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HomeMy WebLinkAbout0064 TROTTERS LANE - Health 64 Trotters .Lane Marstons Mills - P A = 047 125 I 00007V ld,5 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR . DEPARTMENT OF ENVIRONMENTAL PROTECTI qpR 2 S�° a Tow 200, hFq��REp T'�gCF T TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A �-- CERTIFICATION Property Address: (4 7 /ro-#P✓' L4 In'I IS n ;11 %(o y's Owner's Name: o o / Owner's Address: 6 4 r� t,- L _ WiArs Fp s y-;,16, Date of Inspection: -ola-O/ 1 Name of Inspector: (please print) �A r K Company Name: SI Mailing Address: P0 cx /d gy _ H 0 4.)-- Telephone Number(-a8 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 Fails Inspector's Signature: T�wDate: -�v2o�-0 The system inspector shall submit Jcopy 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 ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7-o 9 rS LN Cqy Owner: o W, Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy m 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.Anv failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined'please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will . pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 67 c 411 L/� Owner: POW l t Date of Inspection: 3- a-O/ C. Further Evaluation is Required by the Board of Health: WConditions 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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 7 r/'d ks- zlt W 0.4 c#-g Owner: 0 Lae Date of Inspection: —aA-0 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N_ o/ V/Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool �/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or /clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or / cesspool I // Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped . _ V 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. V' Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. 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/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. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: T� rS 0S 1M r s. oa b +f S Owner: )�0 Lvelt Date of Inspection: — -O Check if the following have been done.You must indicate`Yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks 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 t/ Was the site inspected for signs of break out Were all system components,excluding the SAS,located on site v — 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 kWas the facility owner(and occupants if different from owner)provided with information on the proper mamtenance 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 V _ 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 dis tance stance is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 6(4 / 1-o tk,-s LN 117 Owner: o we Date of Inspection: -v2a-01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): S DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: S Does residence have a garbage grinder(yes or no): //U Is laundry on a separate sewage system(yes or no):/VO [if yes separate inspection required] Laundry system inspected(yes or no): N°0 Seasonal use: (yes or no):hV Water meter readings,if available(last 2 years usage(gpd)): A- 14 Sump pump(yes or no): A/0 Last date of occupancy: .3440 l COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CUR 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 Source of information: 00 �" �`1/I�C 1 US r `�-o u E� ✓s — Was system pumped as part of the inspection(yes or no): IV If yes,volume pumped:____gallons--How was quantity pumped determined? Reason for pumping: T'YP,I 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) Tight tank _Attach a copy of the DEP approval Other(describe): . Approximate age of all components,date ir talled(if lipwn)and source of information: Were sewage odors detected when arriving at the site(yes or no):/U�f? Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -1 rp L/V Owner. O we Date of Inspection: .3—M-01 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: t iron V40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): •Z(locate SEPTIC TANK. on site plan) Depth below grade:�� Material of construction:—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) J X Q Dimensions: O Sludge depth: �r/i Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: •S// Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottoo of outlet tee or e: Lill' How were dimensions determined: f role A4-f Qv,ce Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as relatedd t outlet invert,evidence o�,1.eakage,etc.): II I C O {Qtt/� 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(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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -6#ees L& 7'1�� I IT wi, s dig oa6 Owner. �p(„�I Date of Inspection: 3— 1-0/ TIGHT or HOLDING TANK:I(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: fflllons 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: /(I;ffl present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 00rW ai 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.): I / do x 001FS l,P�-e �. A/O 5 4 dS A/O L eG cs PUMP CHAMBER: ,�/ locate on site plan) LIL( P ) 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.): .: . Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .� SYSTEM INFORMATION(continued) Property Address: c1 . �✓ 4 L V M 0s Owner. O w / Date of Inspection: o SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: (0)1-4 wl l YA vV leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovativetalternative system Typetname of technology: CommeS ts(not condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): UI I 014 d S4VIe QrOWIIJ J o n :7 e S :I g 3 Ro CESSPOOLS:-4 (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:_A/(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.): C Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM y PART C SYSTEM INFORMATION(continued) Property Address: T,ol1 6 Wl�►�S hs V1 r s LL� Owner: ip welt Date of Inspection: — — 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. a. -3 I 1 f__ ,..,..:_ .__ _•._ ...... � � :.:- — < - »-Y•-- -*�v- —.�{ z .�fiz.w e�3'•a,-ems:+ i Page l l of 11 _ � i f• OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION_(continued) Property Address: b ..Tr. M,;Xr54V,15 Owner. LO LIWIP Date of -�inspection:P 3— / SIn EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water S2 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: _ ✓ 2a,OS Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must rZ how you lishe�i e high ground wa er elevation: / ey Alf5/.S' /pc✓ G�✓ Sd �✓ � 53 TOWN/OF BARNSTABLE ✓ LOCATION �17 /� � 6�� SEWAGE # -3 VILLAGE, f SfD!'!5 /Lli��ls ASSESSOR'S MAP&LOT/J�7i�ZS INSTALLER'S NAME&PHONE NO. �4�'7�0�1�l��4f�c5J; 7f g SEPTIC TANK CAPACITY LEACHING FACILITY: (type) --GPQG 'l0��7 4 (size) NO'OF BEDROOMS 3 ' BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: ff Maximum Adjusted Groundwater Table and Bottom of Leaching Facility � T Feet Private Water Supply Well and Leaching Facility (If any wells exist �O on site or within 200 feet of leaching facility) f Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) , Feet Furnished by ear !S3-�g ✓ /�. •� •. No..?6 ..3 THE COMMONWEALTH OF MASSACHUSETTS FR R e....... BOARD OF HEALTH TOWN OF BARNSTABLE App iration for Di-tipm3al Wnrk,i Tomitrur#iun Vernnit Application is hereby made for a Permit to Construct ( ) or Repair (V5*an Individual Sewage Disposal System at: 1.9...r:r®Aer:� � C� ` �r Toys�l//,s----------------------------------------------------------------------------------------- .------- //� Location-Address or t No. .......................... ,.......-------•-••----•-•••• .........................................--............................................. vner Addres Installer Address UType of Building Size Lot............................Sq. feet —No, of Bedrooms.__........ ........ExpansDwelling ion Attic ( Garbage Grinder (� Other—Type of Building No. of persons----_--__-__•_______________ Showers — Cafeteria 04 Other fixtures ------------------------------- - - W Design Flow..............//lJ----------------------gallons per person per day. Total daily flow.............3.30 gallons. ----------- ------- WSeptic Tank—Liquid capacity&*__gallons Length-----lr, r__ Width........6----- Diameter_._ Depth...,..r..... x Disposal Trench—No. .................... Width.................... Total Length... _.._ Total leaching area....................sq. ft. Seepage Pit No........../_.-._....-- Diameter....../._..._.._... Depth below inlet........ ......... Total leaching area_.__:Z4/�2....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `.� Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................