HomeMy WebLinkAbout0152 TIMBER LANE - Health 1 mber Lane -
Marstons Mills P
A = 149 o62
c
1
Town of]Barnstable P# 3 6
Departiment of Regulatory Services
nuwarABLz, i Public Health Division Date
NAM
rED �� 00 Main Street,Hyannis MA 02601
Date Scheduled Time A d
er
Soil Suitabili Assessment
tY o� Sewa e Disposal
Performed By:_�"I qU i C" el4 0 wY Witnessed By:_�z
�
LOCATION& GENERAL INFORMATION
�r,� �f c��
Location Address Owns Name "
. l 'SAa - er'-
p- 4 S f6 rt5 M 1 1 S Address ( •roT/h 6t-1- L✓4"e-
Assessor's Map/Parcel: (�Gj /O �
6 2— 1 / Engineer's Name &4Kzevl L�Pt"S�S
NEW CONSTRUCTION <REPAIR Telephone# 570 9— '17 7 ' g5 gS 7.
Land Use: .I_c5,Alp Slopes 96
P ( ) ® Surface Stones_ no
Distances from: Open Water Body coot ft Possible Wet Area i00+ ft Drinking Water Well LDO4 ft
Draihage Way f ft Property Line i�_ft Other
ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands I!n proximity to holes)
A::� t 76-80
Well
TIP-t
Parent material(geologic) rrFw�S Depth to Bedrock a
Depth to Groundwater. Standing Water in Hole:., In if Vie Weeping from Pit Face "12%t
Estimated Seasonal High Groundwater
]DETERMINATION FOR SEASONAL.HIGH WATER TABLE
Method Used: Weti 1`,n 6
Depth Observed standing in obs.hole: 14, Depth to soil mottle!: �I In.
Dcpth to weeping from side of obs,hole: \ in, Groundwater Adjuatment ft.
Index Well# Reading Date: Index Well level -__ Adj.factor— Adj.Groundwater Leval
Observation
PERCOLATION TEST Date 61 S Time al &MM
'
Hole# Time at 9" VA l�1
Depth of Perc t h Time At 6" n 6 9 •
Start Pre-soak Time @ �I I I Time(V-0)
End Pre-soak I I•'2-
Rate Min./Inch 2 un t t h C z•�o t�s ` `
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN). N
Original: Public Health Division Observation Hole Data To Be Completed on Back--------
�r
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:SEPTICIPERCFORM.DOC
DEEP-OBSERVATION HOLE LOG Hole# t
Depth from Soil Horizon Soil Texture .Sdil Color Soil- Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
o i ten y.%'Gravell
4 - 12 Loam to Y'R 3l \)Ohe Fri'4.
�Z -�la 1' �jr�� Caa✓n �o.: .� �6' `� Fd`i al�tp
76 z
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA)
(Munsell) Mottling (Structure,Stones,Boulders. -
o sis en %Gravel)
Loq m icy�k 3/ Vojjr \
3 70 Ct 50,E La�tr,1 [D �R� `' � ubIe.
'70- 131 C2 VET- Lsose
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.Tg O c
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stone9;Boulders,
Consistencv. Gravel)
y
Flood Insurance Rate Map: /
Above 500 year flood boundary No= Yes
Within 500 year boundary No—k/, Yes '
Within 100 year flood boundary No.✓ Yes
Depth of Naturally Occurring Pervious Material
Does at least four feat of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? `(eS
If not,what is the depth.of naturally occurring pervious material? _
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consiste i
the required training,expertise and experience described in�10 CNM 15.017. �3N OFMgss9C'
Signature �+ �, C?"'"''—'� LSC Datblvv'e G, 201 ° QD 1D yarn
U COUGHANOWR N
s� "C N SEO Q
QAS.EPTIC ERCPORM.DOC ,� VALUPLO
_ TOWN OF BARNSTABLE �
F OCA11ON ��Z t1N1��'L `—� SEWAGE #
VftLAGE ki'R` Ibc,4S. tAkkkS ASSESSOR'S MAP & LOT 1���
INSTALLER'S NAME.&PHONE NO.
SEPTIC TANK CAPACITY �bQC)Q VO
LEACHING FACIL=: (type) (size) QQCo e
NO.OF BEDROOMS
BUILDER OR OWNER m CW*\ y) ,,Q Q
PEItWff DATE: S cc- COMPLIANCE DATE:
Separation Distance Between the: I
Maximum Adjusted Groundwater Table and 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 �C.\��
d
°
� 3
P'A-
p TOWN OF BARNSTABLE
LOCATION I 7ii r L dA CS SEWAGE# 20 Q 2—1—I 9
VILLAGE,/ A,5e 0ns' i S ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. C E?V4.t&b.rite. 0C. 6M-477-D77
` SEPTIC TANK CAPACITY 1006 C,� I /
LEACHING FACILITY:(type) �O A RC,304G. 9-0 (size) aO'x /4, 3-7.'
NO.OF BEDROOMS
OWNER a k/i d av1�.e Ott ZO /
PERMIT DATE: (® � i,o COMPLIANCE DATE:
Separation Distance Between the: 't m 0;,/ -Edd L4104 t"
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ®I1C.0 UA-q'er4,p4, Feet
Private Water Supply Well and Leaching Facility(If any wells exist on 4
site or within 200 feet of leaching facility) %� o�, Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) / Feet
FURNISHED BY Col gAp ei vG �f� Q[✓1��3 (,lam
1.
