 OR EQUAL. ,
7- I 1 a• 1------- '•':L----_._._JA r I 4. ALL UNSUITABLE,.: ,,.,.• .. _., •. .. : DIA. L.
" -- - - ---J :•• Z 6 BLE MATE��AL (TOPSOIL,
CO '
. .. • ...• +• w .•..-• .:: •a+:•..,;. ••= �:•• ::► SUBSOIL CLAY ENCOUNTE
RED BELOW
SA�c!
I - � coo-80TTOfi1ON I
THE
INVER
T OF THE LEACH PIT TO
BE REMOVED FOR A DISTANCE OF
' � tf°TT011°M LEVEL tMRi[ �At/[ d� � LEVEI.a`TABIE IO DIA.
' CROSS-SECTION N1EN► �� CROSS-SECTIOP! BASE 10� AROUND AND REPLACED WITH
A✓EL PLAN VIEW
'SS-SECTION CLEAN COARSE SAND.
/44�► 52:� � ; V
No �4TEJ�
DATE: DATE: DATE: DATE: INVERT V ERT ELEVATIONS:
5-31=88 .
: , Y• TEST BY:
T 9Y. ?EST 8Y. TEST fl
TES " INVERT AT BUILDING 1 63.�•
STEPHEN HAAS
WIThIEScrLD BY: 1F/iTPlE53E►7 BY: WITNESSED BY: WITNESSED BY:
INVERT AT SEPTIC TANK(In) G1 :Ll '
JERRY DUNNING g INVERT AT SEPTIC TANK(OU0 �3
PERC. RATE: PERC. RATE: PERC.RATE. PERC. RATE. INVERT AT TWIST. $OX�m� 9
< 3 MINJINCH MIN./INCH WIINJMCH MINJMICH 1
INVERT AT .U1ST BOX(out) <02.79 '
INVERT AT LEACHING PIT (Z.4
a� L o-r- 7
Ar 1 BOTTOM OF LEACHING PIT 5(0.80
DATUM
p�' l U.S.G.S. MAXIMUM GROUND
VERTICAL DATUM: N.G.V.D.
WATER ELEVATION
�a / OBSERVED GROUNDWATER
BENCH MARK USED: � l�3
ELEVATION
M28RA DISK M.H.B . ROUTE 28 EL. � 61 .76 N.G.V.D. � -
\,, E/1/I�itl T .
W . .
I
'1
ED R.
,
Z 0 N . .
SETBACKS OPEN SPACE) : N -ro 3
S � iv 9 E ,
FRONT 30 / ' 45 •
1 5
SIDE . �
REAR. 15 �U LOT �o
o
9
85 i
,
,
0 46 ACV' �4
� EI
..,_... _ ATE
,
I
h
-o r `DESIGN FLOW:
3 110 3
,—BEDROOMS AT G.P.B.ID 30 G .. ,
s
/ 1
o
..�
NO GARBAGE GRINDER
s
•
k
. s
o '
d � � E�pE TheBSCGrCw .- .. .. �. . ,
RPROPERTY LINE INFORMATION SEE PLAN 1 1�) P ,.
i . FOR V
`.. 1 ! r
�/ a ;REQUIRED SEPTIC TANK.
RECORDED AT THE BARNSTABLE REGISTRY OF DEEDS, Q U �o
PLAN 'BOOK 447 PAGE 44• �c q
• / \ .Q q p• "e >.� _ 330 X 150 % 495 `GAL:
.o , ] �9,v ' ♦ ♦ a
T7 E TOPOGRAPHIC INFORMATION SHOWN WAS i , �a. SEPTIC TANK PROVIDED: = 000 GAL.
2. 6 3 R, O �•
STAIN Y AN ON THE GROUND SURVEY.
'OBTAINED B \ Ca Cod Survey Consuhantc , .
cj 2 Pe eY
-; I r► ,. _ SIZE OF LEACHING FACILITY REQUIRED. .. .