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 ------ ---------------------------------------•---•----------------••••---••••------------•------------•--•...------••-•-•-•••--•••••-•-••--.... O Description of Soil_....� L' ... �' x W ••• ....-•------- ------ U Nature of Repairs or/Alterations =Answer w,)�✓Qpp�licaable--.__� -/?ld'...... .. �r v ...--•-•-•- -`t --•--1....-•---.4`��lS:._t:�'--e-• -�-�-�--•-*--•----'"' --- .._.. ..- `--- - ............................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with. the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complian ha ee s b the board of health. / / Z l�' Signed .......... ... ... ... ....... ................................... .............. ---------- :.----- Application Approved BY --- ----- -- --------------------- ----------- Application Disapproved for the following reaso r: ... . Da[e Permit No. ----------------- Issued ------------ - d W 7 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Divjipm ttl Wnr1w Tomitrurtinn Vaunt Application is hereby made for a Permit to Construct ( ) or Repair (V<an Individual Sewage Disposal System at: • -•-•----- -- ---- •--------------------------- ` Location-Address q r� P�S or t i o. vQ t caner Address, Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms._.__._.._.............................Expansion Attic (?/m Garbage Grinder ( aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures .................................. w Design Flow..............I&----------------------gallons per person per day. Total daily flow.............3:3d.....................gallons. W Septic Tank—Liquid capacityl&Pd...gallons Length.-.--fit S._ Width........----- Diameter....A4r ------ Depth__ ..... x Disposal Trench— No- -------------------- Width-------------_-_-_ Total Length................ Total leaching area....................sq. ft. 3 Seepage Pit No........../.......... Diameter...... ............ Depth below inlet..._............ Total leaching area.....7.&/U._._sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------- ---------------------------------------------•---------------•---- Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..--__----_.____---____. P4 ---•-•--------- ---------------------- ------------------------------------------------------------ ------------------------------ - ... •-------------- •----- DDescription of Soil.....-��__�� Q�z...............................................-----------.....---------•------------------------------------------•---------------- x U W .....................-------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when _ applic�able...... , � ....._ Vmac ' f -F..__.f... _" ...............................................................Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliant ha een-iSsued by the board of health. pSigned ...... .... ':G ... -------------------------------- ------2./��e.��......:...... Application Approved By ... .......... (.-:. c� .............� [ ------------- /��+ ..........Y.,.t.7/.. ...... Dare Application Disapproved for the following reaso,S: .............................................................................. ............................................... -------------- ..... -- -----------------------------................-`----------------------------------------- '------- .......-----------------.-- Q - PermitNo. .... ...- ............................ Issued ------------ . ..f..>............................Dare............ / DarSP ------------------------- - -- —THECOMMONWEALTHOFMASSACHUSETTS OLf 7-- / z- 5 BOARD OF HEALTH TOWN OF BARNSTABLE Certificate rtificate of Compliana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by ---------- dGo. /....1 o h � i?`7f?"---------------------------------------------------------------------------------------------------------------------------- at ........ 1� �/ �r-�..../dJ�----------/�O/^_l./.�H`>- ���1/ /7.............-------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5,of he Squ1e,Fnvironmental Code as described in the application for Disposal Works Construction Permit No. ....._.............._. J.._............ dated .......---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE/CONSTRUFA AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �' Inspector... DATE....... .........: ... .......... ........................ r '�a = -------------------------------------------t-------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No._ FEE............... ...... 3 Disposal Wort Tomitr�ation Vrrmit 13'� rr"a C Permission is hereby granted--------- .. ........ -----',/ �5 to Construct ( ) or Repair( 1/�an I dividual Sewage Disposal System at No.----.....�y ��---��''=5----• �' Zaf,2 ...----- �/I�rS eW!h� -��//f��--------- - - ---------------4-1 Street as shown on the app ication for Disposal Works Construction I�rm�it` No._ �_ --_�__. ated.T -'�...........:.......... Q �Z Board of HealthV� DATE.............. ----— r C FORM 36508 MOBBS 6 WARREN,INC.,PUBLISHERS Y/OL_ET EL/ZAgET /f_i 0.70 f ` itrjt ly1.r N �L 3 `' ,,% 71/ o Y , d jc .1 . . "7ZR ;j t L-1. I 1�1?. r.y�rG �c qj •ey 0 y 7 CERTIFIED PLOT PLAN ' F • bra eF�iij,i,�; y�A•3` Vie. : ; r � v •.ROBERT. ,G NF t —COh1STRUCTION ONLY , L-OT"y, BRUCE rO7 ' •Iti.t i��'�V 1J.: .Y•ky. (��- -OUNDATION IS�_ FGE L, IN , (!61CgVE L OW POINT OF ADJACENT AnASTASL. �A1 A•��V D. • / :'' 3O' DATE 7 & 7� ' Il SCALE I CERTIFY THAT THE .. ... _.....___ C L I E N T j(21_0_AL f wiE;01;TEnED FREGISTERED �� SHOWN ON THIS PLAN IS LOCATFO CIVIL. ILAN® 11013 N0. _.. .�'1 ON THE GROUND AS INDICATED AND L'It omEIER}- RVEYOR, pR,pY: ,� CONFORMS TO THE ZONING Lllt �3 • �, OF ®ARNSTABLE MASS. 3 NO. MAIN ST 712 MAIN ST. CH.®Y= R 3� 77 / 4: !. YARMOUTN, MAS . HYANNIS, MASS. SHEET-LOf EQ. LA �D =f^— ` '— N SUI-VEY®R, i. F �•g«: �_ u yr. r IC- FT MIN _�------ --- _ 41 PVC.. PIPE. CLEAN SAND cd'NrRETE . KIN PITCH COVERS_ --, 1/81 PER FT C�NCR VER to' 7 _ �' LIQUID LEVEL-' c DNA ST _.. _ �r -r -�! ,•; - - , • -a=.L OF LAYER I/8 3/8 y i . ,. MIN PITCH- _ ° • • • , WASHED STONE SEPTIC TANK DIST. ° , , • • • • • • . ' , ' 1/4 PER FT 60X P • •� EFFECTIVE' ' '° 3/4"- I 1/2" DEPTH • ' ' ' . , WASHED STONE . 1 ej a • • . • . PRECAST SEEPAGE i • gig • • • • • / ` ° PIT OR EQUIV. INVERT ELEVATIONS _• 6. FT DIA. +. 10 FT. DIA. C (SEE-- TABULATION) INVERT AT BUILDING 'L FT. INLET SEPTIC TANK FT. - GROUND _.1NATER,;-TABLE - OUTLET SEPTIC TA;J,4 FT SECTION , OF _ INLET DISTRIBUTION BOX - FT SEi►V,4GE :'=DlSFOS�1 = SYSTEM r '!:ET DISTRIBUTION BOX FT. w " { SCALE: 4/4 = /---0 InILET SEEPAGE PIT FT TABULATION£° DIMENSION A DESIGN CRITERIA - DIMENSION B 6 _FT FT. NUMBER OF BEDROOMS _ DIMENSION C�-FT _ -GARBAGE DISPOSAL UNIT Al TOTAL ESTIMATED FLOW 300 GAL./DAY SOIL LOG SOIL TEST NUN&ZR OF SEEPAGE PITS i ELEVATION DATE OF SOIL TEST 6; ZV 7 SIDE LEACHING PER PIT /AB.S SQ. FT RESULTS WITNESSED BY — P,m ' BOTTOM LEACHING PER PIT 7,5.s SQ. FT. PERCOLATION RATE &57 L Z MIN/INC TOTAL LEACHING AREA ESQ FT " RESERVE LEACHING AREA -Z67 SQ. FT .3/0 '54/13SOdL ° IA Or 1 T -%$ .S Z 4^ ` PNLIP uliG No._366.4 �, ,4,, �.A ELD_?EDGE EI41y11"IEERINC� CO. 1%1 �`,,�'�`� - CarP.4VE'L) 33 NO. MAIN ST. M MAIN/ =3Q. YAK."ICUTH, MASS. Fi';'"`.. NN! CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PER MIT(WITHOUT DESIGNED PLANS I, Rod�rTJm� ��l hereby certify that the application for disposal works construction permit signed by me dated 2- 17 G �� concerning the property located at 1Y- .�oe,:�*,�Af4eets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : DATE: Z /7/3�� LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NLJMBER 6 [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. tiz f�-: ...fk�`�,:Y ��� �.3�3" x ``'Fy�a x��h��'�^'t�.��+'�ti�.��v tTu,.� ,, v�?,izt�.tY�acA•� k y,r••''a'^u��7-,. .£s'i>.;d.�'-`a`'-sx =�� ate' K, r 't� i"'-�� d „ Y .` a ' H' 'f�'y`F•€ `b'"..... 3 1 F�'„u n',.s.. F , saw w . TOWN OF BARNSTABLE LOCATION `qn:s Cane, SEWAGE # 0f47 VILLAGE, a2,.rc40,Ai ASSE SOR'S MAP&LOT i "� AME&PHONE NO95/` /lh g rg SEPTIC TANK CAPACITY /O� LEACHING FACILITY: (type)�i"� C�� (size) /Ob 0 Cr'O A' . NO.OF BEDROOMS 3 BUILDER OR �R' D OnZ PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility y Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Al 114- Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching ty) 1�/�i� Feet Furnished bv' �b 42c11kLL6,n S/�C lu OU IS ti4 Lp �3 � HM ] 51 H E A L T H M A S T E R ] HELP [ ] R E C O R D ] ACTION I] For Parcel Number 0471 1251 ] ] Rental Property(Y/N) [ ] Owner Name POWELL, JAMES B & JOSIE ] Zone of Contrib (Y/N) [ ] Location 64 TROTTERS LANE MM ] Contaminant Rel (Y/N) [ ] Business Name [ ] Area Number Contact Person [ ] Phone [000] [ ] Fuel Storage Tank Permit [ ] Card on File [ ] Perc Test Well Septic File/Permit No. [ ] [ ] [96-37 ] Issuance Date [ ] [0208961 Completion Date [ ] [021596] Last Communications [ ] (MMDDYY) Comments [REPAIR-MAX. FEASIBLE COMPLIANCE. ] Cancel [ ] NEXT SCREEN [HM ] ACTION [ ] PARCEL NBR [ ] [ ] [ ] TANK NBR [ ] ] PAR ] Real Estate System - General Property Inquiry] Help [ ] Parcel Id: 047 125- - Account No: 29739 Parent : Location: 64 TROTTERS LANE MM Neighborhood: 12CC Fire Dist : CO Devel Lot : 4 Lot Size : . 