O,
� 3
L3-1
14.
T-, 74 a'4 8-3 4i 0 C74
S'r 60
B-4 54
II-5=43`L
No.��7.,r) Fee 00 eye
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2pphration for bisposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. X T litho tX_c j, � Owner's Name,Address,and Tel.No.
DAVQ> € ®&-5'0_ . DgaCeV_0
Assessor's Map/Parcel ,�-9 0(V 0e T 5a„-ri"4 LA4-)6_ KAA=kE A4 iLL
Installer's Name,Address,and Tel.No. 509 -t+'11 Z7 Designer's Name,Address,and Tel.No. Wef-09Cjq
(,wezwtp;;� GEC
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building VE5 XM.-x7rji4-__ No.of Persons Showers( ) Cafeteria( )
Other Fixtures '
Design Flow(min.required) 30 gpd Design flow provided 3 5 S n- gpd
Plan Date to-- 6-go(2, Number of sheets I Revision Date
Title t 5 3- -r(,4j ,G!�, LA,6J 1ff MA CZ.S-DIJ S" I'K(L.LS
Size of Septic Tank 1000 Type of S.A.S. A o too l c--FU 09. : f Xj FIGLb
Description of Soil V>LT ( M1rZ-7) -G 06�6 Oak IQ't P L"r*a! " -co 40-5 er --5*oj-b @ '70 e t
ScIG7 PcA
Nature of Repairs orAlterations(Answer when applicable) U C�G6 YZ0,.1f� (Doo &kL, S H 1 "tn maj
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
S' ed DateZ-
Application Approved by Date to/6 20 r-Z
Application Disapproved y Date
for the following reasons
Permit No. Z®i 2 171 Date Issued 6 i Z
����.
No ' OD
. Fee 00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
f
ltlYlLatlOn for isposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair Q( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 5}T 1 � . tN MJ 4 Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel DA�ttp � Pe$�.A. OE�zo
LL
Installer's Name,Address,and Tel.No. $'0'2 -471 Designer's Name,Address,and Tel.No. 5v9-3(ay,U$gy
1✓16d�Es'"1A94�ji�i E:K.1Ct�D�t� '� �,Q.O—T EC,.'-( ENV!RoN���77�'4-
Y 5'
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
' Other Type of Building 17 Try No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) b�34) gpd Design flow provided e 5 5+�, gpd
Plan Date !6— 10 n 1 Number of sheets t Revision Date
Title 1 15 1 -r 1 M4'-
Size of Septic Tank 10,00 &OAA n J Type of S.A.S.
Description of Soil P tT it 1 yr. GR'10•Q rT *E1 ow 4"-D
a
Nature of Repairs or Alterations(Answer when applicable) u 5C_:, t= l1 � � C 'rn N
1 C
� V I
i
Date last inspected:
Agreement:
i
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
i
Compliance has been issued by this Board of Health.
I Si ned gzz Date
Application Approved by Date //6 2,,
Application Disapproved Date
for the following reasons
Permit No. 7=p(Z-- 17q Date Issued 7,0 (:
--------------------------------- ---------------------.--------------------------- ----------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS {
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded( )
Abandoned( )by 0A-0 1 4; x pn(S-65
at ]_ �� has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No °r2"17 dated
Installer �► SaDA(Ser Designer
#bedrooms �� Approved design flow S 5 e 1 gpd
The issuance of this permit shall of be construed as a guarantee that the system wil ffictio e .
Date �!//� �, Inspector 1
-----------------------------------------------------------------------------------------------------------------------((-----------------
No. ZO 1Z - I�� Feery'
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 6pstem ConstrUrtion Permit
Permission is hereby granted to Construct( ) Repair(r) Upgrade( ) Abandon( )
System located at �5 Z'" ( 6 A, e C r!na t,,,I ,5G'
f
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date �7® �Z Approved by v
Town of Barnstable
Regulatory Services
_ Thomas F.Geiler,Director
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-86246" Fax: 508-790-6304
Installer& Desi ner Certification orm
Date: ' Z i - Zo i 2_
Designer. 'kv l 1) n. 0006H PrN 0 W 1Z Installer:
Address: TZI A-W 6 L C 6 R Address: _ ® 7(-3
On 04"WAv-
was issued a permit to install a
ate) Installer)
septic system at t S Z- Timber Leine based on a design drawn by
(address)
C0VGH/ N01W T;Z�, dated -20, 2
/ (designer)
I certify that the septic system referenced above was installed subs
tantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
'(H OF MqS�
go DAVID cyG�
(Ins lei s Signa e) COUG ANOWR
to
No. 1093
C �• -4N1�C G� TA1Pkk
(Designer's Signature) (Affix Designer tamp Here
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DMSION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
1
8 3
,,"-C,•A T ION T'"�` 4""`` SEWAGE PERMIT NO.
