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0100 WATERSHED WAY - Health
IUU watershed way . Marstons Mills P A = 059 009007 TOWN OF BARNSTABLE LOCATION /00 W,47�t,-Y'.S'Lit%� G(//�y SEWAGE# 36'? VILLAGE&Arery /� ���/S ASSESSOR'S MAP&PARCEL dnS� -/�009-007 INSTALLER'S NAME&PHONE NO.,SD$'y20-g73F JaS �L� (if4r`GS SEPTIC TANK CAPACITY I ZO LEACHING FACILITY:(type) °1-s d0 ��,c¢�rlf�/-f'.S (size) . SIK /j NO.OF BEDROOMS OWNER kn,6AI I AINO PERMIT DATE: /0-.2 3-l S COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY � Frah' J � 2G• } 13-1 1- 2 - 2i.g,, No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: %, PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftphration for Bisposal 6pstpm Construction 3permit Application for a Permit to Construct Repair(of U grade( ) Abandon( )_ ❑Complete System ❑Individual Components Location Address oLLA No./DO G�/2�Tf != w�`� Owner's Name,Address,and Tel.No. Assessor's M c 0O -00 15 Installer's Name,Address,and Tel.No.,S O '51 0- 973 Designer's Name,Address,and Tel.No.,rok'-SG0-'3311 Joj,t: o i D-a 13'4evnP w yls-r i Soh/'S Z.r/lf /C 01W-o IV /1�/�i,Sro�f !L/.%�1 !:'• av cLi Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ,r4S7,,W11 P114n 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 his Board of Health. 041 o Date Application Approved by Date Application Disapproved y Date for the following reasons r Permit No. Date Issued No. Fee lot! THE COMMONWEALTH U MASSACHUSETTS Entered in computer: 'Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yication for Disposal .6 stem Construction Permit Application for a Permit to Construct Q1,K Repair( U grade( ) Abandon( ,) ❑Complete System ❑Individual Components Location Address oLLA No./OL'!/�G47/' Owner's Name,Address,and Tel.No. Assessor's M Ir c (;&q_ )p' 51a,-Ii: Installer's Name,Address,and Tel.No.S OZ''K4AU- T 30 Designer's Name,Address and Tel.No.s��s'?G�i-3311 ' ,.loS�j'✓ti U� /,iarvUS «�_y r�r �S°��>s r��� Type of Building: } r Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S;A.S.,rtr ., Description of Soil 0 _ Nature of Repairs or Alterations(Answer when applicable) '4S� /, � ?G O(! �� l"7��f'/ Date last inspected: Agreement: r The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in, `4 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. 1__ Date ..� Application Approved by , Date �. 17 Application Disapproved by r Date for the following reasons µ 4A Permit No. Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS ui BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed Repaired Upgraded( ) Abandoned( )by o at !rr; yw Kias been constructed in accord e'e with the provisions of Title 5 and the for isposal System Construction Permit N Installer ,�0�G/'`i /l-e�j�/,yUS Designer #bedrooms /3 Approved design flow 2 gpd The issuance of th per1nit shall not be construed as a guarantee that the system will functionas designed. Dat2- b 'Inspector r ----No.------------------ - - ----------------------- --------------=--------- ----------------------------Fee--- --------------- �f o THE COMMONWEALTH OF MASSACHUSETTS ^I PUBLIC EALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted to Construct( C-4-- Repair( L)--- Upgrade( ) Abandon( ) System located at /DO wl6 Ti=1-.5<111�- /��14l�'STU yl 5 GJIi//S � 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:Const ct'�b must b comLle ed within three years of the date of this permit. Date Approved by j DEC/08/2013ME 09:04 AID FAX No. P. 001 Town of Barnstable Reg i latoiy Services i �verAe�, i RichardV.Scali,Interim Director NAM Public Health DivWon Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax., 508-790-6304 Installer&Designer Certification Form Date: Sewage Permit# Assessor's MapTareel D 1o�`�007 Designer: MP LOW- YVl( j>'1 G • Installer; Address: 0 11-zll� Address: D2�37 On was issued a permit to install a (date) (installer) septic system at 100 VV4JSf-5tW-V1NV M,M t 111ased on a desiga drawn by (address) Memg,('4 Zi�Ls dated JD 1� 1- (desiLnie 1A,� X certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e, greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &Local kegulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was cotes fiance with the terms of the M approval letters (if applicable) i°OF DA REN M' M. it taller's Signature) n, Nil �A (Designer's Signature) ( tamp Here) PLEASE RETURN TO B STABLE PUBLIC HEALTH DIVISION: CERTIFICATE OF COMFLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC IMALTH DIVISION. THANK YOU. Q:1Septiclbesignar Certification Form ltev 8-14.13.doc � Town of B• -nstable P it � Department of Regulatory Services • - Public Health Division Date Mes& i639 tee$ 200 Main Street,Hyannis MA 02601 4D Date Scheduled Time�_:�_a_� Fee Pd. $oil Suitability Assessmnent fog- Sew e- , ispos l Performed By. 1 ,t lf'f e`j P�� Witnessed By: w` Pf i LOCATION & GENERAL INFORMATION Location Address D® 'ICU AT�q4 ft.0 