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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI
A DEPARTMENT OF ENVIRONMENTAL PROTEC
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PARCEL ,, b23
OT 5�. - SEP 2 12004
TOWN OF BARNSTABLE
TITLE 5 • HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 193 WHEELER ROAD MARSTONS MILLS,MA 02648
Owner's Name: MENARD
Owner's Address: 19720 THREE OAKS WAY SARATOGA CA 95070-6467
Date of Inspection: 8/17/04
Name of Inspector: (please print) JOHN GRACI,INC.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below
true,accurate and complete as of the time of the inspection.The inspection was performed based on myanning 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: ;� y
X Passes w M
_ Conditionally es
_ Needs Furthe aluation by the Local Approving Authority
Fails
Inspector's Signature: ° Date: 8/17/04
The system inspector shall submit a py of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspectio . 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
SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****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 Tncnrrfinn Fnrm 6/1 S/1000 1
r
Page 2 bf 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 193 WHEELER ROAD MARSTONS MILLS,MA 02648
Owner: MENARD
Date of Inspection: 8/17/04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
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.
n/a 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
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
_ distribution box is leveled or replaced
ND explain: n/a
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
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 193 WHEELER ROAD MARSTONS MILLS,MA 02648
Owner: MENARD
Date of Inspection: 8/17/04
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 ti
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 n/a
"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:
n/a
i
I
Page 4'of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 193 WHEELER ROAD MARSTONS MILLS,MA 02648
Owner: MENARD
Date of Inspection: 8/17/04
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for alLinspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facilit
y ty and the presence of ammonia nitrogen and
nitrate nitrogen o en is equal to r
g q o
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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.
d
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 193 WHEELER ROAD MARSTONS MILLS,MA 02648
Owner: MENARD ,
Date of Inspection: 8/17/04
Check if the following have been done. You must indicate "yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks
_ X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out
X _ Were all system components,excluding the SAS,located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information.For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CMR 15.302(3)(b)]
5
f
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 193 WHEELER ROAD MARSTONS MILLS,MA 02648
Owner: MENARD
Date of Inspection: 8/17/04
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 6 Number of bedrooms(actual): 6
DESIGN flow based on 310 CMR 15.203
5. 03 (for example: 110 gpd x#of bedrooms): 660
Number of current residents: 0
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): YES
Water meter readings,if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no):NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings,if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components; date installed(if known)and source of information:
APPROXIMATELY 20YRS PER OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
h
Page 7ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 193 WHEELER ROAD MARSTONS MILLS,MA 02648
Owner: MENARD
Date of Inspection: 8/17/04
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage, etc.):
WATER Irjtl I,J6Q
SEPTIC TANK:X(locate on site plan)
Depth below grade: 12"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 2000 GALLON SEPTIC TANK"
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 33"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions determined: MEASURED
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions:n/a
Scum thickness: n/a
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
Date of last pumping: n/a
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
7
Page-8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 193 WHEELER ROAD MARSTONS MILLS,MA 02648
Owner: MENARD
Date of Inspection: 8/17/04
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF 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 IS STRUCTURALLY SOUND.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
n/a
R
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 193 WHEELER ROAD MARSTONS MILLS,MA 02648
Owner: MENARD
Date of Inspection: 8/17/04
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 2
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LEAC
H PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS
OF FAILURE.STAIN LINES INDICATE PIT "E"HAS NEVER HAD MORE THAN 1'OF LIQUID IN IT.
BOTTOM IS AT 10 FT.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no):NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
4
l
Page fO.of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 193 WHEELER ROAD MARSTONS MILLS,MA 02648
Owner: MENARD
Date of Inspection: 8/17/04
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.
KWIC A,
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Page J.1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 193 WHEELER ROAD MARSTONS MILLS,MA 02648
Owner: MENARD
Date of Inspection: 8/17/04
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked, date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators,installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+FT.