t, a
VILLAGE /y�cov3rh :1
INSTALL E %NtA.R AJPHOEADDRESS
SE-
W"t 8anSUble, Mass. 02668
BUILDER OR OWNER
F 144hh
f�9�H w r S/"
DATE PERMIT ISSUED —r �� _ 79
DAT E COMPLIANCE ISSUED ��� `,
�,,_ _
j ,
�� �
�i
�/
`��
�/� � V
' 6�i0
1
��� �
Q�
- I°'
1
�ks� �., �,p 6 ; 'µ�,... •°y + { ` 7 c �i} ' Y Y '� f ti L�Y�-rt G r3'etf� ��"'�}�, �'���{
,�r y '� -B.:: ` ear:.-` Et2 a,a3p*''aigb ,` 7' i �•r�, yz,`',Es's a 't"�,� ,;1
41
ILI
c,i3Ls'aX--; t.t'1:�+ _2.o:,•i:y 1^w+' rFrJ 'y.�.ydY-.•.ic, ate• . ra4. ..1'=Y��! !"'vl• 1 .utt'a..?.t ...i'.`�T.o ,
r srjJlcv ?►�%'r-'�.,sf1i ys�t :w�, r
T �- v ,'dye •i fk��,�✓ �':-��1,f t � M s ::f��'`.GOr�St4��l4e�
r k f
r� r LDS-*� //jk-•�`" � ,
JQ
To I
1 � i;i /y.s �`�,•` '�F�-$���'� 4 4_ ti (�li�`!r�.:.?1hN' "::� r;^ (`�.rJ' ��d �2`(a� h ' � t� .,
. -.
r s yyrr Y}.,�.�yway�
.•_t r< .,�.-�. ,.��.�lr�-. :r lye ti ' ,'�.,a r—,�f'��tZ'`.1�. > .'fj•r� I r�J, X;�, X 2 �O `�'`�•►le
C�1�y 7 Pr '� �." � � �r ���� 't.•� c�ti�.'t ;i Mr! "rr . ,�i *" �'' A^ y = � ` o.
i 1 rat :, fN
I"Fs/1'fp�ys��i�l-/'v�1���I.�r.p�• V�1j��C�OiJ14)y�: `✓ n• o
�! a ^,� r� �+`.F' ��1 J k 0. �., �� %Il 1`lV f•'f!•✓'F'. 'r {,r�� �>;� F tf ri`.ay r -u;
�i.µ`!C L'a' .�_ ' Tfh;;l ' f. 'l�al a�•ra off. ¢•-
�y....✓G..�+t�1i
ol
�'� •�'&•f;'-t''r•- Ci'I`L'p'f' e� ,_j� C:a�'a v �°d. '• .' ti � � x 3 . n � ��,.
1-
7
;- ..e ^-',, �', ��;:{'-� ✓ rrht;� +�.f",�`'�aJ 'fi"` ��'��r'o � '.��'"1 ��*"� 4�y;;��j+y,.i
-"f-' loci!-k 'a1.. T.0
sw
4.
V i
R
y1_. §5✓^G' % • R _ �3
�a Gv Tr
74
` , �' / .-.`.I '".'1T�Y .'r"-�1�...�.f f.�,•-� ^.�..., t- f�.... 4l'"�� „6��f yC' .�f-. tic fiyy' ij'$
. • �c�i„ l 1.•�-r�.!• . . : r• :: . , .�, � -r!',
. �yy/\/I.✓r� ✓✓�v�� {//,y{,/,..fir' T�If...t� ,. ,VY�`R!�1 ✓'i. G��!' ��
L
I.�'� Yr/✓v I :%/f/_ I ,..v, �� TLvry ✓Yfr � �e+'r � ✓(` L .� '��w:�../ /�� a„ '' y+ta,E,� 5 .r.,
,.yam•I ..�. Cs3�"'� c,G7 « B��"�
-�,,,�sS ��-• , i " ` r4 ! � .. , � � � �'A'1"�.=., ; 7r''2�1rt'1 �L"�'o:� ' _ � 7 ���-�
No.........
9
� _ Ficz.....c2.g................
THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH
.................... ...OF...............
ApplirFation for Uispnonl Works Tonstrnriiun ramit
lu Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal.
�Syst at:
is ...., .0 ._ � . . .. I..•--.-•-•.• . -.� 31.1.................. ............
---....--..-
Address a or Lot No.
.......... . ..... & -------------------- --------•---••---••-•••••---••---..............--•...............................................
Bwner Address
a ........ .. .. .:................................... ......•........................
Installer Address
UType of Buildi ig/ Size Lot............................Sq. feet
Dwelling v—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder I� .
Other a —T e of Building )—Type g ____________________________ No. of persons__._._._.._______.._..___._. Showers ( ) — Cafeteria
Otherfixtures -----------•----•--------------•-•-•--------------•-----•••-•----•-----------•••------•----------•----•.........-----•---•----••-•--•-.........------
w Design Flow........... ................... g�lions per person per day. Total daily flow......... _ ._ !._.0-............gallons.
WSeptic Tank Liquid capacity/44-allons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No .................... Width.................... Total Length.................... Total leaching area................
._ sq. ft.
Seepage Pit No---------�_._..... Diameter...._._ . ...... Depth belolPit_
et......�p........ Total leaching area__.- sq. ft.
Z Other Distribution box ( ) Dosing tank ( /
'~ Percolation Test Results Performed by................... ....._........... Date......Test Pit No. 1................minutes per inch Depth of Tes ................_ 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----- ..:.. ..y. _Q�= �'`�t�+,. -= ` -�. � isa�c�
x
w
..........................................................