W� ' Owner's Name lV �I Address S A.PA Assessor's Map/P4rcel: 0 S'q J O� q/®07 I Engineer's Name / �( I w �33 ► NEWCONSIRU�'i'lON REPAIR '\ j Telephone# a 36 Land Use Slopes(%) 'S r�' Surface Stones f>" Distances from: Open Water Body it •Possible Wet Area> (7 ft Drinking Water Well;!: ft breinage Way /bb ft. Property Lineft Other ft` SKETCH:($treet name,,dimensioriS of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) I . I i i i I I Use, Parent material(geologic) I Depth to Bedrock " Water in Hole:' Weeping from Plt FAee Depth to Groundwater. Standing W n i Estimated Seasonal fth Groundwater DtTE ATION FOR SEASONAL HIGH WATIC T"LE Method Used: _in. Depth to Sall mottles; In. Depth dbpervedLdfiing.,in obs:hole: - p {}, Depth toiweeping from side of obs.hole: in. ©toundwa[et Adjustment ! raundwnterievel A .faetor-- AdJ.O ,,,e Index Well# �. Reading Date Index Well leVd-;- i PERCOT,ATI01r1 TEST Date,,.._. 7clnir Observation ' I Tittle at 91, �.• -------- Hole# _ Time at 6" Depth of Pere Time 9"-6") Start Pre-soak Time CO) ll---- - • End Pre-soak `J Rate MinJInch Additional Testing Needed(YIN) Site Failed; Site Suitability Asseissment: Site Passed . Original:.Public l lelth Division Observation Hole Data To Be Completed on Back----- ***If percola jibn test is to be conducted within 100, of wetland,you must first notify the Barnstable 6 servation DiV ision at least one(1)wedk prior to beginning. O // S DEEP OBSERVATION HOLE LOG Hole# Depth'from Soil Horizon Soil Texture Soil Color Soil Other .Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsistenc %Gravel A *272� C1 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) H h "� (,oaw► +n� 4 3 �� .fit, b �Sl 43m- . DEEP OBSERVATION HOLE LOG Hole# NIX— Depth from Soil Horizon Soil Texture Soil Color Soil T Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders: Consist enc go Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consisten ra I a Flood Insurance Rate Map: Above 500 year flood boundary No Yes 'y ' Within 500 year boundary No 7 Yes Within 100 year flood boundary No-7 Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? e If not,what is the depth of naturally occurring pe ious 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 consistent with the required training,expertise and experience described in 3,10 CMR 15.017. b Signature t., Date Q:\,SEPTICIPERCFORM.DOC Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Watershed Way Property Address Gamrecki Owner's Name 4wmtabte- (� ) ry lrl I MA 02648 6/17/10 Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: I bD33 Frank Nunes III Name of Inspector saa Company Name 25 Deer Ridge Rd Company Address Mashpee MA 02649 Citylrown State Zip Code 508.272.6433 Telephone Number B. Certification 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. 1 am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority jalr— 6/17/10 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. ****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. V Commonwealth of Massachusetts Title 5 Official Inspection Form 5 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Watershed Way Property Address Gamrecki Owner's Name Barnstable MA 02648 6/17/10 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Pumping suggested every 3 yrs to prolong the life of the system 13) System Conditionally Passes: 4 ❑ 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: n/a ❑ 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 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a ,» 100 Watershed Way Property Address Gamrecki Owner's Name Barnstable MA 02648 6/17/10 Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: n/a ❑ 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: n/a C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Watershed Way Property Address Gamrecki Owner's Name Barnstable MA 02648 6/17/10 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a 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 an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M �'( 100 Watershed Way Property Address Gamrecki Owner's Name Barnstable MA 02648 6/17/10 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 100 Watershed Way Property Address Gamrecki Owner's Name Barnstable MA 02648 6/17/10 Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments >VO,� 100 Watershed Way Property Address Gamrecki Owner's Name Barnstable MA 02648 6/17/10 Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Vacant Date Commercial/industrial Flow Conditions: Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date n/a Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 100 Watershed Way Property Address Gamrecki Owner's Name Barnstable MA 02648 6/17/10 City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: pumped 2004 per BOH file Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1987 per permit Were sewage odors detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 