11
7Z)
James M. Ford
Title V Septic System Inspections
Post Office Box 49
AIR Osterville, MA 02655
(508) 862-9400
July 23, 2000
Mr. Joe Menard
193 Wheeler Road
Marston Mills, MA 02648
Dear Mr. Menard:
As requested,to-Jay I checked the toilet in the boat house at your property and it discharges
into the main septic syst:m. Enclosed is an updated sketch of your septic system which includes the
boat house.
If you have any question,please call me.
Very truly yo
/Y1
2400
James M. Ford
vti'e
Encl. s
cc: Town of Barnstable
Board of Health
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7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 193 Wheeler Rcwm4 Marston Mills, AM
Owner: Michael Sokolowmki
Date of Inspection: April 21, 2000
Map. 082
Pare&023
SKETCH OF SEWAGE DISPOSAL SYSTT' d:
include ties to at least two permarea reference landmarks or benchmarks
locate all wells within 100' (L,oc aw where public water supply comes into house) .
wail 30�,�
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revised 9/2/98 PWtoof11
g
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of Environmental Protection % �
One Winter Street, Boston MA 02108 (61 n 292-55 p ow
g- TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 193 Wheeler Road, Marston Mills, MA Name of Owner: Michael Sokolowski
Address of Owner: 83 Arnold Road
Date of Inspection: April 21, 2000 Newton,MA 02459
Name of Inspector:(Please Print) James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: James M. Ford
Mailing Address: P.O. Box 49, Oyerville. MA 02655-0049 Map: 082
Telephone Number: (508)862-9400 Parcel: 023
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper funetion and
maintenance of on-site sewage disposal systems. The system:
✓ Passes
Conditionally Passes
Needs Further Z By the Local Approving Authority
ails
Inspector's Signature: Date: April25, 2000
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days
of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable,and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Page Iof11
Printed an Recycled raper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 193 Wheeler Road,Marston Mills, MA
Owner: Michael Sokolowski
Date of Inspection: April 21, 2000
INSPECTION SUMMARY: Check A, B, C, or D.-
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon
completion of the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health)
broken pipe(s)are replaced
_ obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 193 Whee#er Road,Marston Mills,MA
Owner: Michael Sokolowski
Date of Inspection: April 21, V
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 the
public health, safety and 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 THE PUBLIC HEALTH AND
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 AND SAFETY AND
THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 193 Wheeler Road, Marston Mills, MA
Owner: Michael Sokolowski
Date of Inspection: April 21, 2000
D. SYSTEM FAILS:
You must indicate either"Yes" or"No"as to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
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 Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a 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.
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. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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 H of a public
water supply well
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 193 Wheeler Road, Marston Mills, MA
Owner: Michael Sokolowski
Date of Inspection: April 21, 2000
Check if the following have been done: You must indicate either"Yes"or"No" as to each of the following:
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health.
*✓ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection. (*House has weekend use.)
✓ _ As built plans have been obtained and examined. Note if they are not available with N/A.
✓ The facility or dwelling was inspected for signs of sewage back-up.
✓ _ The system does not receive non-sanitary or industrial waste flow.
✓ _ The site was inspected for signs of breakout.
✓ _ All system components,excluding the Soil Absorption System,have been located on the site.
✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
✓ _ Existing information. For example,Plan at B.O.H.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[15.302(3)(b)].
✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
l -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 193 Wheeler Road, Marston Mills,MA
Owner: Michael Sokolowski
Date of Inspection: April 21, 2000
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): n/a Number of bedrooms(actual): 6
Total DESIGN flow 1320
Number of current residents: 0
Garbage grinder(yes or no): Yes
Laundry(separate system)(yes or no): No; If yes,separate inspection required
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last two year's usage(gpd): Private well
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gad(Based on 15.203)
Basis of design flow
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
None on file-per treatment plant.
System pumped as part of inspection(yes or no): No
If yes,volume pumped: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information: 1984-per as built card.
Sewage odors detected when arriving at the site: (yes or no) No
revised 9/2/98 Page 6of11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 193 Wheeler Road,Marston Mills,MA
Owner: Michael Sokolowski
Date of Inspection: April 21, 2000
BUILDING SEWER: _
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron 40 PVC _other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting,evidence of leakage,etc.)
