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HomeMy WebLinkAbout0347 WHEELER ROAD - Health 47 Wheeler Road Marstons Mills F/R A 082 002002 Commonwealth of Massachusetts pgafb0� Oba' re p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 347 Wheeler Rd Property Address Manning Owner Owner's Name / information is Marstons Mills V Ma 02648 6/30/2020 required for every i page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information S # AAPL� on the computer, Chad hathaway use only the tab key to move your Name of Inspector cursor-do not Hathaway Septic Inspections use the return Company Name key. ± Company Address Forestdale Ma 02644 City/Town State Zip Code low 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 6/30/2020 Inspector's gnature Date The system inspector all sub It a copy of this inspection report to the Approving Authority(Board of Health or DEP)wit in 30 ys of completing this inspection. If the system has a design flow of 10,000 gpd or greate , inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. I Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . �� 347 Wheeler Rd Property Address Manning Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/30/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don't's can be found at town health dept or mass. ov 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 347 Wheeler Rd Property Address Manning Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/30/2020 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 347 Wheeler Rd Property Address Manning Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/30/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or.a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Qther: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/2 612 0 1 8. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 1 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 347 Wheeler Rd Property Address Manning Owner Owner's Name information is Marstons Mills Ma 02648 6/30/2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less than Y day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 347 Wheeler Rd Property Address Manning Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/30/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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. ❑ Z Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �o 347 Wheeler Rd Property Address Manning Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/30/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. 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 Description: as built 3 bedroom house Number of current residents: 0 Does residence have a;garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: well located 175' + Sump pump? ❑ Yes ® No Last date of occupancy: part timeDate t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 c� Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 347 Wheeler Rd Property Address .Manning Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/30/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding.tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: no info Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Y 347 Wheeler Rd Property Address Manning Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/30/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 7 feet Material of construction: ❑ cast iron 2)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.): plumbing is under concrete floor in basement. toilets flushed with good flow. no oders or visable leaks t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form `I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 347 Wheeler Rd Property Address Manning -Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/30/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 6.75 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1500 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'6"x5' Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? tape and sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): recommend pumping tank for maintenance is due. tees in place no visable decay l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 347 Wheeler Rd Property Address Manning Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/30/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts r; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 347 Wheeler Rd Property Address Manning Owner Owner's Name information is Marstons Mills Ma 02648 6/30/2020 required for every �I page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Dbox located under paved driveway with no access cover. disconnected 2"speed union on pump force main and ran cover to dbox. Dbox at normal level with no major decay present t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 347 Wheeler Rd Property Address Manning Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/30/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes . ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Alarm in basement audio and LED light works. Pump runs with weeping hole * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Leaching chambers are located under driveway with no access . Dbox at working level with no signs of backing up indicating a failed SAS Type: ❑ leaching pits number: E leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts @ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w Y 347 Wheeler Rd Property Address, Manning Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/30/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ., 347 Wheeler Rd Property Address Manning Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/30/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) - 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 347 Wheeler Rd Property Address Manning Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/30/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately tinA t� ^ 6/1 14 - Gy, 6 y � Q o ��- /0 a w 0M t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts fn - Title 5 Official Inspection Form iSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 347 Wheeler Rd Property Address Manning Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/30/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 36' 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: 2004 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: elevated SAS with pumping chamber. Estimated SAS bottom at 5' below grade based off 2"force main elevation. low in area mistic lake el. 46' lot el. in area of septic el. 82 town GIS mapping. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form t w, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 347 Wheeler Rd Property Address Manning Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/30/2020 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: Z A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 r' TOWN OF BARNSTABLE LOC.,;VTION SEWAGE # V1Lit GE �S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY lJao GaG f �oGe GaL .5� i0 Cl L,K . LEACHING FACILITY: (type) sic (size) �3sx 33r xy NO.OF BEDROO BUILDER O OWNER �41 PERMITDATE: 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 on site or within 200 feet of leaching facility) � � Feet Edge of Wetland and Leaching Facility(If any wetlands exist within.300 feet of leaching facility) Feet Furnished by__ C fl IE-H l e,2 y� (K•Cd//6dA"(� " No. AOO ��. .< Fee f� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZI pplication for Aigozal 6pgtem Cott.�truction Permit Application for a Permit to Construct( , j Repair( )Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. 3 Q-1 �( Owner's N e,Address and Tel. o. YN V�0.Y� �e, i rva� Assessor's Map/Parcel _ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tyl.No. ?�- ;7 Type of Building: Dwelling No.of Bedrooms--j� of Size ( ,Qq sq.ft. Garbage Grinder(�) Other Type of Building e�S No.of Persons Showers(3) Cafeteria(K� Other Fixtures Design.Flow gallons per day. Calculated daily flow y® -gallons. Plan Date Number of sheets / Revision Date Title Size of Septic Tank Type of S.A.S. 44L Ay C /ZV* /�/' Description of Soil S'- ��� /E'�rc� �-<! 'o �/- Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t ' B d eal SignPortheRf6t1lowing Date Application Approved by Date Application Disapproved Mreason Permit No. Date Issued �'i ,i 00 No. �* 1 Fee Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSi4CH:USETTS ZIppYication for -Migpoof &pgtem'Congtruction permit Application for a Permit to Construct( , .)Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 'J t�"� � �� (r Owner's Name,Address and Tel.No. CQ e-\y y-\ Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. - 9 77- 72 7 Z Type of Building: Dwelling No.of Bedrooms Lot Size J ,Qk4 sq.ft. Garbage Grinder(Y ) Other Type of Building f"2 S►ci et A 1 cL I No.of Persons Showers(3) Cafeteria(N) Other Fixtures Design Flow I , _gallons per day. Calculated daily flow y �� gallons. Plan Date `f D y Number of sheets / Revision Date Title Size of Septic Tank Type of S.A.S.1400 Vor Description of Soil 3 --5�� �5 /�CJG�S CI�C/at,FEE'ls r Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by Bo d of-Healtly Signede- , � -'� A n _ Date / Application Approved by _ r 7 x a g Date Application Disapprovedffor the following reason Permit No. '_ _�� r� Date Issued ---------------------------- — -------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ' Certificate of (Compliance THIS IS TO CER Y,that the On-site Sewage Disposal System Constructed( Repaired( )Upgraded{ ) Abandoned( )by at 34-/:2 W{tea -kr go YTN Y�"1 has been constructed in accordance with the provisions f a d t for Disposal System Construction Permit No n dated III h Installer e, ' t Designer The issuance of this permit shall not be construed as a guarantee that the`"syRt{�tn r` 1'fu`nction as designed. Date Inspect �1� l Lam_�.,.•� --------------------- ------------------ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 1i5po5af *pgtem Congtruction Permit Permission is hereby granted to onstruct( )Repair( )yU grad, (yam,)Aba.don System located at N' 1�F �!C M A Jl ) ,p - r a� and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construe ion must be completed within three years of the date of thierm Date: by No. THE COMMONWEALTH OF MASSACHUSETTS FEE ,,,, BOARD OF HEALTH WYA OF APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair (,-,/Upgrade ( ) Abandon ( ) - M-1c'Omplete System ❑Individual Components Location Owner's N e Colt, L)o Map/Parcel# Address Lot# / a t Teleph egrt # _ ( �ULU.h'C7 �� Installer's Name �� Designer's Name Address Address Telephone# Telephone# Type of Building: Lot Size': ' 3 (J"_,;' Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min. quire d ) gpd Calculated design flow gpd Design flow provided�gpd Plan: ate r 'L Number of sheet ) Revision Date Title �. - Wlo o " � -- Description of Soils) - c, l�� Lc�OIM� 1 I�- �1 Ylhs�'S� Cv-CA Soil Evaluator Form No. Name of Soil Evaluator�, - Date of Evaluatio -2 -!� 1 DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated Approved Design Flow (gpd) Installer Designer: Inspector Date The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 ----------------------- ------------- ----------------- ----------------- No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. dated Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met. Date Board of Health FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBSB WARREN TM PUBLISHERS- BOSTON NN x ..rwrr' •5 J ���r � x'.a� v.