100 Watershed Way Property Address Gamrecki Owner's Name Barnstable MA 02648 6/17/10 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 3'feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 216"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) Riser at inlet and outlet to 6"of grade If tank is metal, list age: ' years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000g Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle n/a Scum thickness 0 Distance from top of scum to top of outlet tee or baffle n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a How were dimensions determined? measured Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 100 Watershed Way Property Address Gamrecki Owner's Name Barnstable MA 02648 6/17/10 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): n/a Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a 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): n/a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 100 Watershed Way Property Address Gamrecki Owner's Name Barnstable MA 02648 6/17/10 Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping:' Date Comments(condition of alarm and float switches, etc.): n/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Level w/the bottom of the pipe 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.): �D-Box 3' below grade. Average condition for its age Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: 0 Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M yy 100 Watershed Way Property Address Gamrecki Owner's Name Barnstable MA 02648 6/17/10 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach Pit 6' below grade, bottom of pit 10' below grade, pit is dry at this time,no distinguishable stain line, no signs of backup Commonwealth of Massachusetts AM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,.•'°Y 100 Watershed Way Property Address Gamrecki Owners Name Barnstable MA 02648 6/17/10 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer --- -- Depth of scum layer Dimensions of cesspool — -- Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): n/a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,0 100 Watershed Way Property Address Gamrecki Owner's Name Barnstable MA 02648 6/17/10 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 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. t a 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 100 Watershed Way Property Address Gamrecki Owner's Name Barnstable MA 02648 6/17/10 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. >12' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1987 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION f P7 CD TITLE 5Q'; "! OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS! ENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM Co Co PART A w r ' CERTIFICATION Property Address: Owner's Name: ('r. . e MAP Owner's Address: PARCEL Date of Inspection: Name of Inspector: pi se p 'nt) e Company Name: Mailing Address: Telephone Number:, 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 CM11 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Inspector's Signature: k 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. Title 5 Inspection Form 6/152000 page 1 Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTY PECTION FORM ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL ASYSTOM INS CERTIFICATION (continued) Property Address: Owner: a Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of section D A. system Passes.: found any information which indicates that any.of the failure criteria described in 310 CMR I have not f 15.303 or m 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments:`— - 1 l�� N e System Conditionally Passes: to be replacd or or more system components as described in the"Conditional Pass" section b the Board of Health ewill s. repaired.Th stem,upon completion of the replacement or repair,as app Y n not de fined(Y,N,ND)in the for the following statements.If"not d ined"please Answer yes, o or explain. The septic tank is metal and o 20 years old*or the septic tank(whether etal or not)is structurally in' t.System unsound,exhibits substantial infiltration exfi ttrattiion o stank failure by them oardnof Health will pass inspection if the existing tank is replaced with a complying s PP 'A metal septic tank will Pass inspection if it is aurally sound,n eaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is ailable. ND explain: I in tion Observation of sewage backup or break o even Thigh dis stbutio box.System Il pas�in pecti n if(with- broken, x due to ken or obstructed pipe(s)or due to a settled o approval of Board of Health): br en pipe(s)are replaced struction is removed distribution box is leveled or replaced ND explain: year due to broken or obstruc pipe(s).The system will The system' quired pumping more than 4 times a y pass