3. UNDERGROUND UTILITIES WERE COMPILED FROM AVAILABLE / 4'F a' R�,t, d� O DESM PERC.RATE 3 MNJNCN
2
y_ 3236Main Sueet
' RECORDED PLANS OF UTILITY COMPANIES AND PUBLIC AGENCIES � o ' '
AND ARE APPROXIMATE ONLY. BEFORE CONSTRUCTION CALL 1 � , Rme6A
'DIG SAFE* i-800-322-4844. / I
`j• t 330 G. P. D. CAPACITY Bamstabie Viillage MA
6'OEEP X G,"VIA. , ` 02630
/ . 8133
� 1V/2 STa.vE � � x�; 617 362
N T- .
GEsIcNi �i A'
. TITLE:
SIZE OF LEACHING FACILITY PROVIDED:
PROJECT
L 1
6 DEEP X 6 DIAM. PIT W/2 STONE
SEWAGE DISPOSAL
_SIDEWALL - 178 S.F. X 2.0 = 356 G.P.D.
o d ,
SYSTEM DESIGN
-y
\ N_ �• BOTTOM 79 S.F. X 0.83= 65 G.P.D.
OF
O ,
NTH 0 -,�
�P Mqs� = TsT PIT' ' I TOTAL. 257 S.F. 421 G.P.D. L O T
RENWI
� CK c\ \ . t
N.
B. m \ 421 G.P.D. > 330 G.P. D. .. OK - STONE BRIDGE LN.
CHAPMAN
64.$
,a •p�ND.27654 O 4 I N
Fss, G,� r 1 LOCUS PLAN. 1 - 2083
erra�6N � 1
MARSTONS MILLS MA.
to
\ 06 ,�,
0 i q
DA E PROFESSIONAL ENGINEER - CIVIL 0 ,,y., LOCUS �..�.0
: •--- - c 1007
P \ ,,. P'9• PREPARED FOR: '
004
NICHOLAS FRA NCO
r
H OF ,V 1
1 a -• DATE. JUNE 13 1986
o FRANK _ P� 07
• U WHITING H � � Q '
No. 29669 0
a, A� COMP./DESIGN. S.A.H H.Ar
w�►b�r CHECK: C.F.W. /R.1B
Ira PLAN VIEW << � 1 ��p DRAM: T.A.W
DATE- PROFESSIONAL LAND S VEYOR SCALE: t'= 20' FIELD: R.E.Q./T.A.W.
• a
-
FILE NO: '
0 10 20 40 60
FEET _ DWG.NO: 1336-6 SHEET
JOB NO: 1 OF' I
• 3.3047.0 _
,
SYSTEM PROFILE INSECTION FINP GRADE PORT WITHIN 6" OF TEST HOLE LOGS r
TOP FNDN. AT EL. C,5,5 NOT TO SCALE)
ACCESS COVER TO WITHIN 6" OF FIN. GRADE
ACCESS COVER (WATERTIGHT) TO ENGINEER: STEPHEN HAAS, PE cAPr o
MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 65•0 WITNESS: JERRY DUNNING
2" DOUBLE WASHED PEAS. DATE: 5�31 88
63.4 RUN PIPE LEVEL
FOR FIRST 2' 3' MAX. PERC. RATE < 3 MINZINCH
EXIST. _1000 PIE
GALLON SEPTIC 62.0't* if 62.0' CLASS I SOILS P# 6962
9 STONE eRlocE
TANK (H- 10 ) GAS 61.27' C] Q 0 [] Q Ii m o
ELEV. LOCUS
BAFFLE 1.44.' c> 61.17' Q M M M Cj 0 0 0 E3 " 4' AROUND 1
6" CRUSHED STONE OR MECHANICAL 2' [� [� 0 �] [] 0 [� 59 17' 0" 64.8 �!