53 Acres Current Own: POWELL, JAMES B & JOSIE State Class : 101 64 TROTTERS LANE No. Bldgs : 1 Area: 1372 Year Added: MARSTONS MILLS MA 2648 Deed Date : 030196 Reference : 10086108 January 1st : POWELL, JAMES B & JOSIE Deed MMDD: 0396 Deed Ref : 10086108 Comments : Values : Land: 23100 Buildings : 64600 Extra Features : Road System: 64 Index: 1740 (TROTTERS LANE ) Frntg: 182 Index: ( ) Frntg: Control Info: Last Auto Upd: 020997 Status : C Last TACS Update : 0-62196 Land Reviewed By: Date : 0000 Bldgs Reviewed By: Date : 0000 Tax Title : Account : Taken: Account Status : Hold Status : Cancel [ ] Press XMT for more data Next screen [PAR ] Action [ ] Owners Name [ ] Road Index [ ] Road Name [ ] Parcel Number [047] [126] [ ] [ ] [ ] COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION R CE-WE® AP 4r-7 PARCEL � � NOV 0 8 2004 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 64 Trotter's Lane Marston Mills Owner's Name: Barbara Small Owner's Address: Date of Inspection: 10/22/2004 Name of Inspector: (please print) Patrick T.Sullivan 4 Q0 �. Company Name: Ready Rooter Mailing Address: P.O.Box 371 Sandwich MA 02563 { ' Telephone Number: (508)888-6055 "n 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: asses Conditionally Passes Needs Further Evaluation by the Local Authority Fails 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 ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 64 Trotter's Lane Marstons Mills Owner: Barbara Small Date of Inspection: 10/22/2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D C. System Passes: 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 proved by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND)in the for thfe 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 oriank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank ai;approved by the Board of Health. *A metal septic tank will pass inspection if it is struct�rally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: /ak /Observation of sewage backup or br out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settl/ed or uneven distribution box. System will pass inspection if(with approval of Board of Health): i broken pipe(s)are replaced obstruction is removed r distribution box is leveled or replaced ND explain: ,r The system required�pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with a proval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain. Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 64 Trotter's Lane Marston Mills Owner: Barbara Small Date of Inspection: 10/22/2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Bodrd 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 III 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/bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Sf pplier,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(0AS)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. r 3. Other: f �r Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 64 Trotter's Lane Marstons Mills Owner: Barbara Small Date of Inspection: 10/22/2004 D. 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 Static liquid level in the distribution box above outlet invert due to and overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow _ 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. _ -.tZ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. —1� Any portion of a cesspool or privy is 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 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/No)The system fails. I have determined that one or more of the above 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 crit ria 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 s ace drinking water supply _the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well / If you have answered"yes"to any question in Sect4 E the system is considered a significant threat,or answered "yes"in Section D above the large system has fail&The owner or operator of any large