inspection i with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND xplain: 2 Page 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Z�S�eCl Owner: M 1 �---- � e Date of Inspection: ` Further Evaluation is Required by the Board of Health: onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing rotect public health,safety or the environment: 1. System 'I pass unless Board of Health determines in accordance with 310 CMR 15.303 I b tha he system is no unctioning in a manner which will protect public health,safety and the environm t: Cesspool or p ' is within 50 feet of a surface water — Cesspool or pri . within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of lth(and Public Water Suppli system is functioning in a manner that prote the public health,safe and environmenmines that the _ The system has a septic tank and soil absorp 'on system(SA and the SAS is within 100 feet ofa surface water supply or tributary to a surface water pply. _ The system has a septic tank and SAS and the SAS ' ithin a Zone I of a public water supply. The system has a septic tank and SAS and the S is wi in 50 feet of a private water supply well. _ The system has a septic tank and SAS_an he SAS is less tha 00 feet but 50 feet or more from a private water supply well".Method used t determine distance "This system passes if the well water al sis bacteria and volatile or y ,Performed at a DEP certifi laboratory, for coliform ganic compo ds indicates that the well is free from po ution from that facility and the presence of ammonia nitroge and nitrate nitrogen is equal to or less than 5 p ,provided that no other failure criteria are triggered. opy of the analysis must be attached to this form. 3. Other. s' 3 IL Page 4 of 11 OFFI CIAL INSPECTION FORM—NOT FOR VOLUNTARY SS ESSMEN FORM TS SUBSURFACE SEWAGE DISPOSAL p� AYSTEM INSPECTION CERTIFICATION(continued) Property Address: "tI Owner. USe Date of Inspection: D. System Failure Criteria applicable to all systems: actions: You must indicate"yes"or"no"to each of the following for all inspections: Yes No r cesspool Backup of sewage into facility to thensurface�of the ground or overloaded or e w lets dueged so an overloaded or �•o Discharge or ponding of effluent or cess 1 overloaded or clogged SAS or S 1� verlo clogged SA due to an o Static liquid level in the distribution box above outlet invert flow cesspool L Liquid depth in cesspoo Required pumping more than 1 is less than 6"below invert or available volume is less thansy e(s).Number 4 times in the last year NOT due to clogged or obstructed p of times pumped�O is below high ground water elevation. Any portion of the SAS,cesspool or privy —' ithin_100 feet of a surface water supply or tributary to a surface � Any portion of cesspool or privy is w water supply. is within a Zone 1 of a public well. 1,0 Any portion of a cesspool or privy " Any portion of a cesspool or privy is within 50 feet of a private water supply well. nD 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 aocacoliformhbacteria sand volatile orgalnicis system passes if the l water compounds analysis, performed at a DEP certified laboratory,f indicates that the well is free from pollution from a5 facility ro idthe d that no other failure criteria nitrogen and nitrate nitrogen is equal tot less thanto triggered.A copy of the analysis must be attached to this form-1 are gg �Q (Yes/No)The system fails.I have deteilure criteria exist as rmined that one or more of thahe above er should contact the Board of described in 310 CMR 15.303,therefore the correct stern the fa we. sy Health to determine what will be necessary Large Systems: stem the g y system y g d to 15,000 To a considered a large s stem must serve a facility with a design flow of 10,000 gp gpd. es"or"no"to each of the following•. You mus ' dicate either"y (The followi criteria apply to large systems in addition to the criteria above) yes no supply _ _ the system is w in 400 feet of a surface drinking water the system is within 200 t of a tributary to a surface drinking wate pply Area—I WPA)or a mapped the system is located in a nitrogen sitive area(Inte ellhead Protection Zone II of a public water supply well If you have answered"yes"to any ques ' n Section E th stern operator of any larg system considered ered a significant threat,or answered "yes"in Section D above the lar ystem has failed.The own significant threat under on E or failed under Section D shoanal office ll up e ththe Department.e system in accordance with 310 CMR g pro hate regional 15.304.The cyst weer should contact the a p p 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Us Owner: Date of Inspection: 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 T M0 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? _ Y1D Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the-facility or dwelling inspected for signs of sewage back up-? _ Was the site inspected for signs of break out? e _ 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 df the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? 