SEPTIC TANK: ✓
(locate on site plan)
Depth below grade: 13"
Material of construction: ✓concrete _metal _Fiberglass _Polyethylene other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 2000 gal.
Sludge depth: 5"
Distance from top of sludge to bottom of outlet tee or baffle: 23"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How dimensions were determined: Measuring stick
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.) Both ba0`les were present. The liquid level was even with the outlet invert. There were no sign of leakage.
GREASE TRAP: None
(locate on site plan)
Depth below grade:
Material of construction concrete _metal _Fiberglass _Polyethylene other(explain)
Dimensions:'
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 193 Wheeler Road, Marston Mills,MA
Owner: Michael Sokolowski
Date of Inspection: April 21, 2000
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or at time,of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present:
Alarm level: Alarm in working order: Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: ✓
(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was level, and there
were no signs of solids or leakage.
PUMP CHAMBER: None
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order: (Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of11
SUBSURFACE WWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 193 Wheeler Road,Marston Mills, MA
Owner: Michael Sokolowski
Date of Inspection: April 21, 2000
SOIL ABSORPTION SYSTEM(SAS): ✓
(locate on site plan, if possible;excavation not required, location may be approximated by non-intrusive methods)
If not located,explain: {
Type:
leaching pits,number: 2-6'x 6'
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure, le,.vi of ponding,damp soil,condition of vegetation,etc.)
Pit#3 had 2'of water on the bottom. There were no signs of failure. The bottom to grade was approximately 9'.
Pit#4 had 6"of water on the bottom. There were no signs of failure. The bottom to grade was approximately 10'.
CESSPOOLS: None
(locate on site plan)
Number and configuration:
Depths-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection).
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
PRIVY: None
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 193 Wheeler Road,Marston Mills, MA
Owner: Michael Sokolowski
Date of Inspection: April 21, 2000
Map: 082
Parcel:023
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
wall
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revised 9/2/98 Page 10of11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 193 Wheeler Road, Marston Mills, MA
Owner: Michael Sokolowski
Date of Inspection: April 21, 2000
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater 30 +/- Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
✓ Checked with local Board of Health
Checked FEMA Maps
Checked pumping records
Check local excavators,installers
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
The bottom of the pit to grade was approx. 10'. Using the Barnstable topographic map and water contours map, the maps
were showing approximately 30' +/-to groundwater at this site. Using the Cape Cod Commission Technical Bulletin, the
high groundwater adjustment for this site(SDW 253, Zone B, 3100)was 5.1'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty
or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,
written or implied, relating to the system, the inspection and/or this report.
revised 9/2/98 Page 11of11
_ i
12
Lx
1� 1
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AF AI12S S O a
DEPARTMENT OF ENVIRONMENTAL PR ON r � /��
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 O O�L 6 9 W
� y�Pyoysrq� 'l9�
WILLIAM F. WELD TR e C XE
Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO C
ARGEO PAUL CELLUCCI PART A 9=AVIDB.STRUHS
Lt. Governor CERTIFICATION Commissioner
Property Address: 193 Wheeler Road, Marstons Mills, MA Address of Owner: 124 Commonwealth Ave.
Date of Inspection: Siptember 4, 1997 (If different) Boston, MA 02116
Name of Inspector: James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: James M. Font
Mailing Address: P.O. Box 49, Osterville, MA 02655 Sewage #84-39
Telephone Number: (508) 775-7927
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
✓ Passes -- --
Conditionally Passes
Needs Further Eval tion By the Local Approving Authority
ails
Inspector's Signature: Date: September 6. 1997
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure 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.
Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the-date of the inspection;
or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or
tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic
tank as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
®EP on the World Wide Web: http1twww.magnet state.ma.uSMO
h r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
f <, PART A
CERTIFICATION (continued)
Property Address: 193 Wheeler Road, Marston Mills, MA
Owner: Harrold 7heran
Date of Inspection: September 4, 1997
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect
the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT
FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT
PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply
or tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private
water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 193 Wheeler Road, Marstons Mills, MA
Owner: Harrold Theran
Date of Inspection: Siptember, 4, 1997
D] SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of 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.
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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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 lI of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 193 Wheeler Road, Marstons Mills, MA
Owner: Harrold Zheran
Date of Inspection: September 4, 1997
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
✓ Pumping information was provided by the owner, occupant, and Board of Health.
✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of
this inspection.
✓ s As built plans have been obtained and examined. Note if they are not available with N/A.
✓ The facility or dwelling was inspected for signs of sewage back-up.
✓ The system does not receive non-sanitary or industrial waste flow.
Y rY
✓ The site was inspected for signs of breakout.
✓ _ All system components, excluding the Soil Absorption System, have been located on the site.
✓ _ The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
✓ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance
of Sub-Surface Disposal System.
✓ Existing information. Ex. Plan at B.O.H.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[15.302(3)(b)].
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 193 Wheeler Road, Marstons Mills, MA
Owner: Harrold Themn
Date of Inspection: Siptember 4, 1997
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 1320 g.p.d./bedroom for S.A.S.
Number of bedrooms: 6
Number of current residents: N/A
Garbage grinder (yes or no): Yes
Laundry connected to system(yes or no): Yes
Seasonal use (yes or no): No
Water meter readings, if available (last two (2) year usage (gpd): Private well
Sump Pump (yes or no): No
Last date of occupancy: Presently unoccupied
CO MMERC IALANDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present (yes or no):
Industrial Waste Holding Tank present (yes or no):
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
None on limper treatment plant
System pumped as part of inspection (yes or no): No
If yes, volume pumped: gallons
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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: June 21, 1984 -as built caul
Sewage odors detected when arriving at the site (yes or no): 116
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 193 Wheeler Road, Marstons Mills, MA
Owner: Harrold Theran
Date of Inspection: September 4, 1997
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron 40 PVC _other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK: ✓
(locate on site plan)
Depth below grade: 13"
Material of construction: ✓ concrete _metal _Fiberglass _Polyethylene _other (explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: 12'L X 5'D X 6'6"W - 2000 Gal.
Sludge depth: 5"
Distance from top of sludge to bottom of outlet tee or baffle: 23"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How dimensions were determined: Measuring stick
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) Both baffles were present. Liquid level was even with outlet invert. No signs c leakage.
GREASE TRAP: None
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10 _
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 193 Wheeler Road, Marston Mills, MA
Owner: Harrold 7herun
Date of Inspection: Siptember 4, 1997
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete metal _Fiberglass Polyethylene _other (explain)
I
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order_Yes; _No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: ✓
(locate on site plan)
Depth of liquid level above outlet invert: 0" (even)
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
Box was level. No signs g� solids carryover.
PUMP CHAMBER: None
locate on site plan)
( 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.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 193 Wheeler Road, Marstons Mills, MA
Owner: Harrold Theran
Date of Inspection: September 4, 1997
SOIL ABSORPTION SYSTEM (SAS): Yes
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number: 2 - 6'
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
No signs g' hydraulic hilure orponding. Grass covers the system.
CESSPOOLS: None
(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 (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: None
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 193 Wheeler Road, Marstons Mills, MA
Owner: Harrold 7hemn
Date of Inspection: September 4, 1997
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent references, landmarks or benchmarks.
Locate all wells within 100' (Locate where public water supply comes into house).
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Jos
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 193 Wheeler Road, Marstons Mills, MA
Owner: Harrold 7heran
Date of Inspection: September 4, 1997
Depth to Groundwater: 40 +/- feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
✓ Observation of Site (Abutting property, observation hole, basement sump etc.)
✓ Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
✓ Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
Using Bamstable Observed Water Table Map and USGS Data. Maps were showing 40'to water. Property abuts Mystic Lake and
has an elevation tf 40'higher than the lake.