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
f '
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i I:'E 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.
ign •. --••----•---------------- ---------••••---......----••.......---
Dates
Application Approved By.....°---- �-= -•----. ..--�(/ • -- ................ -
Date
Application Disapproved for the following reasons: ---------------•----•---------------------•-----------•-----------....-----••----•-••-----...•---•-
.................<........••----••----.•-•-......-•----•....•----•-•-.....-•---._......_......----•-•••-•--•••--•---.........•---•--•-•-•-•---•---••-••--•-•-••------------------•-
®^� Date
PermitNo.. ......................................... Issued-- � ............
Date
No.........'�. �".... FEs.._..��..5_.._ ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
AVVfirau#.jt for D sp.a�af, urkt Tonstrurtinn .rrmft
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syp ' ,,- � .......... ..... ,.8 __---_-____------- ....... ---
.. .. --..
i ne-Address E or Lot No.
.......... y ... _........ ... .
- caner Address
W
Installer Address
d Type of Building" Size Lot............................Sq. feet
aqwelfingAf No. of Bedrooms_________________________________________...Expansion Attic ( ) Garbage Grinder {� �
Other=Type of Building No. of ersons____________________________ Showers ( )
a yP g -------------•-•--•-----.... p ( ) — Cafeteria
� Other fixtures -----•--------------------.-•-------•---•-•---------------•-••----•---- --•- -------..._----•--------•-•-
W Design Flow ......... lions per person per day. Total daily flow........ .............gallons.
1:4 Septic Tankf-Liquid capacity _______gallons Length................ Width................ Diameter__.__ .__-__.__ Depth................
Disposal Trench No _______ Width__ ....... Total Length____________________ Total leaching area____ sq. ft.
Seepage Pit No...._:_.. Diameter_._.... Depth below et____..�.__.___ Total leaching area._ � '_ sq- ft.
Z Other Distribution box-,(,. ) Dosing tank
y
Percolation Test Results Performed b __________________ _ _x_.__ ... __ _ _ Date__,_. s✓ d
Test Pit No. 1.... .......::minutes per inch Depth of Tes Pit.................... Depth to ground water_........................
(s, Test Pit No. 2.................ihinutes per inch Depth of Test Pit-........... Depth to ground water..........................
j,
O Description of Soil4�_..-. -- ' 2 "� r
9�4
-. =
W '
UNature of Repairs or Alterations—Answer when applicable.................................................................................................
---
Agreement
1.The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of SITLE 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.
f;
............. ---- ...-----•--....---------
Dat
Application Approved By....... .' ' �'-----------------_ --•.....•. -• '
Date Application Disapproved for the following reasons_________________________________________________________________
----------------------------------------------
-•---•.........................•-••-----•••-•--...••---------....._........_..-----•-•--••--•-----•-•-••-•-------..._.....---------------------------•-•-................-�---•-....--------------------
Date
PermitNo......................................................... Issued.....................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
..........................................OF..... :. ... '. : ...................._...........................
Intif ira#r of Tomphanrr
J64
S1
TO CE IFY at the Individual Sewage Disposal System constructed ( �r Repairedby_... --p '
is
ta t
I_!Ak
V .
application for Disposal Works Construction Permit o.__ _____ datedy Code as described m the
has been installed i accordance with the provisions of TI, Thei8tate Sa.nitar-' `* as described
}
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CbNSTR A RANTEE THAT THE
SYSTEM WILL FVNCTION SATISFACTORY.
... Ispctor ............................
DATE.... - .._.. ...� ...-•-----•••------_._.. ------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
p
N 7� �6-S . ....OF t FEE 'I A -�
tntn
�is�rns r�s n rilan rrnti�
Permission s reby granted_..... ---�`---- l . ..:. -•-•------------------------- ------------------------
-------------
to Cons or Repair ( ) n I iv ual Sewa ispo steal
.................
at No.__
Street
ag�shown on the application for Disposal Works Construction krpit No ." ated___.����✓*._,� �._......_.
....................-
✓/ Board of Health
DATE.................... .................................... ,. ..
FORM 1255 HOBBS & WARREN; INC., PUBLISHERS
No................_....... Fx$..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................................OF
Allpliration for Disposal Works Tonstratr#ion rrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
..................._....
.........................•-....... .. ......... - - ..........................................
Location-Address or Lot No.
......................»...-...................................................................... ..................................................................................................
Owner Address
W
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building J...... No. of persons...........................: Showers — Cafeteria
dOther fixtures -----------••--••---------------------------------•----------•---------•-•--•-•-----••----•------•-'-----•------------.....-----..............------.
W Design Flow............................................gallons per person per day. Total daily flow----........................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter..--............ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.--.....................
•---•-••'-------------------------------•--•----.......--------......------....----•---•---'---...._....................................
•-----------------
-•-
O Description of Soil........................................................................................................................•------------------. ...........--...........
x
U ........-•-•-•---••-•--••-•..............'----•-•---......-----•-••-•-••---•---------•---•...••-------••••-------------••--••-•------------•-•----------.....------...........---•--......--•---•.....•.
w
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
...---•-•-•---•-----------------------------------------•--•--------......-•----------..............----•----------------------------------....--------•------------------------------------•---•-------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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...........................----------•-•-•----'•-------••---•"•--...--•'---•-'--------•----_.... ........................................
Date
Application Disapproved for the following reasons_______________________________________________________________•_.._.----.---------------........._....._..__....