system considered a significant threat under Section E or failed unde Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the propriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 64 Trotter's Lane Marstons Mills Owner: Barbara Small Date of Inspection: 10/22/2004 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No v/_ 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? IZ _ 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? __tZ _ Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank,inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? _/_ Was the facility owner(and occupants if different than 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 f_ 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(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 64 Trotter's Lane Marstons Mills Owner: Barbara Small Date of Inspection: 10/22/2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330G,§?,5c), Number of current residents: 15 Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):.A2Nif yes separate inspection required] Laundry system inspected(yes or no):= Seasonal use: (yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump Pump(yes or no): Last date of occupancy:G COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(ye r no):_ Non-sanitary waste discharged to the tle 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: �0 allons--How was quantity pumped determined? Reason for pumping: vN(\ 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) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: ( Vu�". Were sewage odors detected when arriving at the site(yes or no): Aje f Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Trotter's Lane Marston Mills Owner: Barbara Small Date of Inspection: 10/22/2004 BUILDING SEWER(locate on site plan) Depth below grade: / J',' Materials of construction:_cast iron�0 PVC_other(explain): Distance from private water supply well or suction line: Z// Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: locate on site plan) Depth below grade: 5" Material of construction:�oncrete_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: H -15- Sludge depth: Distance from the top of sludge to bottom of outlet tee or baffle: Q Scum thickness: q k' Distance from top of scum to top of outlet tee or baffle: °c Distance from bottom of scum to bottom of outlet tee or baffle: 1(D 6 k How were dimensions determined: -- yv\�,, Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): r GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fib rglass_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 out t tee or baffle: Date of last pumping: Comments(on pumping recommendations, ' let and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of lea ge,etc.): f f Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Trotter's Lane Marstons Mills Owner: Barbara Small Date of Inspection: 10/22/2004 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: gallo,s/day Alarm present(yes or no): Alarm level: Alarm in rking order(yes or no): Date of last pumping: Comments(condition of ala and float switches,etc.): DISTRIBUTION BOX:%,/-(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:-I` Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): '` L �4 'PTV �3Wdt.`� �� L su.o ��•I� S e 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 chamb ,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 Trotter's Lane Marstons Mills Owner: Barbara Small Date of Inspection: 10/22/2004 SOIL ABSORPTION SYSTEM(SAS): locate on site plan,excavation not required) If SAS not located explain why: Type sLleaching pits,number: 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.): s- y CESSPOOLS: (cesspool must be pumped as part of in ection)(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: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of by raulic 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: 64 Trotter's Lane Marstons Mills Owner: Barbara Small Date of Inspection: 10/22/2004 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. 