COMPACTION. (15.220,(21)
DEPTH OF FLOW - 4' MIN MIN 3� " TO 1 1/2" DOUBLE WASHED STONE TOP & SUB
TEE SIZES: ( 1 9 SLOPE) ( � SLOPE3/4"
INLET DEPTH - 10"
" - 24" 62.8'
14
OUTLET DEPTH = LOCATION MAP NTS
FOUNDATION---- EXIST. SEPTIC 'TANK 45' D' BOX 12' LEACHING MED, TO FACILITY 637' COARSE ASSESSORS MAP 125 PARCEL 006-008
SAND WITH
GRAVEL AND
'INSTALLER TO CONFIRM ALL BUILDING SEWER OUTLETS AND
ELEVATIONS PRIOR TO INSTALLATION OF PROPOSED SEPTIC FINES
SYSTEM, 84" 57.8'
52.8'
MED. TO
LOT 6
19,685t SQ. FT. COARSE
+ 65 8
SAND AND
i
GRAVEL
+ 65.2
144" 1 52.8'
NO, GR+�UNDWATER ENCOUNTERED NOTES:
,
EXIST. SEPTIC TANK, CONFIRM MIN. + 66.1 - '�OT S:
I 1000 GAL SIZE PRIOR TO INSTALLATION
OF ANY PORTION OF SYSTEM. tq
�{ 64.5 NGVD
rn
�/ \
r'^Ti AA t(;
12' OAK + 65.a rn SEPTIC DESIGN: (GARBAGE DISPOSER Is UQT11 CLWF�
tow, -. _..
E>
66.0 DESivrd rx_CW: BEx.F2i.)Unll ( v. b) = �-Y v►'V MUM PI PITCH TO BE $" P 1 PAVED � �\ � � ,y 3. �} PE 1 f PER FOOT. -
DRIVE USE A 330 GF'D DESIGN FLOW 10
6a•6 _ {� 4 P 65 4. DESIGN LOADING FCR ALL• PRECAST UNITS TO BE AASHC H
• • SEPTIC TANK: 33�J" GPD ( 2 ) = 660 5. PIPE JOINTS TO BE MADE WATERTIGHT.
44 EXIST.
4 DWELL. \ USE A 100D- GALLON SEPTIC TANK (RE-USE EXISTING) 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.
q- c 4. TF 65.5 L ENVIRONMENTAL CODE TITLE V.
c �o / o LEACHING: 7. TH`.S PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT
4 �"�� v\ + 65 SIDES: 2(25 + 12.83) 2 (.74) 112 TO BE USED FOR ANY OTHER PURPOSE.
BOTTOM: 25 x 12.83 (.74) 237 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
+ 6 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT
\ 63.2 �, 5� 64.6 TOTAL: 472 S.F. 349 GPp INSPECTIONBY BOARD OF HEALTH AND PERMISSION OBTAINED
' 6 L=48 22' •5 4.7 USE (2) 500 GAL LEACHING CHAMBERS (ACME OR FROM BOARD OF HEALTH.
R=52.50' + 10" W.PiNE EQUAL) WITH 4' STONE ALL AROUND 10. PLMP & REMOVE (OR FILL Wf CLEAN SAND) EXISTING LEACH PIT
62. 64.9
4.5 + 64.8 Cn
T- T-----T 6a.5 + 64.5 TH 90
titI �' ��"" TITLE S' SITE PLAID
- '.�.E.___--E N LEGEND
E N D
64 .
-s3 100.0 PROPOSED SPOT ELEVATION OF T R
11z59 STONE BRINE LANE
186 44, 100x0 EXISTING SPOT ELEVATION IN TI•'E TOWN OF:
+ 62.0 BENCH MARK - CORNER 100 PROPOSED CONTOUR � MARSTO N S MILLS) BARN STABLE
OF CONCRETE BULK ir.-EAD 4 + 64.1
ELEVATION = 64.9 100 EXISTING CONTOUR PF'EP ARED FOR: ALAN AND POLY LUTZ
+ 62.7
20 0 20 40 60
BOARD OF HEALTH
APPROVED DATE MA SC.'V1j,: 1" = 20' DATE- JUNE 6, 2003
off 508-362-4541
tax W8 362-9880
I
down cape engineering, inc. OF
of
✓ , ARNE Al NE H.
w CIVIL ENGINEERS o nLA N vylA
LAND SURVEYORS ti5 •26 NQ 3=2
939, Main st• yarmouth, ma 02675 'A. . WOJAL L S. DATE
03 � 33 A. .
--
....