-•------------------------------------------•---.....------------..........------.........................----.......----------------------------...-----------------------------------------....._--'-•-
Date .
PermitNo......................................................... Issued.......................................................
Date
- - - - --- ---- L
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
fit
ClErdifiratr of TontpliFanre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-----------•----------------•--------------------------------------------------------------------- ----------------------------------------------------------------------------------------------
Installer
at......................................................................................................................................................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.......................................... dated..........................-.....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF.....................................................................................
No......................... FEE........................
Disposal Nab Tonstrudion rrmit
Permission is hereby granted............................................................................
'•----•-------------••••--------.....
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo....................................................................--'--•'---.................-----------------•---------•-••------------------•--•-------------.....----
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
•--------------••-------•--•-•-•----....---------------------...--------•-'•----..........'•---•-...:....
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
No................ ....... FEs.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................ .......-----....--...OF................................................................
,z pp iration for Dispooal Works Tonstrurtion rrmit
Application is hereby made for a Permit to Construct or Repair
pp y ( ) p ( ) an Indrvldual Sewage Disposal
System at:
................__.............................................................................. ......----••.....-------•.................•••-•-••••--.......................•..............•••--•
Location-Address or Lot No.
......-•........................................................................................•• •--••.............-•••-•••----....................--•-•-............•..........................._.
Owner Address
W _
W
Installer
Address -
Type of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ----------------------------------------------------------••--•-•---•-•..........-----•---•--••--•••••••-•----•-•---.......-----•--•-............•---
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
W .-Septic Tank—Liquid capacity............gallons Length................ Width --............ Diameter------.......... Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter..........-:........ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........---.............
44 Test Pit NO. 2................minutes per inch Depth of Test Pit---................. Depth to ground water........................
9 •----•-----•-••---------••--•••.............................••-----••-•-•---•---••••--......-•-..............................................................
0 Description of Soil........................................................................................................................................................................
x
U ........---•--•-•---•••.....-•--.....••-•--••-•-•.....---•...-•-----•-••-------•--•...•----------•-----•-••-•---•-----•----•-•---•-•------•--••-•----••...--•--.........••----••----•--••--•--•--••--•••-
w
UNature of Repairs or Alterations—Answer when applicable......................................................................................_.......-.
-------------•---------....----------------------•-------------------------------------------------------•---•-.•.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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.................................................................................................. ........................................
Date
Application Disapproved for the following reasons---- -----------------------------------------•---------------...----------------------------•--••-•-•--....._...
---------------------------------------------------------------------------------------------------------.............------------------------------------..............................................
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
(Intifiratr of Tompliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by....................................................................................................................................................................................................
Installer
at.._..
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................................1.........O F.....................................................................................
No......................... FEE........................
Disposal Works Tonotrurtion rrmit
Permissionis hereby granted...............................................•---•-••---••-•--•--•-•------•--•--••-•...........-•-•--......................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No. - -
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
.................................................... .................................................
DATE................................................................................
Board of Health
'�� FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
r
CERTIFICATE OF ANALYSIS rage: 1
Barnstable County Health Laboratory
Report Prepared For: Report Dated: 1/21/2003
Order Number: G0318684
Debra DeCenzo
152 Timber Lane
Marstons Mills, MA 02648
Laboratory ID#: 0318684-01 Description: Water-Drinking Water
Sample#: 18684 Sampling Location: 152 Timber Lane Marstons Mills Collected 1/16/2003
Collected by: D DeCenzo Received 1/16/2,003
Routine
ITEM RESULT UNITS MDL MCL Method# Tested
LAB: IC Lab
Nitrates 5.5 mg/L 0.1 10 EPA 300.0 1/17/2003
LAB: Metals
Copper <0.1 mg/L 0.1 1.3 SM 311113 1/17/2003
Iron <0.1 mg/L 0.1 0.3 SM 311113 1/17/2003
Sodium 16 mg/L 1.0 20 SM 311113 1/17/2003
LAB: Microbiology
Total Coliform Absent P/A 0 Absent 309 1/16/2003
LAB: Physical Chemistry
Conductance 144 umohs/cm 1 EPA 120.1 1/16/2003
pH 5.7 pH-units 0.1 EPA 150.1 1/16/2003
Note: Sample has higher than average levels of Nitrates.Monitoring is recommended(2-3 times per year)to establish any upward
trends.
Approved BY:
(Lab Director)
t/L/AZ 1`03
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
.UVCOMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS�
DEPARTMENT OF ENVIRONMENTAL PROTEC ON
ONE WINTER STREET, BOSTON KA 02108 (617) 292-5500 j
�s\ TRUDY CORE
WILLI" F.WELD Secretary
Governor
i
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Commi«ioner
Lt. Governor
n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
r��`� — 1`�G1 PART A
V�U r to L CERTIFICATION
Property Address: `S2 =�" ` � �N t Kvl�"C�owS Address of Owner: "k kc4_
Date of Inspection: Q�, I `[1 ' (If different)
Name of Inspector:
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: 'r L--
Mailing Address:-P In
Telephone Number: Cr,`•— `11 — l _cam
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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance
of on-site sewage disposal systems. The system:
Passes
_ Conhionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_` Fails
1yQ Date:
Inspector's Signature: `"
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any
failure c iteria not evaluated are indicated below.
COMMENTS: � S'\�'v\ c Si , G
c 1
BJ 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.