(revised 04/25/97) Page 10 of 10
LOCATIQNN SEWAGE PERMIT NO.
VILLAGE
� F t let— Reap ors f� &ZA
I N S T A LLER'S NAME i ADDRESS '
.1 g 1�v- fi r w; s
BUILDER OR OWNER
DATE PERMIT I S S U E D 4Z14Z r,�/
D_A,J.E COMPLIANCE ISSUED
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1_ TOWN OF BARNSTABLE
LOCA,noN.�•�3' (�I�2e�c� RCS. SEWAGE #
VIi AGEAACMAS .✓h,1 IS ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY o�000
LEACHING FACILITY: (type) oZ" Q' 1 S (size)
NO. OF BEDROOMS (D
BUILDER OR OWNER M,�9- 30k0l Ow Skl'
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the: '
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist ' 'r
on site or within 200 feet of leaching facility) //0 Feet
Edge of Wetland'and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
$ O1
tow 'Ed
6 LO r -t
'� b$ -yew
•d y• OL
�� 1
r
t.
No.P.. :J.,�..:: Fim..............................
THE COMMONWEALTH.OF MASSACHUSETTS
BOARD OF HEALTH
1� tom. ......
Appliration for Dispagal Workii Tomitrnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: 1�3
......� / :..., c ............ .................. ------------------..... -•-••.....---------•-••............•----
or
lion•Address ......................................... ...Lot No. =
Ow . Address
W -----------•............ ................................ ........._......................................_..
Insta kr Address
UType of Building Size Lot.............................Sq. feet
., Dwelling—No. of Bedrooms.....96.................................Expansion Attic ( ) Garbage Grinder
Other—Type T e of Building No. of persons............................ Showers
a YP g ••......................••-- P ( ) — Cafeteria ( )
Q' Other fixtures -•-••••--••---•-----•--------•................
W Design Flow._________________________��..gallons per person per day. Total daily flow-----,..3.- ®.................gallons.
WSeptic Tank—Liquid capacity26.2�5�.' allons Length................ Width................ Diameter............ .... Depth................
Disposal Trench—No..................... Width................. Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No.......2.�-t........ Diameter....._/ .... Depth below inlet....... ...... Total leaching area.__5�� .sq. ft.
Z Other Distribution box O Dosing tank ( )
a Percolation Test Results Performed by.........................................................
...... Date---•-------,........._.....-------•--
Test 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 ...............•..._................---•....-----........._...............__.._..---------•-•................................................................
0 Description of Soil.................................
W
V ...............................................•-•---.._.-•-----•----........._......----------_......------..._.._.....___.......-------•--...------------...._................._.------....__..........
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 iITI.2 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Complianc has been issued by the board of health.
igned..................................................................................... y ........
Application Approved By- . ----•----•-...•••••-•--•-••--•---------------•----.....--•--------• ----�
S//J'
- --------------
Date
Application Disapproved r t following reasons:..............................................................................................................
----------------------•-----•--------......__...._._......._.._._..-----...........---...._._....__.._--------------•--....-----._.-•--.......------...................................................
Date
PermitNo......................................................... Issued.....................................................
Date
} ism
No.. .......J_2. -; FEs............._............._
THE COMMONWEALTH OF MASSACHUSETTS
BOA13D OF HEALTH
i-sfQ .N1 ,84.7. ..... ��rl
App iration for Diipuial 10jarkii C omtrurtivtt Vamit
Application is hereby made for a Permit to Construct ( ) or Repair (X an Individual Sewage Disposal
System at:
............ ..............................•-•---------- -•------•-----.................-----••----
tion-Address -or Lot No.
17----------------•----------------- ...............----.......-- ----•-------------------------..............--
Owner Address
W
Installer Address
Type of Building Size Lot............................Sq. feet
►� Dwelling—No. of Bedrooms.....A�.................................Expansion Attic ( ) Garbage Grinder {
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ......................................... - ................................ ••••-
.�_. allons per erson per day. Total daily flow...._ .
w Design Flow_ __._-..•:. �� g P P P Y Y +13----------- lons.