6 3 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Trotter's Lane Marstons Mills Owner: Barbara Small Date of Inspection: 10/22/2004 SITE EXAM Slope Surface water Check cellar L - Shallow wells Estimated depth to ground water'z I'afeet 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 the local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: , You must describe how you stablished the high ground water elevation: � 'iLOCATION �^ SEWAGE PERII�IIT NO. �j�/7 ?1 VILLAGE IN.STA LLER'S NAME & ADDRESS lv? .5S BUPLDER OR OWNER DATE PERMIT ISSUED r DAT E C0-MPLIANCE ISSUED / �. �- � - C fl ._ C Q*7 ` ID ,J - 0 -� �v� ` (�77) No.. -371.... Fxs._.. ®��....... THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F H A TH ............. .............OF...... ............... ... .... .................................... Appliratiun for Uiipuual 10orkii Tunutrnr#iun Famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ddesi nA r t N .i!� t / ............... a 5 ...... .O . . &x � Address ..=---. r- 4 ------------------------------------------------------ Installer Address Type of Building Size Lot._Z_0�_(�.-l7.....Sq. feet U g _.___Expansion Attic {�g Garbage Grinder (Ala Dwellin —No. of Bedrooms____ _____________________________ — Other—T e of Building _______________ No. of persons............................. Showers Cafeteria p' Other fixtures ................ W Design Flow_ ......................... allons per person per day. Total daily flow......' 6..........................gallons. WSeptic Tank—Liquid capacity ___ allons Length................ Width................ Diameter__._____--______ Depth................ x Disposal Trench—No. ___ j ........ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No, 6. _ y...t] met ............_...... Depth below inlet_._ ._.. otal leaching area.................. ft. Z Other Distribution box ( ) Dosing to (_ ) 016`inlet-;,,.--�`foe 77 '-' Percolation Test Results Performed by. 1 ✓`,+_ _�___ N _tiu.. :__._` ___....... Date........ e__.__.. a �7 Test Pit No. 1-----------_....minutes per inch Depth of Test Pit............. epth to ground water........ . Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q+' ••-••---• - ---_`_____.. ...............�} __---•----,....... O Descri tior; of Soil U- �' ` r<QOo� ••-��•--..' -� �1... . •.-'2- ..y-S-- - J 4 ---- --" U ... U° •-•-------------- W x -•-•.._----•----------------------------•------•---------------•---•------------•---•-•---•-•••--••---•-•-----•-----•--•--•-•-------•---•--•------•-•--••••---••••---•••-•----•-•------•--••---......_. 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 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 heal . Sign ....�._...... -q-- - ----__y__---• --------•--•--••--_----•- - -7'"-7-_7-•-- Date Application Approved By---_• .......................... �--�-7------- _. Date Application Disapproved for the following reasons_________________________________________________________________________________________________________________ -•----•----------------------------------------------------------•-•---•-•-------._....----••---._.....-------•------•--•------•----••----••••-••-••...................................................Date 7 Permit No......................................................... Issued.---- .. � Date P -707 No..................... Fss... S ..-............ THE COMMONWEALTH OF MASSACHUSETTS BOARD F H A TH ...._._....-V--�1 h..........OF..... ........................... ... ------------...............--------- Apphration for Disposal Works Tonstrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _ J ...`�:.......-•---------------•------------. ......................` ` ...........------. ss .:.. - 1��J ... &cl IC`CaeeS._...... .ti? �✓/`Q!C t/ �-orf/: �"�,Si..'T ............... Address a � Installer Address ^f-" Q Type of Building Size Lot_ �y __Q. ......Sq. feet Dwelling l='�No. of Bedrooms----.33......................................Expansion Attic (f6) Garbage Grinder (A/0) Other—T e of Building No. of persons............................ Showers 0 — Cafeteria Q' Other fixtures --------------- --------------- . Design Flow--5--S -- ____ _ gallons per person per day. Total daily flow....32.0...........................gallons. W �••..-- - - -- -'�� WSeptic Tank—Liquid capacity/........gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. _._..._..__.dry i ltl�y��._ ---------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit Nq_ .�- ____.- Diame� ................... Depth below inlet._:.,._.: ____ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosin tank ( ) -'�' �e � ` k /a--7-7 ~' Percolation Test Results Performed by.��rLdh_E.... '_►_'��.!��.t-_h(�'"__W ............ Date......�.`.