Indicate yes, no, or not determincd (Y. N. or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection. or the
septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exftltration, or tank failure
is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 04125197) Page 1 of 10
db
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is dtie to broken or obstructed pipe(s) or
due to a broken. settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health).
Describe observations:
broken pipe(s) are replaced /
obstruction is removed
distribution box is levelled or replaced /
The system required pumping more than four times a year due to broken or o tructed pipe(s). The system will pass inspection
if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health i order to determine if the system is failing to protect the
public health. safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETEP-MR4ES THAT THE SYSTEM IS NOT FUNCTI0N-D4G IN A
. MAIN-NER WIUCH NN'ILL PROTECT THE PUBLIC HEALTH AND SAFETY A.ND THE ENVIRONNIENT:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vege ted wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEAL , (AND PUBLIC '"'ATER SUPPLIER, IF APPROPRIATE)
DETER,ti11r1ES THAT THE SYSTEM IS FUNCTIONII�I IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorpt' n system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil abs Lion system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil ab rption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil sorption system and the SAS is less than 100 feet but 50 feet or more from a private
water supply well, unless a well at analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facilit and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
Method used to determine distanc (approximation not valid).
3) OTHER
i
(r.erised 04W/97) Page 2 or to
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D] SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
— — i
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System. cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply.
i
Any portion of a cesspool or privy is within a Zone I.of a public well.
Any portion of a cesspool or privy is within 50 fee/Of a private water supply well.
Any portion of a cesspool or privy is less than�1'00 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the wellpas been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compoun , ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the ollowing:
The following criteria apply to large systems i addition to the criteria above:
The system serves a facility with a design w of 10,000 gpd or greater (Large System) and the system is a significant threat to public
health and safety and the environment bec se one or more of the following conditions exist:
Yes No
the system is within 400 f t of a surface drinking water supply
the system is within 2 feet of a tributary to a surface drinking water supply
the system is located n a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(mvised 0412S/97) Pace 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: QI}S
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_ Pumping information was provided by the owner, occupant, or Board of Health.
^ 1 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.
_ The system does no[ receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles o_r
tees, naterial of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
—The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
(15.302(3)(b)]
(revised 04M/917) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: �J�--
Owner:
Date of Inspe lion: `���C
U FLOW CONDITIONS
RESIDENTIAL:
Design flow: -) p.d./bedroom for S.A.S.
Number of bedrooms:-_
Number of current residents:O
Garbage grinder (yes or no):�1
Laundry connected to system (yes or no):��-
Seasonaluse (yes or no): Q t
Water meter readings, if available (last two (2) year usage (gpd): I-` -� \6C
Sump Pump (yes or no):�U
Last date of occupancy:_�S�+tiT
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:_ allons/day
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 readines, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GEINERAL IN'FOR.MATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: Gallons
Reason for pumping:
TYPE OF SYSTEXI
_ 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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, dace installed (if known) and source of information: A-- �
Sewage odors detected when arriving at the site: (yes or no)�U
(rertsed 04125/97) Page 5 of 10
it
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
P �
Date of Inspection: '8
BUILDING SEWER: ^_
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANKS
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal. list.ace _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:
Sludge depth:_
�t
Distance from top of sludLe to bottom of outlet tee or baffle:
Scum thickness: Q'`
Distance from top of scum to top of outlet tee or baffle: l
Distance from bottom of scum to bottom of outlet tee or baffle: (o 0
How dimensions were determined:
Comments:
(recommendation for pumping. condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, tructural mAcgnt,.
evidence of leakage, etc.)
;i�l)sL
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
(revised 44/2.5/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: ( SQ1
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in workine order _ Yes: _ No
Date of previous pumping:
Comments:
(condition of inlet tee. condition of alarm and float switches. etc.)
)ISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:�w`UvKIT S N'a_Q�
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
-ID—` k �o Lam-- 5 ��T �U C Vv .t���_ 14e_S Q- C-C�vt 02Lt
' t
PUMP CHAMBER:
(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.)
(revised 04125/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
T p SYSTEM INFORMATION (continued)
Pe Y
Pro rt Address: ,l ��(:Vz_ LAJ .
Owner: 10 1 'L
Date of InspectiQon�ttU
SOIL ABSORPTION SYSTEM (SAS): S
(locate on site plan, if possible: excavation of required, but may be approximated by non-intrusive methods)
If not determined to be present, explain: _.
Type:
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches. number.length:
leaching fields. number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc. j
-Z`2--
�9
CESSPOOLS: _
(locate on site plan)
i
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, etc.)
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.)
(revised 04125197) Page 9 of 10
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propert Address:
Owner.