WSeptic Tank—Liquid capacityZ allons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No.................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........2.-_....... Diameter."Z'.1.�'_._... Depth below inlet.......s6_....... Total*aching area._6�_sq. ft.
Z Other Distribution box ( Doi ng ta'`nk
aPercolation Test Results Performed.bY =`=-----------------•------........•--•••--•-•-•---••......--•--••••--.. Date----•••••••-••-•--••--•-••-••----•-----
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•---•--------------------------------------------------=---•---•--------............-•------•-....-•.........................................................
0 Description of Soil........................................................................................................................................................................
x
U
w
UNature of Repairs or Alterations—Answer when applicable.................................................._...........................................
...
Agreement:
The undersigned agrees to install'the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Complianc has been issued by the board of health.
igned. •---•••-......-•--......... ......•......•-•----•...................•-_..__
Application Approved By. =• .......e`. ..... ......................................................... / Y �
...............
Date
Application Disapproved r t following reasons:................................................................................................................
--•..........................•-----------•--•---••-•-•---------•-•--•-------------------•-••------------.••--•••••--•••••••••••••-•-•-••••••••-•-••---------•-••--••••••••-----------•-•--••---•--•••---
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
x F;w_ 0F....,�Y..!..7-;5:.- --0 1'l ......
Trrfifiratr of Tumplittttrr
THIS IS TO CERTIFY, That the Individual Sewag isposal_,System constructed ( ) or Repaired
by = ;.....�: ... ........................• ------------------------.....----•-----......-----..........•---•...._..__....
`` Installer
at. ( l� --........
.............been installed in accordance with the provisions of TI��y 5-9 f�yThe State Sanitary eta e, ibed in the
application for Disposal Works Construction Permit No.._1J-_•............................... dated-��1.__.�_....___._._..-._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISF CTg0 I v
DATE........-••................... �' ,-t Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
3ey //ar.- s., i./. ..O ........ /f
Bispviia1 Works Tonotr "qn it
Permission is hereby granted................................................6v---•••-6ZOA ........................................................
to Construct ( ) or Repair ( an Individual Sewage Disposal System
r. �r at No.. ���� �1 ............................................................... ......................................................
Street
as shown on the appli tion for Disposal Works Construction Permit No ..._. . Dated..........................................
••............. ...............................................................................
Board of Health
DATEl 1 ..... . .......................................
FORM FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
D IJ. TOWN OF BARNSTABLE �"�N UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS \ YA L
/ � r
ASSESSORS MAP NO. ® �� PARCEL NO.
ADDRESS: 3 VILLAGE, PA
NAME',.
CONTACT PERSO A75 P(PW6 ")PHONE NUMBER
LOCATION OF TANKS: CAPA ITY: TYPE OF FUEL, AGE: TYPE: LEAK
OR HEMICALS DETECTION
�iQOn r ��5 2 d 1Z l/�
�,o
DATE OF PURCHASE OF. EACH: 1. 2. 3. 4. 5.
DATE OF FIRE DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS
PLEASE PROVIDE A.SKETCH SHOWING TIIE LOCATION OF TANKS ON THE BACK OF THIS CARD.
4
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1 2 3 5 6 7 6
17-1
- - - - - - - - - - - - - - - - - - -
0
EXISTING INTERIOR
ND CHANGE
EXISTING NOON
TO Be RENOVATED AND
EX—NDEO
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
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FIRST FLOOR
E E
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T,.I.
Addition to the Residence of TVR.ro
EXISTING FLOOR PLANS
MR. PAUL GRABSCHEID AND MS. SHEILA BLOOM MR. PETER C. FITZPATRIC&BUILDER
ScaI A.
193 Wheeler Rd.. P.O. Box 1165 A .
o Marstons Mills, MA 02648 Osterville, MA 02655 °' °°E" z°°'
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4
LIME 6 TOD' TOYi
NOW TETLAND /
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LOIE OETECIpt—.� `
CEILING WOIMTEO
... .. ... - .. ... .. .. i — — — — — — — — — — — — — — — — — — — — —.— — — —
2'l0'V-D 3'. 3. 3'0'1 {O 24'-T 11.