+a� 3",e No. .3I�. �' TH,ExCONr 0'NWEALTH OF MASSACHUSETTS '" FEE BOARDnn ``OF, HEALTH ({j OF • APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a'Permit to Construct ( ) Repair ('Upgrade ( ) Ab�a ndon ( ) - [Complete System ❑Individual Components Uw�l� v ta-M� Location Owner's N e Tyr T Q Map/Parcel# Address s �y Lot# Installers Name Designers Name r• N=Address Ad d/s�. Telephone# Telephone# Type of Building: Lot Size Sq.feet Dwelling—No.of Bedrooms Garbage Grinder Other-_T e of Buildiin z t y Type g No.of persons Showers "( ), Cafeteria ( ) Rtlieextures, A , _ __�..w--• f f Design Flow('min.r qutred)4 gpd -•^`Calculated design flow gpd�, Design flow ppv dedR. 6_:S gpd I Plan: ate - -p q Number of sheet Revision Date Y Title Van, ''IIccy 11 II __ '+ cc,, ` Description of Soil(s) (�- CFOr U�� 4 LO&4v 49l�-' 4A°L �d sc��d -lob C�c�t Soil Evaluator Form No. Name of Soil Evaluato'rp c- c Date of Evaluatio -Z�S" _ DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to ins II the above described Individual Sewage Disposal System in accordance with the provisions of t'--_.,,,,,,, ,TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed r Date l { Inspections ' i FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 j-a No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH f CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑Complete System vJ The'undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: Nil, + at has been installed in accordance with the provisi-010of 310 CMR 15.00 (Title 5) and the approved design plans/as-built . plans relating to application No. dated Approved Design Fldwt r1k (gpd) Installer :- Designer: Inspector i _ The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 -- — — — — - s -- --�— -- ---- j 1 No. THE COMMONWEALTH OF MASSACHUSETTS FEE } BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT . Permission is hereby granted to Construct ( ) Repair (; ) Upgrade,{) ) Abandon( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. dated f Provided: Construction shall be completed within three years of the date of this permit.All local conditions must_ be met. ( Date Board of Healt k, FORM 2 - SCP { D .P APPROVED FORM 5/96 d FORM 1255 (REVS/96) H&W HOBBS&WARREN TM PUBLISHERS BOSTJN L � ^:,� Er,n 'ytkairb}y+ll,. 9/16/03 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems. Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM A hereby certify that the engineered plan signed by me dated ///`//, Y , concerning the property located at 3,417 � �' �� /G r �?v `r � meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business.uses associated with the dwelling. • The.soil is classified as CLASS I and the percolation rate is.less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct deep test holes and percolation tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the. Frimptor method when applicable] Pleas e complete the following: g A) Top of Ground Surface Elevation(using GIS information). B) G.W. Elevation .SS, a +adjustment for high G.W. DIFFERENCE BETWEEN A and B / 9 SIGNED : L'L/ DATE: 5` NOTICE Based upon the above information-,a repair permit will be issued for bedrooms maximum.. No additional bedrooms are authorized in the future without engineered septic system plans. gASepticlpercexe 3p.doc k Dec 21 04 08: 00a 5084779072 p. 1 �FT"E'Oa. Town of Barnstable • Regulatory Services 9 MASS. Thomas F. Geiler,Director �FD1AP�6 Public Health Division Thomas McKean, Director 200 Main Street,Hyannis, [VIA 02601 Office: 608-862-4641 Fax: 508-790-6304 Designer Certification Form + Date: 20.o Designer: bC A74 j­�-t`w <,�y-, Address: l�U 7oL� On ��G O nJ�y�, III �swv�, was issued a permit to install a (date) (installer) septic system at 3 LJNAAA.Lt,( �21 l.O based on a design I drew, (address) dated Z I certify that the septic system referenced above was installed substantially according to the design. I certify that the septic system referenced above was installed with changes but in accordance with State & Local Regulations. Revision or certified as-built by designer to follow. Fry, (Designer's Signature) Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Sepdc/Designer Certification Form -APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS LOCATION �� VILLAGE �/ DATE APPLICANT % , " FEE 5_,O.O- ADDRESS_ 9� �,� � D Gyyj, �ij , TELEPHONE NO. d/��./pps Non-refundable) •ENGINEER TELEPHONE NO. DATE SCHEDULED — (Appli t' signature) • • • • • • • o 0 0 0 o e • o • o o•o 0 0 • • s • • • • o 0 0 • o • • • • • •�• • o • • • • • • • • • • • o • • • • • • • • s •o• • • • • o • • o • • . • • • SOIL LOG _ x SUB-DIVISION NAME DATE TIME Vj EXPANSION AREA: YES L--'NO ENGINEER .TOWN WATER PRIVATE WELL BOARD OF HEALTH EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: A­60 65e /Jim=vim N N. PERCOLATION RATE: Z1N► TEST HOLE NO: ELEVATION: TEST* HOLE~ NO: �cueo' ELEVATION: 3 4 . 4 _ = � 5 � 5 6 6 7 7 8 8 9 9 10- 10 11 11 al '' 12 N 12 13 10 13 t 15 15 ' 16 16j SUITABLE FOR SUB-SURFACE SEWAGE : LEACHING FIELD �HING PITS_��, LEACHING TRENCHES UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS : NOTE : ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED TN ENTIRETY BY P . E AND RETURNED TO BOARD OF HEALTH COPY: RETAINEDBY APPLICANT /TOWN OF BARNSTABLE LOCATION 3 y7 �i✓� /..- /S�� SEWAGE # VILLAGE /96 ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. �e% SEPTIC TANK CAPACITY o� LEACHING FACII.TTY: (type)_S?-i Gw 4-4-7•701 �3� (size) /3r'x 33r'yr?� w NO.OF BEDROO ° BUILDER O OWNER PERMIT-DATE: `7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Arell and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by C tI OE"4iget-2r 3S/7 i i I w 1 (PCyn�vpL r i FAIED INSPECTION S 5 0 -Z fo =,. COMMONWEALTH OF MASSACHUSET T,'z EXUTIVE OFFICE OFF'NVIRONME4fALfiPP'AiRS' 4, 09 DEPARTMENT OF ENVIRONMENTAL PROTECTION year ( R 2 _ PARCEL 402 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSIN'TS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_3_412Wee ei '1 i I 0 6YIr L?wncr'"a Nmnv, -c • -r PARCEL OWnerss Address: 1 T Date of lnspeetion: Name of inspector:(pt at S�aw�✓'l`-E/�v� Company Name: l►►77 r: Aliaiiing Address: r Telephone Number.