�!!._? ....._.... Test Pit No. ................minutes per inch Depth of Test Pik................... Depth to ground water-____` �___._....__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ = ---- -------------•; ... -----•-- -•------ DeSCrlptl }1 Of Sold --„ v y ,—; .y — G `' - c G------ `-------�/-S```'--- - ----•------- -- 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 T I T TIZ 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. ,r - � �_ _Signs . n ); ------------------ )`! '7....7.-7-..... Application Approved By.. ... tlr�" 7............... Date Application Disapproved for the following reasons___________________________..--•---•---••-•-------------------•-........................... ----........» ---•.............•---------...-•------------------•--------------•--------------•----•-•-...•------•-•-•.._......_....--•----•-••--------•-••-•-•••---------------------- ............................... Date PermitNo.........................................................-------------------- Issued-------.........•-- �f-. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , 3 ................... ........OF............ .. .....................................'.......:...... Trrtif irFatr of TompliFanrr THIS IS TO CER FY, at t e Individual Sewage Disp��sal System constructed (A"') or Repaired ( ) `f' ... Installer at........................` e ! GZ- -.---_------------- has been installed in accordance with the provisions of ' ;^LF 5 of The State Sanitary Code as4escribb (L n the application for Disposal Works Construction Permit No----------- 2_4----------------- dated-.�-- ............................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WIL FUNCTION SATISFACTORY. DATE 1....:.:.. ��.......7 :._....... Inspector - ----•�`� ----- -- --------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �.............OF....�� 1-41..................................................... -c� No......................... FEE Z�r•--.............. Diego, t ' ork i nstrnr#ion rranit Permission is hereby granted--•=---s•�..... ------ -- -------•----•-----------------------,---e.......-............................................. to Constn(ct r it ( "an Indivi 1 Sewa .e I�ispos_ Syst atNo. _- --•-- ----•------•-----•-- = ... l Street _ as shown on the application for Disposal Works Construction Permit No"_f✓�!1._._.. Dated...�. � 7 7 i .....!................................................. •_-..._ .................._.. �,r '�/ Board of He Ith DATE......-/--`-�-(-----�-..._ ' FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS ���'. 'rrEi.;"4 "�.f4. t:t 'a, ..a ,/1} .lt",:,4 �. ''�.'° 5f / 9�5��'�-� ` • t ..ki f,itw:•r :-i:• ,`ir-'� '.'n t „r Y:*t, Y� ' .�';.t4�. 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O / r F e♦ .- - - . c ° 1 • •� E' ' e _ ,�{,•• .. _ • .. ° LV �-- 3/41Y. .! Imo" ° 1 • r.DTHT• • .,. WASHED . STONE �' �• s. -. x. '• �� •i' +SAE •C a..F" .-�"+ ,. ��'. .a �'" 4 ° PRECAST SEEPAGE { i . • 4 `,, . . ..:. PIT. OR EQUIV. INVERT ELEVATIONS � �5 �.�T. DIA.. . ~` 10>FT DID► C_!SFE�U:BULATION) ; _ 1;y .. l4 _ T _ - _ _:- A ,:BUILOItJ`G � , •-`FT '�'" .a•-.....,..,- .. F-. _^ ,_ .,- -i..:: .-- ,,. _ .•.,,y�-'�, �....ti�""-� �"a, :^.�., .t. �t��,, M1.�,r ar-a y .�rw. ``•,,,. x,,'-�:.^ .-t � �k'.. � 1 °:�'' �.. .: . iNLE'!`' SEPT!•C TAN�C: :-r ,. .,. FT ... _. ti--,� - •��.��_ ��,� _ f� 1 .ET,: .,`SEPTIO'••yx7A.N'y�( :, r R R-, STABLE x -.� ,. ` y... DIST IBtT 7 Y R 10 N= :BOX;,_ � yr �.�� -•,�' DISTRIBUTION: BOX' ft .• - ) I,y / 'SEEPAGE" PIT, FT - {TABULATLON '- - X DIMENSION A -Ft - DESIGN CRITERIA - - DIMENSION G FL F , MA - NUMBER OF BEDROOMS _ y DIMENSION CFT z .=-GARBAGE DISPOSAL UNIT NGWE - SOIL LOG SOIL TEST w TOTAL ESTIMATED FLOW 300 GAL./DAY g r. a n { NU� OF SEEPAGE- PITS / - ELEVATION r DATE OF SOIL TEST & Z'/ 77 SIDE LEACHING PER PIT /ee.s SQ FT. y"�oA.•� RESULTS WITNESSED BY t?�?B. �/ , BOTTOM LEACHING PER PIT 78.E Sep. FT. ,. _= PERCOLATION RATE T �- Z t MINANCH - . TOTAL LEACHING AREA Z�7 SO.' FT. . t ' RESERVE LEACHING AREA Z�7 SQ. FT. - 360 SUBSo/C. - � ��T�a�.-Ta�T 7F `.3�, ..-'ao -. sT '.;'. ."z:•..t :.fir,. v.� (.- ..rtq.y�a'S. ;J ��yy ... 3-.-. -E-LDREDGE` m"EN�9Ir`,.EERiNfa' -:= y[ -f.,•Yr,,.�"4_ _ S•, i. a .r. ":`�: - -�j _ y� h` P.yv"� �y I V. 4'i /G.r. ;:'�^. a{ 4 V V. N� e ;'+. •�. AIIAK _7t MAIN itr©'ti1/AT�Fr', Sa.wYAftit�E3U7`H -�d�_ FiYANI�IFS 416+tASS. ,'K`3 - ,r s:. 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