4!n _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ 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 9 unacceptable)[310 CMR 15.302(3)(b)J 5 Page 6 of I 1 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMi INFORMATION Property Address: - Owner: Date of Inspection: L FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3_ DESIGN flow based on 310 CT 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: __ Does residence have a garbage grinder(yes or no):jh_0 Is laundry on a separate sewage system(yes or no):jj_©[if yes separate inspection required] Laundry system inspected(yes or no):JI(3 Seasonal use:(yes or no):.[_U Water meter readings, if available(last 2 years usage(gpd)): AJ Sump pump(yes or no): K U Last date of occupancy:XLzn� C MERCIALINDUSTRIAL Type o blishment: Design flow d on 310 CMR 15.203): gpd Basis of design flow ts/persons/sgft,etc.): - Grease trap present(yes or n Industrial waste holding tank presen or no):— Non-sanitary waste discharged to the Title a or no):_ Water meter readings,if available: Last date of occupancy/use: OTHE scribe) GENERAL INFORMATION Pumping Records 4- Source of information: 0_n%` j C_ �U 1P'_r"S Was system pumped as part of the inspection(yes or no):_ 1 If yes,volume pumped: i,Cad gallons--How was quantity pumpe d termined? l 1 G✓l �- Reason for pumping: nACt 'rk4e ja(,/t C� _ n(1/lbVte►lf'a. C r'1 J 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) _ ovative/Altemative technology.Attach a co of the current operation and maintenance contract(to be Inn PY gY 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: Were sewage odors detected when arriving at the site(yes or no):jb D 6 Z Page 7 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARYINSPECTIONASS SSMENTS SUBSURFACE SEWAGE DISPFOR OSAL C SYSTEM SYSTEM INFORMATION(continued) Property Address: V Owner: e —�-` r Date of Inspection: (7 7 LL�J--��" -- BUILDING SEWER(locate on site plan) - Depth below grade: 3 J Materials of construction: cast iron ._/40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition f' mts,ve ting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) IC Depth below grade: �76 glass col eth lene Material of construction: concrete—metal-_fiber Y Y other(explain) es or r1o):—(attach a copy of If tank is metal list age:_ Is age confirmed by a Certificate of Compliance, y_ certificate) Dimensions: Sludge depth: / Distance from top of sludge to bottom of outlet tee or baffle:l _ Scum thickness: YLOAC- Distance from top of scum to top of outlet-tee or baffle: Distance from bottom of scum to bottom of utle tee or baffle: _ How were dimensions determined: Comments(on pumping recommend tions,inlet and outlet tee or battle condition,structural integrity,liquid levels as related to tlet invert, vide ce of leakage,etc.): GREASE TRAP: (locate on site plan) Depth below grade:y _concrete_metal _fiberglass polyethylene_other Material of construction: (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: integrity, Comments(on pumping—recommendations,in and outlet tee or baffle condition,structural q liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: op 1'e L&Lt Owner: C G e . Date of Inspection: L TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow:_ gallons/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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: c/ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,an evidence of leakage into or out of box,etc.�1 y Of n�l 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.): R � Page 9 of 1] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 c. ed Y)Cc - Owner. \ ckse_ -- Date of Inspection: /i n y SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: TypF �L leaching pits,number: L l0 OD cd-c-l 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.) _ .. C SSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number a configuration: Depth-top o ' uid to inlet invert: Depth of solids lay Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow( or no): Comments(note condition of soil,signs hydraulic failure,level of ding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note dition of soil,signs of hydraulic failure,level of ponding,c dition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: O je WCL+ Owner: 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. 3 - 316' 10 R Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ��S�� ON FORM ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water t#—feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Zone- Accessed-USGS database-explain: You must describe how you establishe the high ground water elevation: _ }- V 6 1/c6 V O TOWN OF BARNSTABLE —17,4 LOCATION eS � � SEWAGE # ti VILLAGE "A,7 S xt_S ASSESSOR'S MAP & LOT -° a INSTALLER'S NAME & PHONE NO., b��, zl< lay iot SEPTIC TANK CAPACITY LEACHING FACILITY:(type) ,l&ALA` 2r (size) NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER �G DATE PERMIT ISSUED: DATE . COMPLIANCE ISSUED: ��e VARIANCE GRANTED: Yes No l S �'�f .