__10 Y?6--6205- CERTIFICATION STATEMENT I certify that I have personally inspected,the sewage disposal system at this address and that the information reported below is eves accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper fraction and maintenance of on site sewage disposal systems.I am n DEP approved sysfew iupecter Pursuant to Section I5-W of Title 5(310£Milt 25.000) The system: Passes Conditionally Passes _-,,,Iree&Further]~valuation by the Local Approving Authority V FallsInspector's Signature.- Date; 9 Xt pq_ The system MsPwor shall submit a copy of this inspection report to the Approving Authority(Board o£Healih or DEP)within 3fl days of completing this iusp on.If the system is a shared system or has a design flow of 10,000 Wd Or gtmater,the irrspectOr Bad the system owner shall submit the report to the appropriate regional office of the DEP.The original should be seat to the system owner and copies sent to the buyers if applicable,and the approving authority. Notes and Commen f �� e S ea C W Bre dokf f e ****This report only describes conditions at the Haag Of Inspection and under the Conditions of use at that time.rWs inspection floes nut addnw ituw the system will pwrorm in the fulum under the same or different coalitions of use. T1 tl+.�q 1ror."evrr,Vnr rl1 SMma Nee 2oflt OFFICIAL INSI'EC N FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3�7 ► s e(M� � Owner: Date of€nspec#iartt: �/��y intipmtion Summxry: Cheek A,B,C D"E t ALWAYS eam;plete all of Section D A. System Passes- 1 have not found any Information which indic;au-s that any of the failure criteria described tut 310 CUR 15.303 or in 3 10 CUR 15.304 exist.Any failure criteria not evaluated are indicated below. , Comments: s B. System Conditionally passes: { Ors ormore syslsrre—Toaents es deemibed in elm"Conditioner Pass"seovoa 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 lay=old*or the septic tank(whether metal or not)is structurally unsound,exlrrbits substantial infiltration or exfiltration or task failure is imminent.System will pass inspection if the exiatin wmk is Laced with a c I tic tank as roved *c Board 9 � �P �P 3'�8�P approved by of Flea th. *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. NI3 explain: Obmrm ion ofaewage backup or break outorlugh smric water Ievel in the distribution box due to broken or obstructed pipes)or.due to a broken,settled or uneven distribution box..System will pass inspection if(with . approval ofDoard ofitlealth): broken pipe(s)are replaced obstruction is removed dis'b ution box is leveled orreplaced ND explain: The system mquited pumping more dm 4 limes a year clue 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 No explain: Page 3 of I! OFFICIAL SPEC N FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: W W4eeler ux Si Owner: Date of Inspection: -O 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 CMKR 15303(1)(b)that the system is not ft:uc toning in a manner-which will protect public health,safety and the environment: _ Cesspool.or privy is within 50 feet of a surface water _ CesspooI or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS).and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank-and SAS and the SAS is within 50 feet of a private water supply Well. The system has a septic tank and SAS and the SAS is less than l00 feet but-50 feeEUr more from a private water supply well**.Method used to determine distance **I"uis 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 foam. 3. Other: } Page 4 of i I OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION(continued)' Property Address-Ve.rjkts ��& Owner• i Date of Inspection: ^� D. System Failure Criteria applicable to all systenw. You must indicate"yes"or"nor to each of the following for ail inspections: Yes lV'o/ 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 clue to an overloaded or clogged SAS or / cesspool t , ,/ Liquid depth in cesspool is less than 6"below invert or available volume is Iess than!4 day flow �Requircd pumping more than 4 times in the last year LNOT 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.suppiy.: I - I 10 y portion of a cesspool or privy is within a Zone I of a public well. _�y 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.rMs system.passes If the well water Analysis, performed at a DEP certified laboratory,for coliferm bacteria and volatile organic compounds i„dicutes That the well is free Irani pollution from%at facility and the presence of ammonia L9trcoged and nitrate nitrogen is equal to or less than 5 ppm,provided that no outer fallure criteria ..are triggered.A copy of the analysis must bye at`acbed to ibis form.] yest fea�vo)The system t��is.I have detemfuied that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system falls.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 now of 10,00 gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the followi y n . (The following criteria apply to large stems in addition to the criteria above) yes no the system is within 400 feet-of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply _ T the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well if you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECT ON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ,'CHECKLIST Property Address: IqZw4eelar Owntr• ,Date of Inspectiow. - Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No/ _ t/ Pimping information was provided by the owner,occupant,or Board of Health VI/Were any of the system components pumped out in the previous two weeks? Has the system recel ved normal Mows in the previous two week period? _ ZHave large volumes of water been introduced to the system recently or as pan of this inspection Were as built plans of the system obtained and examined?(If they were not available note as WA) Was the facility or dwelling inspected for signs of sewage backup" v — 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 ui the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facHity owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal system,? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes na/ ✓ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the fdilure criteria related to part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J Pane 6 of 11 OFFICIAL INSPEeMN FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACESEWAGE DISPUSAL SYSTEM INSPECTION FORM PART'C / SYSTEldI'INFORMATION Property Address: 7 k4eeB/ d Owner: _ Date of Inspeeiiou: -/ "0 FLOW CONDITIONS RESIDENTIAL, Number of bedrooms(design): Number of bedrooms(as:tual'}: DESIGN flow based on 310 S.203(for example: I i 4 Lpd x#of bedrootus): Number of currem residents: Does residence have a garbage grinder(yes or no): !J Is Iaundry on a separate sewage system es or no): -v[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): Water meter readings,if able(last 2 years usage(gpd)): --- Sump pump(yes or no): o Last date of occupancy: 7` COMMERCiAL/INDUSTRM L Type of establishment: Design flow(bused on 310 CivIR 15203). avd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): _ Nan-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping.Records Source of information: Was system pumped as part of the inspection(yes or no): _ If yes,volume pumped.,gallons—Flow was quantity pumped determined? Reason for pumping: TYPRIOF 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 arty) � _Innovative/Aitemative technology.Attach a copy of the current operation and maintenance contract(to be Obtained from system owner) _Tight tank _._.Attach a copy of the DEP approval ___-Other(describe): Approximate age of all componeuU,elate installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):& I Page 7 of I I OFFICIAL INSPECTON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 til �ei Owner: Date of Inspection: 9-Ir--yV BUH,I)ING SEWER(locate on site plan) Depth below grade: Materials of construction:—cast iron PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition ofloints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction: ✓concrete metal fiberglass_polyethylene —other(explain) If tank is metal list age:____ Is age confirmed by a Certificate of Compliance(ves or no):_(attach a copy of certificate) Dimensions: Ff��",r r/%D" Sludge depth: 1 Distance from top of sludge to bottom-of outlet tec or baffle: v fee Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottop cif outlet tee or baffle: How were dimensions determined: ¢ / Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): A o GREASE TRAP.•_{locate on site plan) Depth below grade:_ Material of construction: concrete(explain): metal fiberglass___polyethylene outer 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 bathe: Date of last pumping: Comments(on Pumping recommendations inlet and outlet tee or baffle conditio l r as related to outlet invert,evidence ofleakage,eta); m'srructuraote sty,liquid levels Page 8 of I I OFFICIAL INSPEC N FORM—NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 7 Wkede, a_ Owner: Date ofdnspection• TIGHT or HOLDING TANK: (tank must be pumped at time of inspecti0n)(10mte on site plan) , Depth below grade: , Material ofconstruction: concrete metal fiberglass---Polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: sallousiday Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): J Date of last pumping- Comments(condition of alarm and float switches,etc.): DISTRiBUPION BOX: P/ (if present must be openedXIocate on site plan) Depth of liquid level above outlet invert t Comments(note if box is level and distnbution to outlets equal,any evidence of solids carryover,any evidence of leakage ipto or out of box,etc. Ca-nd.=ry�ia PUM[p CHAMBER. (locate on site plan) Pumps is working order(ycs or no):' Alarms m working order(yes orno): Comments(cote condition of pump chamber.condition of pumps and appurtenances,etc.): D V Page 9 of 11 OFFICIAL INSPECON FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART C SYSTEM INFORMATION(continued). Property Address: �7aws .1(r Owner Date of Inspection: SOIL ABSORPTION SYSTENI(SAS)-. (locate on site plan,excavation not required) If SAS not located explain wby: Types, ✓leaching pits,number. leaching chambers,number. _teaching galleries,number _teaching 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.): 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY- �(locate oft site plan) a Materials of construction: Dfinenstons: Depth of solids: ` Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of I I OFFICIAL-INSPECT N FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION`FORM PART C SYSTEM INFORMATION(continued) Property Address 3y 7 wL4eelee el Owner: Bate of Inspecdon: ?-/fr-aY SKETCH OiSENiAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at Ieast two permanent reference landmarks or" benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. O we It L,-a Page I I of I I OFFICIAL INSPEC' ON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ��L eC er l iffs Owner: Date of Inspection: f-(T-oy SITE EXAM Slope P Surfacz water Check cellar Shallow wells Estimated depth to ground water A9 feet Picasc indicate(check)all methods uscd 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 Heft-explain:_�Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you establish the high ground water elevation: I 5 a s see o �o �Skaw !o a��r a wf aa� Gr" e 5� Title 5 Inspection Forst 6/I5/2000 I I 1v3 7 LOCATION SEWAGE PERMIT NO. VILLAGE { INSTALLER'S NAME A ADDRESS BUILDER OR OWNER DA T EC/P ERMIT 1S74v D 181.2y/s°e DATE COMPLIANCE ISSUED ��• .. . s,., .. , ., �� ® y 1 d ' / r �,� // � yy / �J w�✓��r �,�.,(1.90�.� , FmcNo....e............... ........... THE C0jMM0NjVEALTH OF MASSACHUSETTS BOARD -QF HEALTH ............ ................... ....OF.....-..-..-.........-......._.........-----------._....... Appliration for Disposal Works Tonstrartion Pumit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at:. 'd-l" *,7 ...IT......44,21.., .................................. .................................................................................................. L 'on-Address or Lot No. .X................................................ ................................................................................................. . ...............(,Vwne.r Address ._dej...... . ...... .......................................... .................................................................................................. Installer Address Type of Building Size Lot__+A' A�:......Sq. feet U Dwelling—No. of Bedrooms........--?...............................Expansion Attic Garbage Grinder (toe) P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures .......................................................................... .............................................................. Design Flow............................................gallons per person per day. Total daily flow.............................................gallons. 9 Septic Tank—Liquid capacity..6- gallons Length................ Width_._..-.......... Diameter_________._.____ Depth................ Disposal Trench—No..................... Width_...__......__._._.. Total Length._.________...._.... Total leaching area....................sq. ft. Seepage Pit No....L+Z....... Diameter.__. .../...... Depth below inlet......./_......... Total leaching area..................sq. ft. Other Distribution box Dosing tank_4 Percolation Test Results Performed by...... ......................................... ...... Test Pit No. 1................minutes per inch Depth of Test :Pit________._:_________ Depth to ground water.....?7----------- 44 Test Pit No. 2................minutes per inch Depth of Test Pit__.__._._..______... Depth to ground water....___..____.____._____ 9 ----------------------------------------------------------------------------------*....."------------------*......"---------­---­*----------------------- 0 Description of Soil........................................................................................................................................................................ ........................................................................................................................................................................................................ ......................... ............................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ .......................o...............................................................................................................................:.............................................. A Agreement:— The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of',.i T LE 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 bqpLrd of health. Si ed.. ..................... I/ Date J . . ................. .... 01/........ Application Approved ... .... . . .. .............. ate Application Disapproved for the following reasons:.............. ............................................................................................ tY. .:..................................................................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date No... ' ��... FEs. ............ ,THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................O F...................................................................................... Appliratilan for Diip.aiial Works Tnnitritrtilan ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: JLocalion-Address or Lot No. .. .. . ........................................•--. ----....----------........---............. -----....................................-••--•....... ---- - avner ------------------------•-----• Address Installer Address Type of Building Size Lot-_t�4,.A ......Sq. feet U Dwelling—No. of Bedrooms.__..._4................... .Expansion Attic ( ) Garbage Grinder (Va) Other—T e of Building No. of persons............................ Showers — Cafeteria PiOther fixtures .. -------------------------------------------------------------------------------..................................................... W DesignFlow.............................................. gallons per person per day. Total dailyflow............................................gallons. WSep Tank—Liquid capacity....>._ ..gallons Length................ Width................ Diameter.:.............. Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..1.1.2._.__.. Diameter.... .......... Depth below inlet.....f............ Total leaching area..................sq. tt. z Other Distribution box ( ) Dosing tank ( ) .......................................... Date__ : , ..._. _...... Percolation Test Results Performed by. Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.._•'7_-_--....... (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ri --------------------------------------------------------------------------------------7...-••--•............................................................. 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 A IT 1,;-. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued�b��y1the /board of health. Sin.. �, --.. ! .....-- OV Date Application Approved By.. <-X,-t.- -- -- ... '.. /.6'�±! Date Application Disapproved for the following reasons:..........................................................----.---------------------•----•••-••--•-------...--- ---------------------------•----------......------------------------------------------------------.......•----•-•............ Date PermitNo.................................................._.... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD. OF HEALTH ..........................................OF.................................................................................... Trrtifirate of Tuntpliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) �Y .. by.............r,... ......... .........................------•---------------.............------------......---.................-----•---•------.........---- Install at....------•-----•�' ---------.. '.�' �' . ,- ,�_... I ........................ has been installed in accordance with the provisions of TITIE/ 5 of The State Sanitary Code as described in the application for Disposal Wor s Construction Permit No.-- F ca dated............................................... THE ISSUA CEO THIS CERTIFICATE SHALL NOGUARANTEE THAT THE SYSTEM WIL FUN ION SATISFACTORY. DATE__/._.. .. Insp THE COMMONWEALTH FBOARD OF No.......... .....•-•-••• FEE. ................ Maposal nrkii TPUInstrnrtinn rrmit Permission is hereby granted-...- .._.� `-•--•-• - ------------------------------------------------•--•--••--- to Construct_ <Or Repair ( ) an Individual Sewage Disposal,System atNo........... >........... ........ --------- � --------------------•-------------------------.................. Street as shown on the application for Disposal Works Construction Pe mit No..................... Dated.......................................... oa rkiealth DATE................................................................................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS I 46 LOCATION =+ SEWAGE PERMIT NO. :.Y wli BQ/-er- VYLLAGE �- o s INSTALLER'S NAME /&� ADDRESS wo/m of S� W, /91`1�s tlill-1 B'UI'LDE R OR OWNER LAP-1v h foI'3oJI- 6.4t/�9 b� r 4 Pllwl k,7 rt DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 1s6o 2 i J -/ y , \ 8 r. / r p No........... ............ ��� Fps..%✓..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH Applirtttiurt -fur 4iupuiittl Works Tonstrurtiutt Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: L�// 1. _ �j�•• �... -•-•-•••---•- .U14,e-el f _.!'....: !/L � �h-!=�=1//� '��� Z ------------- Location-Address // or Lot No. 0 er Address Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms-----;;5...................................Expansion Attic ( ) Garbage Grinder Other—Type of Bolding --------------------------- No. of persons..-_-_-_--__--__----.------- Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------•-----•-•---------------------------•-------•-------•--•---•--•---•-------...------ W Design Flow.................... d--__-_------.gallons per person per day. Total daily flow.............,e, ..d'� --_. _gallons. WSeptic Tank—Liquid capacityiSeO.gallons Length................ Width---__-.._.._-_ Diameter................ Depth-.-..-_--__--_. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit Diameter.................... Depth below inlet_..__. __...._._... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed bY---------- ............................................................... Date--------------------------------------- Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water...-.-._----.-.-_.-_--- f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--.-_._.__-._.-----..__. a' ••-•-•••••----------------•-•----------- ---................................................................................................. 0 Description of Soil "' 4-.Gf.Ei�_4.I- _ - ------------- - - W ---------------- �•-'t �[2/� e1?�✓.t� .�_... C..�./ r x ------------ �`� �� l = =---------------_ U Nature of Repairs or AlYeratJnns—Answer when applicable.---------------------------------------------------------------------------------------------.. ----------------------------------------------- ------------------------------------- ----------------------- ---------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been 'ssue by the board of he th. ignd - ---------- --- 16- �( Date Application Approved BY ..... 2' IL.--�---------------- ----- �" `��--_-� Application Disapproved for the following reasons:.............................. .... .......................................................Date-------------- ---------•--•-----••---•---•--••---------------- ••---------•---------•••-----•---••...-••----------••-•--•----------•-•••-----------------•---•---•-----------•-------------•------------•---------•--- Date PermitNo......................................................... Issued........................................................ Date 1 r -, dw %6 -y� No.. ........v....... ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD �QF HEALTH a.............0F.....yt�. J '. ---.................... Appliration -for Maposal Works Totuarnrtion Vrrniit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ` me-,1_2 &2) '--'-••---••'•'•"'--tv'1� 11..-`---� -���'��~ /-t a----------------•--•----•. Location-Address 'A 7 / or Lot No. 0 ner y�7 j� q_ Add;es / .._.._`". .� �.cr r!I! a /.l!'� .. .�.� ... Installer Address Type of Building Size Lot............................Sq. feet a Dwelling—No. of Bedrooms._.____.............3.................................... Attic ( ) Garbage Grinder (y aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria .( ) Otherfixtures i--•--- ---------------------------------------•---•---------------------•--•------•----....._..........---..... W Design Flow..................... ...............gallons per person per day. Total daily flow-------------,, _.O-_7_­Z1_.....-`-_gallons. WSeptic Tank—Liquid capacity/f0'�'gallons Length---------------- Width................ Diameter................ Depth.--_----.-.---- x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------.-----sq. ft. Seepage Pit No... Diameter-------------------- Depth below inlet_____-_____-_._-.-.- Total leaching area-----.............sq. ft. 1 z Other Distribution box ( ) Dosing tank aPercolation Test Results Performed bY.......................................................................... Date--------------------------------------- ,� Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water---._-_-.--.--._-.----. f14 Test Pit No. 2................minutes per inch Depth of 'Pest Pit.................... Depth to ground water--.--.---__--_-.-.-----. P; ---------------------------------------- .i...........................................................-•-••"••-•-------•--------....................-----•... O Description of Soil '-- -----=5.,_N �._ � ✓�:L----------------------_--�!