RENONATEO[ICIEM O t[xCtiOiT�EO
. .. Y 01.1.0.Tq f.YILT NOW
�_ ... _ 4 '.i iiri iir•i;;:; i,•r,:,i�.id.i'ri::•i;,;stall%!,
DETECTOR
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IE0 Casr�cna
SF
NALL
" LAI➢WRT 1—� I YE►.E DETECTOR '
A.G CEILING IO ATEO--------0
V01LET
G'-3 3/
NEW GAME
GR2 Y
0 I— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 0
1
A.R 1 R
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LEGEND
EXISTING WALL TO REWIN S
NEW EXTERIOR STW WALL
NEW INTERIOR STW WALL
E E
- T/e.iro Ti.I.
Addition to the Residence of NEW FIRST FLOOR PLAN
MR. PAUL GRABSCHEID AND MS. SHEILA BLOOM MR.PETER C. FITZPATRIC& BUILDER
193 Wheeler Rd.. P.O. Box 1165
o Marston Mills, MA 02648 Osterville, MA 02655 O1'Apr
i t 2007
1 2 3 5 6 7 B
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TINLOETECTOR
- � �SIOL INO[TEC nA.
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•rll[STORAGE
0 ..N.... _ \ I(NDIKERED FOR 40 PST LIVE LOAD) 0
d
" STET ID 1'-,O.S••/-
}.x... T...:, *. ... ...__.... /_ .. ..... .. — — — — —\ -/ — — — — — — — KW RIOGE LINE— — — — — — — — — — — — — —
LEGENDOw
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ATTIC STORAGEITKW OORIER
EXISTING WALL TO REMAIN
i,
rOETEC101R
//�_ CEILINC IEO,TEO
NEW EXTERIOR STUD WALL C % ^.-T. — — — — — — — — —KW RIOCE LIRE
LY—.t — — — — — — — — — — — —
NEW INTERIM STUD WALL
SECOND FLOOR
NEW CONCRETE FOI1NDATION WALL
T-4004TE PIER
ON
_
TNA.PAp
-, In UNDER EXTERIM !,
CQ ¢•
— — — — — — — — REFERENCE.•-,0• — — — — — — — — — — — 1 [
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- - - - - - - - - - - - - - - - - - - - - I�1_ J :
I CD DETECTOR
M. I s' s/D WALL 143.01112
23-10 7/6
L
I EXISTING BASEKN/ NEW IIASEKNT STORAGE
L _ ND ORANGE
T I 4 1
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•01A.CON1.rIL%EDI
TO'DE SLAG ELFAV. CON CQ.ON,6'X,SYE yl ( —
} CONCRETE PM I _REFERENCE 0'-0 a ALA SLA9K EA.uV
3•-0,/. a1Lils loirED�
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4
I 1 OUSI SLAG I I I CRAM SPACE I I
I I REFERENCE SEE WALL SECTION I
IL — — — — - - - — - — - 7I — - - — — --- — - - — — — — — — — — — — I 1
I i REFERENCE T'-„•
EL - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
zEDDTING 00LN r-0••/
FOUNDATION PLAN SEE NIILOING SECTION 8-s BASEMENT
Addition to the Residence of
MR. PAUL GRABSCHEID AND MS. SHEILA BLOOM MR. PETER C. FITZPATRICK, BUILDER NEW BASEMENT AND N�I RNA
SECOND FLOOR PLANS
193 Wheeler Rd.. P.O. Box 1165 W W A . 4
Dab.
o Marstons Mills, MA 02648 Osterville, MA 02655 °, °' z°°'
2 m 'S` RACE- CAPE COO
0 in RA �
AIRPORT
. We Ouae . � silt E G
89,19 <
f grade „
. finish K
9
roof � Fl. 76•.�-? 12 min(typ) ,.