Date of Ins, cti,
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
� lS2
2 i
. � 3
(revised 03/25/97) Page 9 or to
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Pro pert Address:
Owner:
Date of Inspection
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators. installers
Use USGS Data
Describe in your own words ho you established the High Groundwater Elevation. Must be completed)
XIti)V2S � 1C� I`fiT C'VVS
y
(revised 04125/97) p4e 10 of 10
71
t
-" �--- ' MARSTONS MILLS. MA
! WELL QP AACF SANE
o CD
J TfM� R o
MEd F
= 7 R t J P
r
lil(V L c oCus
Ca Ln EDGE OF I 50
+13 O.S '� PAVEMENT 1
Z LL1 ��J F P
w
�A O�0 NOT
N
a Illiiiiiiiiillllllll ~ -I 1 �� SCALE
Illllllllllllllummu Y Z RN,
Illlllllllllllllllllmu O WU OQ i 64 ®� LOCUS MAP
z z ullumlllllilllll 0 3 --- --_
_ "IIIIIIIIIIIIIIIIIIIIIII O _ /
o �( 1 O IIIIIIIIIIIIIIIIIIIIIIIII U L - I�8.4 MINIMAL
;j U IIIIIIIIIIIIIIIIII a W tn� 1 > / A — I Ft s4 CONTOURS GRADING
LL1 iiiiiiillllllllll LIJz O 1 \�!. " -���� PROPOSED
m\ �� IIIII MC) O I ! --
Illllllllllummuuu � \ /
Za IIIIIIIIIIIIIIIIIIIIIIIII O 1 �(D EXISTING -4®
llluullllllllllll
2 W r �Illlulllllllllllllllll >�f � (1)= 1 1 1
p n U\ IIIIIIIIIIIIIIIIIIIIIIIII OU B4
�� � Illllllllllllllllmum 0�0] � �_
LD uumlllllllllll OQ Q PAVED DRIVEWAY / I
W lullllilllllll °�m X Illllllllllllllumml i \ \
O= cD Illllllllllllllulllloll / f FROM WELL 2 2
150 t WELL 1 64 /l LS ( La l\ D
I- uloulllllll111111 � L� UV
a� Illlllllllllllllllui O
O IIIIIIIlIIIII lllllllm
QI / 1 EXISTING
ulllllllllllll �1 1 1000 GALLON
_-� ulllllllllllll SEPTIC TANK
m OL<< 4- 1 —� I EXISTING LEACH
l a �� I PIT/CESSPOOL
rar 60U0 Ln 1 VEN T \ 1 �� Net,
•
0.� 1 I PIPE �� ��
OLMn, Ln M 1 Is EENCH MARK ��p � �� I� TEST PIT ® D-BOXG
1 f L PAINT SPOT ON STUMP { �Q ® ®��QD GI� 1 (0
LUWARC 36 HC ELEVATION = 65.76 �e s �� 1 HYDRANT Q ORA/Nz C z(n SOILBARNSTABLE GIS DATUM(a ABSORPTION 1 �o I DECIDUOUS CONIFEROUS
w ca SYSTEM 1 TREE oqq TREE
TP-2 I age 12-M `7�12-P
3� � m IB-O O
-SEE DETAIL
Q' (�J -NUMBER REFERS i0 DIAMETER IN
O C') O = J ON REVERSE 1 INCHES. LETTER DENOTES TYPE.
(v Iti 1 1 O-OAK M-MAPLE P-PINE C-CEDAR
J � r 1
(n< U L� (�j cb Ln
W z Q j LO Ln (y) I 1 TP-1 9
>tl 1 GARBAGE GRINDER p n I
O LL Y 1 IS NOT ALLOWED
l�0 T 3 9
O e/��j�J Cc)
I 1 WITH THIS DESoGN. AREA 20245 VARIANCE REQUESTED
w'VI C O L�—_ I MAY BE GRANTED IMMEDIATELY BY HEALTH AGENT OR HEALTH INSPECTOR.
59.49 Ft ��'--- -- 1 310 CMR 15.221(7) - COMPONENT
_ I DEPTH TO FINISH GRADE. 36 in
Q J � 125.00 Ft --�.._.�.�----�.
J MAX REQUIRED - VARIANCE TO
Cal 0 72 in OF COVER REQUESTED.
O x o a Lu PLAN � ���� j"of�SSq
I-_ m 0 �J o Boa DAVID y�N �o� DAVID °y� �,®� T�� SEWAGE DISPOSAL SYSTEM PLAN
Q SCALE: I in = 20 ft o D. o D �`, + -TO SERVE EXISTING DWELLING
O 1 Sr- COUGHANOWR - "Z COUGHANOWR N EST. DAVID AND DEBRA DECENZO
+ (n 20 O 20 4.o No. 1093
OWNERISI OF RECORD
m (3 O IO 20 �FC/ TE so,�'�ENSE°oQ 152 TIMBER LANE
LL S R�PN EVALUP ��` �f.�i 1995 �,�� MARSTONS MILLS, MA
Oil Ln �Vh� 6 2 O j Z �ON1�� PROPERTY ADDRESS
X X ASSESSORS MAP 149 PARCEL 62
O w ll1 LLl w ; THIS PLAN IS INTENDED SOLELY FOR INSTALLATION OF THE SEPTIC SYSTEM 43 TRIANGLE CIRCLE
n DEPICTED ON IT. FOR ANY OTHER CHANGES TO THE PROPERTY INCLUDING SANDWICH MA 02563 DArE: DUNE 6. 2012
I PLACEMENT OF ADDITIONS. SHEDS. FENCES OR SWIMMING POOLS. OWNER (7�
SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. 506 364-0694
1 JOB o E T E-3 61 PH 112 VERSION
:1
SML NEST LOCH DD C, SMN CQLC ULAT NS
DATE OF TEST: JUNE 5. 2012 DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD
SOIL EVALUATOR: DAVID D. COUGHANOWR, R.S. SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS
WITNESSED BY: DONALD DESMARAIS. HEALTH DEPT.