� � � � �� ��� a � \\� '~�_ �' ,� 4. `I 'I 1 �� 9 A �i TOWN OF BARN�ISTABLE LOCATION o0 e.ev�'N'e \A) A SEWAGE # x ` VILLAGE MM 6-A& /"\\ \�S ASSESSOR'S MAP & LOT INSTALLER'S NAME fa PHONE NO. \K c) SEPTIC TANK CAPACITY \oc>a LEACHING FACILITY:(type) \o ocn, (size) ®© NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER k3j¢\V1. M N 4p W DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No y� :l0 F�s......7 _ ... bV' ®� THE COMMONWEALTH OF MASSACHUSETTS ----_ BOARD OF HEALTH pb I .% ............4..Q.W_4- .........-.OF..... ... .4 <N. C. ----------------- - ------- lirtttioo for Mir ootti Works Toostrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. -.� ---------- ------------------------------•--.......---...---......... O et Address Installer Address Type of Building Size Lot...!P4.!1,1.3.......Sq. feet a -Dwelling—No. of Bedrooms..............I.........................Expansion Attic ( ) Garbage Grinder ( ) Pk Other—Type of Building ............................ No. of persons........................---. Showers ( ) — Cafeteria ( ) G4Other fixtures --------------------------------------------------- -------------------------------------------------------•---------....`._.....••--............-- 5 -.gallons per person per day. Total daily flow.......................J.80.......gallons. W Design Flow ---- ------•------•••-• g P P P Y Y WSeptic Tank—Liquid capacity VC gallons Length................ Width................ Diameter.........--..... Depth................ x Disposal Trench—No. .................... Width_.t................. Total Length..............y_... Total leaching area.....................sq. ft. Seepage Pit No........... ....0 ---..... Diameter. .......... Depth below inlet....... .?-....... Total leaching area..ZVV._sq. ft. Z Other Distribution box V) Dosing_tank ( ) ~" Percolation Test Results Performed by--....- .).TWL' .... : .......................... Date...... .`_!.9.:Jfl ,tea Test Pit No. 1...._ ....minutes per inch Depth of Test Pit........LM- _ Depth to ground water....... ................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.---.................... a -------------------------•------...........-...... ............. 0 Description of Soil-------...................................... .•.•-- ---------------•----_--•-••-----•--•-••------- Gt,. ra N:. :------.�.a o �-------------------Sri.s = = --... x -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... 5 -----------------------------------------•-------•-------•------...............---............--------•-------------------------------------•--------•----------------------------------........••-•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLL 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has Yeen issuedpby),,he bo d of heal Signe - ----•- ---. A4 - Date Application Approved By............. ...... G.c-., k ..... ... ............J5... Date Application Disapproved for the following reasons:.............................................................................................................. - --••-•---•-•-••••-•---•------•--••........--•---...-•------•-...-••-•---•---•••-•-•------••--••--••-•--...-......--•--•---•-•----•-----•---•••----•------•--•-------------------••••-•---•-•-...--------- Date PermitNo.......M:..°; o.?------------------------ Issued....................................................... Date No.... Fss.... THE COMMONWEALTH OF MASSACHUSETTS BOARD ,OF HEALTH ......'...0 v)I �. If s E �..:. :='E- OF..........._.. ......... . Appliratian for Disposal Marks Tonotrurtiun rrrmit Application is hereby made for a Permit to Construct (?(„) or Repair ( ) an Individual Sewage Disposal System at: ........--• __`= .i . . ;. r�.: ............... •--........�...............----•••--. ..:: :.......�:...--....._.......... j Location-Address,-) or Lot No. .....................l_ )�' �..t.�:�!y!�........ i_:JI Cf=.�t1:1.:� ._...._.... ............................«......................»»................ _.'' ..... Owner Address W .... -... •` ....----- - - -•.. ........................f.... Installer Address ..._... . feet a d Type of Building Size Lot.._" t .1 5 q. U Dwelling—No. of Bedrooms.............. Expansion Attic ( ) Garbage Grinder ( ) .••-- `LI Other—Type e of Building No. of persons............................ Showers — Cafeteria a yP g P ( ) ( ) a+ Other fixtures ...............•----------------------------.....--------------------------------------------------........------------------.........-•••-•......••-• Design Flow.................... . ...............gallons per person per day. Total daily flow...................... .......... .. ...gallons. Septic Tank—Liquid capacityr._'(..,gallons Length................ Width.........._..... Diameter................ Depth................ x Disposal Trench—No- Width_t_................ Total Length.................... Total leaching area........._..........sq. ft. Seepage Pit No..........t 1 ........ Diameter.. c)........... Depth below inlet.......La....._.. Total leaching area.._`Z:S'k..sq. ft. " Other Distribution box (/ ) Dosing tank ( ) z - ''" Percolation Test Results Performed b ;' `�_�. -tl.. :�..1.`:�.� ........................... Date........ .----`- -- y--.... .... Test Pit No. 1....`:' _..minutes per inch Depth of Test Pit........(.7.-... Depth to ground water_.................... (i Test Pit No. 2................minutes per inch Depth of Test Pit............--...... Depth to ground water........................ 04 ...............•--.....-•----....•••...................•---...............•• _..••••-•......•--•••......................................................... 0 Description of Soil.....--------------------------------------------•..._•-..,_ ......•...........-•---• 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 Application Approved By------------- `.. .... .......................... ......_..._ Date ---•-- Application Disapproved for the following reasons:..........................................................................................................___ •...........................•---------•-•------...........................---'--------.....................-------•--.......•.........................---------.......-----............................_ Date PermitNo......9-&:..:1.;L.?...................----_ Issued..................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .C;'�.... .. .....OF........... ..� °........ lT.......° !:.E7.......................... At Tatif uttte of Tomplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by----------------------------------------.--.--.-...-.-----f-----------•---•-.--------------._instaii-----.------•-..._......._...q..�.........................: ................... ._..... at.....--------...L..c�.l------ --- -----•--... 1. r�_; • ... W.- ...-....... =!-----------...-----------.... ........------...... has been installed in accordance with the provisions of TIT 5�bf The State Sanitary Code as described in the application for Disposal Works Construction Permit No....... .:..7- -......... dated.............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................................... q Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS -- BOARD OF HEALTH Disposal Works TunstrurtWn f rrmit Permission is hereby granted.............................:..•--------------------••-----...........-----•----...........------................••••......................_ to Construct ('X' or Repair ( ) an Individual Sewage Disposal System at No........- .-a = -• --.....�f,/.ta �? e.. ....... 0. ----....--- ..... Street -as shown on the application for Disposal Works Construction Permit -._.. Dated ._......a .i-----••- Board of,Health ��� DATE....----- .. � µ FORM 1255 A. M. SULKIN, INC.. BOSTON 1 MARSTONS MILLS �} LEGEND PROPOSED CONTOUR ® PROPOSED SPOT GRADE —-- 98 —— EXISTING CONTOUR O.9 + 96.52 EXISTING SPOT GRADE O EXIST. I ,OOO GAL W— EXISTING WATER SERVICE LOCUS ® TEST PIT 100 FQ ve SEPTIC ,TANK y WATERSHED WAY ® �� (� CO,cC�`S t^/ t - �ID I aF 0 D0 "' LOCUS MAP BENCH MARK SOT 23 TOP OF cbN�CRETE BOUND LOCUS INFORMATION AREA = 109,13 sf+— �24 83 713.9 2 TITLE REF: BK 24810 PG 199 PLAN soOk: 426 PAGE 87 LBARNST, BLE GIS DATU PARCEL ID: MAP 059 PAR. 009/007 ASSR MAP59 PCL 9--7 ` 73\ � I - f 4 SEPTIC SYSTEM - -_ _>-O ,,• �< EXIST. 1 ,000 PIT REPAIR PLAN z O LOCATED AT. " I (see Note 1 O) 100 WATERSHED WAY �, t ;-,.� '� MARSTONS MILLS, MA �- 6*10- 1 ti PREPARED FOR � ._ T" 2 MENINNO OCTOBER 12, 2015 / ( ( WATER { `/ GATEOF v 7 0 f ff— $� AR EN M. y� P 11 STONE bPl VEWAY \ p. \ JC�s ° 73 MEYER & SONS INC. ' - 107.9}7 2 P.O. Box 981 ------ E. SANDWICH, MA 02537 PH. (508)360-3311 fax (774)413-9468 meyerandsonstitle5@gmail.com SCALE 1"=20' www.meyerandsons.com SHEET 1 OF 2 J 1491 `I ELEV. TOP FOUNDATION NOTE: PLACE MAGNETIC MARKING TAPE OVER ALL COVERS (Existing) BRING ALL COVERS TO WITHIN 3" OF FINISH GRADE FINISHED GRADE (73.6) MAX = 74.33 F.G.EL: 73.7 F.G.EL: 73.53 F.G. EL 73I6 A MAINTAIN 2X MIN SLOPE OVER LEACHING AREA A' r F.G.EL: 71.43PLACE 2" OF 3/8" DOUBLE WASHED 3/4" - 1-1/2" TEE IN D--BOX 'ARY STONE OR FILTER FABRIC " DOUBLE WASHED STONE s" " 4" SCH 40 PVC 1o"I 14 6 MIN.) TFEt ®®®0®�®®® Cda S= 1 q; ®®®®T " S ARE TO BEINV.70.0 2 E�F. DEPTH ®®®®®a®®®® a °! 4" SCH 40 PVC INV.70.15 INV.69.80 `s 4' 2 X 8.5' 4' PROPOSED DB-3 EXISTING OUTLET BAFFLE I DISTRIBUTION BOX EFFECTIVE LENGTH = 25' INV. 70.40 (H20) INV. ELEV.= 69.70 EXISTING 1 ,000 GALLON SEPTIC TANK f GAS BAFFLE TO BE INSTALLED ON �L`� OFss9 BREAKOUT OUTLET TEE AS MANUFACTURED BY o DARREN s ELEV.