LOCUS
1.
MYSTIC
2of 1, 2
_ y
1
S-O.O
KB
washed stone 2 S-0.02
S=0.02
m
21
O 4 A14(D 3/ 1 1 2
",/ i / 456.8 MIwashed stone6o.S� �D.78 � 8 �
u 79.99 �3
co
0m
POND 4.
DISTRfBUT ON t
co ee (t p)
t30.25 �'we �) _ .
, `BOX -
10 min
10'min from
SEPTIC TANK
FOUNDATION LOCUS PLAN
t tank Scale.1 = 2000 septic
14 dia.
SEPTIC SYSTEM PROFILE
�. LEACHING PIT
-� A01d tr4,-I� A N TS
r� 86
NOTES
s
t State
- CJ, designed and m accordance with he
1. Construct sewage system as
of th
Environmental Code Title 5 and the Rules and Regulations e
9
AN Board of Health. ..
tim
es 2
es
ow equals 1320 d based on 6`bedrooms
o.. e rJ�ron 2. Estimated sewage flow q 9P
Owe ll�%r '� •
Exrsf r� •
in
_ _9 0
2 o a a e render
55 d per person Imes 00 / ( rb
7
persons ;per `bedroom Imes gp P P 9 9 9
80 . ft..
� Leaching area equals 6 s
` q q
�.
9
o, 5 outlet precast concretex.
4 Distrrbution box shall be a prec b
5.Septic ,„tank shall be 2000 gallon capacity recast co
ncrete tank.
e t c SeP � . 9 P Y P
,P _
C.I. or
septic tank shall be 4 diameter
r1t.�#rtf�utron 6. Pi m from the house to the p
'. tank P _ 9
to t
he septic tan
k he
box chloride PVC and from t se c
. 4 Schedule 40 'ol venal chi id (PVC) P
P Y
2729
t V STM D
leachingit shall be 4 diame er PVC (A )
, P
leaching
the two
` 7. minimum center to center distance betweeng
The
4 t 2.
pits
0
f
soils will
. o the insitu II
, where not required,.verification f e
y
8.Because test:: pits h e q ,
. .. or _t e leachin Pits.
. _ . . re u�red durm the `excavation f h _
_`be q g, 9 P
x 35• o
I ..
title "Additions 7 x from ` a plan .titled :Add E�
_ 9 97 0 9. Pro rt line information obtained f P 6 � Pe Y . _
tons ill - Mass.98 � Residence, r `Road .::Mars M
. .. `. � Alterations Theran 193 `Whee e d, ,
r oArchitect, DWG. No.1 undated.
b Dominick Sca f ,
Y
<
a
8�
1
E p v
LEG N
---
7X 6 of elevation
t
9 ,. SP
Ilit v e ..
00
Existingcontours
-- i- o
x
i
-- Property line
Pro. e e
QD
; F P Y
92
61
99
x
9
ect M 1 .
r ;
rr�,f art /� ctak ;
A
El. J1�0.00 sr>krte�)
C
/2 6.
X
.sue
98 71
94
r
WHEELER
E
L
ER
Y
9�X ;
ROAD
I• nt:C fie .
TH _ N
A
•
HARROLD . : . ERA
e1" O
PLAN , 0 PROPOSED- S W SYSTEM
LA _ F SEWAGE
1
,- c? S 5'f" Cry
N �lo��te 193 HE ROAD
� z�l T� R � W ELER
ressr
h
7I�/N G rr�cted add � fi
,: ,V•
. . . MARSTONS MILLS MASSACHUSETTS
. ..
Revision
Date `Ch Indq
. TWA!
.. . .� n b _
_ f Desi ed
9 Y.J.. MS P.E._ TYLER W. N i/
Date: ' /3 984
Drawn b TI�l e_ Tan
Y hr 1 CIVIL_SANITARY CONSULTANT
b Checked WIGt
Y
t
School Street Pembro Massach
usetts
is
T N Scale O E1
` 43 c
Approved by W' AS hl �}-6
1 j