PERC NUMBER: 13662 -,, -, USE EXISTING 1000 GALLON SEPTIC TANK IF IN
SOUND STRUCTURAL CONDITION. IF NOT.' INSTALL
NEW 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED)
TEST PIT 1 PAORENT GROUNDWATER
MATERIAL: P OGLLAC AL OUTWASH DISTRIBUTION BOX: USE 6 OUTLET H-20 D-BOX.
PERC AT 102 in - 2 MIN/INCH IN C2 SOILS
ELEVATION SOIL ABSORBTION SYSTEM:
DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DD I S T R I Q U TOON B O X
64.40 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING INSTALL 20 ADS ARC 36 HIGH CAPACITY BIODIFFUSERS
0-12 Ap LOAM 10 YR 3/3 NONE FRIABLE 20 UNITS x 5.0 ft / UNIT = 100 L.F. O►MENSIONS AND DETAIL USE SHOREY OB-b H-20
100.0 L.F. x 4.80 S.F./L.F = 480.0 S.F.
12-30 B SANDY LOAM 10 YR 4/4 NONE FRIABLE 480.0 S.F x .74 G.P.D. I S.F. = 355.2 GPD NOT
58.57
30-70 CI SANDY LOAM 10 YR 5/4 NONE FRIABLE USE 20 ARC-336 HC 55 2 IO IFF330RG D EOUI EDRED BELOW SHE AS O 16 in
70-144 C2 MED-COARSE SAND 10 YR 6/3 NONE LOOSE REFER TO DEP APPROVAL LETTER TRANSMITTAL
52•40 # X235253 FOR CERTIFICATION OF ADANCED OFROM
K C ` `' TO
DRAINAGE SYSTEMS BIODIFFUSER SYSTEMS. O o SAS
00 o,
TEST PIT 2 NO GROUNDWATER ENCOUNTERED
PARENT MATERIAL: PROGLACIAL OUTWASH 6 in STONE BASE
2 MIN/INCH IN C2 SOILS 1000 GALLON SEPT§C TAN 24 ,n 2� CROSS SECTION VIEW
ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER S LS1� 0
(INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING DIMENSIONS AND DETAIL NOT TO
64.5Oo USE EXISTING UNIT SCALE
0-12 Ap LOAM 10 YR 3/2 NONE FRIABLE SO Q B.SOR p VION
12-32 B SANDY LOAM 10 YR 4/4 NONE FRIABLE SEPTIC TANK IS TO BE PUMPED DRY AT TIME OF INSTALLATION AND IS TO SYSTEM T LS UVU CONSTRUCTION
32-70 CI SANDY LOAM 10 YR 5/4 NONE FRIABLE DETAIL
58.87 BE EXAMINED FOR STRUCTURAL
70-138 C2 MED-COARSE SAND 10 YR 6/4 NONE LOOSE INTEGRITY. INSTALL NEW PVC OUTLET USE ADS ARC 36 HC BIODIFFUSERS
53.00 TEE EQUIPPED WITH A GAS BAFFLE. GRAVEL FREE INSTALLATION - USE DEP
APPROVED INSTALLATION PROCEDURES.
In INSPECTION
TAPER PORr 20.0 ft
NOTES INSTALL 0
C TWO AND
SHOW ON
1) INSTALLER TO OBTAIN , DISPOSAL WORKS PERMIT BEFORE STARTING WORK. o 00 AS BUILT Lo
RIFT LOCATIONS F ALL UNDERGROUND UTILITIES I CARD
2) INSTALLER TO VERIFY LOC O S O o
BEFORE EXCAVATING FOR SYSTEM. "-
3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS o
OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). \�
4) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES \0 20 UNITS TOTAL - 5.0 ft PER UNIT
AND APPLIANCES, AND BIANNUAL PUMPING OF THE SEPTIC TANK. _ %
5) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL 8 f r 6 "' A
STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH CROSS SECTION VIEW
ET OUTLET
SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING. COVERCOVER RESTORE VEGETATIVE COVER
6) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT BACKFILL WITH CLEAN PERC
PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. 3 IN DROP SAND TO TOP OF CHAMBERS
*� �` —► /l FLOW LINE
7) SEPTIC TANK TO BE PUMPED DRY AT TIME OF -SYSTEM REPAIR AND CHECKED FROM IO in 14 TO
FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET; TEE FITTED WITH GAS BAFFLE. BUILDING in D-Box
48 in
8) EXISTING LEACH PIT TO BE PUMPED. COLLAPSED, AND REM VED OR .FILLED. LIOUID GAS 10.75 in HI-CAP
'; -• LEVEL BAFFLE
EFF DEPTH UNITS
SEWAGE DISPOSAL SYSTEM PLAN - Ex1s TING
,- �- z 2.875' SUITABLE
PAGE 2 OF 2 MATERIAL
EFFECTIVE WIDTH = 5 x 2.875' = 14.375'
DAVID & DEBRA DECENZO _ _ ` `' '�'• SEPARATION OF INLET AND OUTLET TEES
SHALL BE NO LESS THAN LIQUID DEPTH
"' USE S ROWS OF 4-ARC-36 HC ADS
152 TIMBER LANE CROSS SECTION VIEW - BIODIFFUSER UNITS-NO STONE
MARSTONS MILLS. MA
1UNE 6, 2012 ETE-3617