= 70.70 TUF-TITE, ZABEL, OR EQUAL M TOP CONC. ELEV.= 70.70 NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING No. 4 INV. ELEV.= 69.70 ® PIPE INVERTS PRIOR TO CONSTRUCTION 2) D-BOX SHALL BE SET LEVEL AND TRUE TO ®®®0000 GRADE ON A MECHANICALLY COMPACTED SIX �NtTAR�p� BOTTOM EL.= 67.70 ®®®®®®® , INCH CRUSHED STONE BASE, AS SPECIFIED IN �b 3.75 5 FT. 3.75 310 CMR 15.221(2) EFFECTIVE WIDTH = 12.5' 3) REPLACE EXISTINGING 1 1,000 GALLON SEPTIC TANK �� � SEPARATION 5.03 FT. DAMMAITHGED,ONOOT GALLON LOADING, R IUNDERSIZED. SEPTIC SYSTEM PROFILE 4) INSTALL INLET & OUTLET TEES W/ BOTTOM OF TESTHOLE EL: 62.67 SOIL ABSORPTION SYSTEM SECTION GAS BAFFLE AS REQUIRED j (500 GALLON H2O LEACH CHAMBER) GENERAL NOTES: SDIL LAGS DESIGN CRITERIA 1• ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL P#: 14806 NUMBER OF BEDROOMS: 3 BEORQOOM BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DATE: SEPI EMBER 9, 2015 SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD SF OF THE STATE ENVIRONMENTAL CODE. TITLE V. AND ANY APPLICABLE DESIGN PERCOLATION RATE: <2 MIN/IN LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: SOIL EVALUATOR: DA0EN MEYER, R.S., CSE #1614 - 310 CMR 15.405 (1) (B): DAILY FLOW: 110 G.P.D. X 3 BR = DESIGN FLOW: 330 G.P.D. 1) A 10.0 FT. VARIANCE FROM 310CMR211 TO ALLOW LEACHING WITNESS: DAVItA STANTON, BARNSTABLE B.O.H. TO BE 10.0 FT (MAx) FROM DwELuNG vs REo'D 20 FT. GARBAGE GRINDER: NO (not designed for garbage grinder) 3. THE SEWAGE DISPOSAL. SYSTEM SHALL NOT BE BACKFIUED PRIOR i SEPTIC TANK: 330 gpd x 20OX = 660 gpd, USE EXISTING 1,000 GAL. SEPTIC TANK TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE Elev. TP-1 Depth i, Elev. TP--2 Depth DESIGN ENGINEER. 73.70 0" " (330) 445.94 S.F. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING Flu i 73.67 0 LEACHING AREA REQUIRED: FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN FILL 74 ENGINEER BEFORE CONSTRUCTION CONTINUCS. 72.03 - 20" i 72.00 20" 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. A LOAMY3 1 ! A LOAMY SANDIOYR USE TWO (2) 500 GALLON H2O PRECAST LEACH CHAMBERS W/ 4' 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 71.78 23" 1OYR 3/1 , THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF B 71.75 B 23" STONE ON ENDS & 3.75 STONE ON SIDES: 25 L x 12.5 W x 2 D HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. LOAMY 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 1pYR SAND � LOAMY SAND BOTTOM AREA: 25 x 12.5= 312.5 SF 1OYR 5/8 B. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED 70.12 43" 70.09 43" SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. C ! C 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE PERC O EL 88.3 MEDIUM SAND i TOTAL SQUARE FEET PROVIDED m 462 vs. 445.94 REQ'0 MEDIUM SAND THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING 2.5Y 6/4 I 2 5Y 6/4 DESIGN FLOW PROVIDED: 0.74(462 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd CONSTRUCTION. 10. PUMPED, CRUSHED FILLED PER TITLE S. PROPOSED SEPTIC SYSTEM UPGRADE PLAN 1 . 48OUR NOTICE FOR ENGINEER ERTIFICA ON 62.70 132" 62.67 132" 1 SYSTEM 2. THIS PLAN IS TO BE USED FOR SEPTIC PURPOSES ONLY iL 100 WATERSHED WAY, MARSTONS MILLS, MA AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY PERC RATE <2 Miry/IN. (-Cl- HORIZON) Prepared for: Meninno 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. NO GROUNDWATER OBSERVED 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. I Engineering and Survey by: SCALE DRAWN 15. ALL PIPING TO BE 4" SCH 40 0 1/8'/FT (UNLESS SPECIFIED) • I, Darren M. Meyer, R.S., CSE, hereby certify that I am currenNy approved by MADEP Pursuant to 310 CMR 15.017 AfEYER&SONS,INC. N.T.S. DMM to conduct soil evaluations and that the above analysis has been performed by me consistent with the POSOX981 requirements of 310 CMR 15.017. 1 further certify that)l have passed the Soil Evol. Exam in October. 1999. 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THIS PLAN IS FO?t DESIGN AND t t *1 ( 1 r 1 t } _ I CONSTRUCTION OF THE SEWAGE r I DISPOSAL FACILITY ONLY • i- : ;. i :2. ALL CONSTRUCTION METHODS AND , :r a_ ; ' - r . . t I MAT 1 LS SHALL CONFORM TO MASS.. _ • - _ - _. �: __ _ __ ._._. . . ._ _... _... . . . _ :_.. _.: . . . D.E.Q.E TITLE 5 AND LOCAL BOARD ---_ _ _.._ ' _-.__I' _ _ ;- _,_ ��5 t6r .. ; - OF HEALTH REGULATIONS. .. . . . _ . . . . L . . . . -- 1k . A 3AGzE 0xl,1 � . .. 1TA .t;,.�t F�wiN s 1. 14. - . 33 ;, pD .._._ ; 5.►_c."TANK"_33Q_x_._:� _ -_.4�.5_G:P.. 1__. , VSk f.�00 _ - ._.. , . _. _ _._. I A1.. T'A NNC I . dui s two sea._ PIT' -ti ;V$M C-1 � /_o ,on 6A L �i r (�'-x G' w/z'sTo►a e) , 51 EM W A LL�4,i4,1:: .i:�7 S o F._ . v- - , , _. "r"'rcat�n ,4 ,. y' S, . . . , . . '�"�Tr4L. # .t�. ZUW z 33c� CI 12 D, : : . ' : . - , . . . : . "IN Z MIN orz L.aSS _ - 1jtAt-k�N . 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