--------- 1 x , , / i J --;� -------------- -- --- ' 1/f. i{. s^it.? </�.....f v� s-- y.�yam ' a� u-7.l -ELnc. w �...... .�_� ---------•-----� �-- - �-( a ems�`� �'r_,�,.f -- =.......... � �J a ) r " of . ! VNature of Repairs or AXterati/o"ns—Answer when applicable------------------------------------------------------------------------------------------------ -------------- ---------------------------------•------------------••--•--•---.----•-------------..-----••--------------------------•-•---------.------------------------------•-•-•---•--------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI '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. C /J 'f / Signed--------- - ------------------------------------------ - -------------------------- Application Approved By___` T _ �._ `�___ '��I �, Date i.1_ 4_4'4� ----------------_ --/F - 7 Application Disapproved for the following reasons:................. ............. .....................................................•-------Date ...'------'-- -----'-•-------------------------------------•---------------------------------------'-•'•-•----'-•'••"'----------------......--••-•-•-••••-------•------'••-•••--------------....-•--------•••••••-'-- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �A✓ 'T'rrtifiratr of TOmphaurr THIS IS TO_CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) � r ����.I - , ----------------------------------------------------------------- a---- % Inst tl]at r� ✓ /� has bedn installed in accordance with the provisions of A icle XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No:�_ _.�� r1_______________ dated..- - ---____---....- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS , a BOARD �OF HEALTH f _ , ..���_O ? ................O F... � ....................... , No.•-••-•-•=---'•••Z-•- FEE.- I�--- ".....'` Di-ripopttii orkii Cnonitrurr "on Vrrmit Permissioni hereby granted;f- / � -............................................ ........................ to Construct l_pr Repair ( )pan •Individual Sewage Disposal System i !f at N6__ �Af '7 = . �-�f ---------------- ^ C✓i-Street- of----- - ••G - _-•-,�-••••- as shown on the application for Disposal Works Construction Permit No. ------- ted. l._'.. .-?_'_ ............... J � BoardGof Heal h DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ac r0 !wJ ,TNt41t?(:aN Y' di=, 6 9 PTI C s Y.arrim Cl 7 ,Q + ►� SO/4 4 Q G O p ' tuo o D f + ArsT 1 t'► ,,fit.c%o w��a:I � �,,�-,a �t, � CoURS�" Go t�i �• `` S4jvb Ra Al Ac_y I �� G�•3 � /moo GAt,�,°�� o �iQRI/�,L °.� Oavctway Nor TO CAE 4ocArD0 � !" CRAIG �n , X�,;/V.S/4/1� � RAYMOND ,� r....._...........,.._ v No$HOR� 3O H . . /S a o o r '`a 4 4 /9 0(:l 9 4 4 iO'p GrST FSSrON NL CE4 TI FIE PLOT PLAN L.O C A r 1 O NI .t1R1 70� /y�4 ,5 3CALE' 1 =tea ' 0AT`= __/P ?�� R C F C R E N C Ir n 7%0 -fA/©w K ,G�N fz Co,�Z ���-p ,q7-�,g,�,�J 7,c�/3L.L �® �/�6 O U A/ T" /el=C�OS T.S�,/ C� !j L ',�'!.�5 /N D A T E f HEREBY •CERTIFY THAT THE DUILDINC � R G. LAND SURVEY R SHO1rIN ON THIS PLAN IS LOCATED OAF TNC GROUND AS SHOWN HEREON AND .O G7 `,S THAT IT CONFORM TO TH [� P�° ,,• S'sq ZONING DY - LAWS OF THE TOWN OF ��� cti� CONSTRUCTED . JOSEPH M. cn� " MONAHAN,JR. ti 13660 O C ASSOCIATES, INC . �IS,Tr-��'®� REGISTERED ENGIbEERS 0 LAND SURVEYORS �boSlui MID -CAPE OFFICT BUILDING- 12® S ROUTE 20 SOUTH YARMJ O UTH, MASS. 02664 i 1 �1� rC/oor 6'.SS SYSTEM PROFILE NOT TO SCALE FINISH GRADE OVER SEPTIC TANK 8s, 3 FINISH GRADE �I FINISH GRADE OVER - _ o_ PUMP CHAMBER B3• '� FINISH GRADE OVER OVER TRENCHES 8'S' DISTRIBUTION BOX 8.�. 'Y 'i0 1' ONTROL o C.I. FRAME PRECAST CONCRETE A C.I.&COWER E BOX GA 500 GALLON DRYWELLS H-10 REINFORCED LOADING ,�°�`-_> •� , '� .:, O;G ., y 1 -,< , , ,'r' ,r •�, ..p 1 '( , '( &COVER =y��- 6, 211DIAIVI. r •r 'r �, ^ r, r fir:.b\ , -•`r r , o. 3 r a;o r ,�r r r 1 r PVC SCHD.40 d' 1 11 INSTALL TRENCH LENGTH = 33-6 y MIN.SLOPE 1% �;1 . LEVEL' NEW PVC TEE __ AL RISERS TO 6" -�� b' 1 " ° '• � OUTLET PIPES LEVEL DRYWELL LENGTH = 8-6 =o= D- WEEP HOLE OF FINISH GRADE FOR 7(MIN.1%SLOPE , ,. - - -� FOR BACK DRAINAGE ° BEYOMI D ` . e ° 13"MIN. °: ? r Q_O:11 ,. •II°.oa v °JD 1 v:r ,1 oa ,`r% " �•,o (-0�1 0 .o •fit /JS� 7.�<� ` S�orse .f c .f O '`' M:1�r.yy� �✓gyp= '�, c �' .11 `Ir. 4 0°vl Tl.� n LI ' '.r',y , .r .• '1 �''( • a' 10 �i y 4 IQ,: b b0�0 1 •i_ _( •�= c -� 9'*/. PUMP o 16-SUMP 6O ,b i ' T rb, `" ;;`. '1 '1 r'' r -1 1 • r '� �' a - MALFUNC IN �2_ i 1 0 :1 •r ox 1 oa s el o.l PVC TEE � ---------------------- --------- -- -- ---- �6 3/4"- 1-1/2" DOUBLE " 11 - _ - =C= 3/4 - 1-1/2 DOUBL EXISTING 1500 GALLON a ��' -- WASHED CRUSHED 4' -, o o 2 :4 ;� s „ =B- DISTRIBUTION BOX STONE WASHED CRUSHED PRECAST CONCRETE a - STONE �9 MINIMUM INSIDE DIMENSION 12" BSMT.FLR. FINISH GRADE -„ OUTLET INVERTS 2" BELOW INLET INWERT ELEV. EL. 6 ? :Q PRECAST CONCRETE i, MINIMUM CONCRETE WALL THICKNESS 2" H-20 REINFORCED s�._��_ -• � INSTALL ON COMPACTED LEVEL BASE , r '10 ,• 1 _.,,, { J - _ iy- - TRENCH SECTION _ \ %y (- °:r`r�•e'1�,!n' '1`\��, .e'r'ol, :���'�1 '�'.\', r -1°�''A `'°r'e r y ,Or�'�1 ' r''`tl 'l =A= -'r a MIN.SLOPE 1%/0e. "" "` NOTE: EXCAVATE TO =C= STRATUM IN ORDER TO r-, SEPTIC TANK - .,, r, '1 �r,;'1 - ,"Ir..,r,,4 /1 , °.' u ,�-��1 a '1 �r�_:'1,,�'''�'o': '�'�r� REMOVE ALL =A= & =B= IMPERVIOUS MATERIAL r. >r Q! �� �r..e o.�\ % ,.e , ,, a rip r � ter.•'r Ol 1 �\ " INSTALL ON COMPACTED LEVEL BASE WITHIN 5'OF THE SAS. REPLACE vJITH CLEAN, "MIN. 3"OF 1/8"- 1/2" %''-- 1000 GALLON PUMP CHAMBER CLAY-FREE SAND 411 DIAM. 6"MAX. DOUBLE WASHED [310 CMR 15.2551 , t. PEASTONE .. •; , • ' Y 1 � e r p'•. j e. INSTALL ON COMPACTED LEVEL BASE ( r a ` 3/4"- 1-1/2" DOUBLE ILI 1 11 11 WASHED CRUSHED 1.PUMP TO BE INSTALLED IN STRICT CONFORMANCE ,. � � / �`, � ti }� 48 5-2 4 ,, _..:.,; •Z STONE WITH MANUFACTURER'S SPECIFICATIONS ��� � _ , 2.PUMP CONTROLS SHALL BE MOISTURE PROOF pr l_., _ :�; � ' TRENCH WIDTH 3.CONTROL SEQUENCE: a ;+Y +j ` 1 11 13-2 A.PUMP OFF ., y, r, ,r l' ..� B.PUMP ON��" DEPTH OF EFFLUENT(//O GAL.) rem;, NUMBER OF TRENCHES 1 C.ALARM ON AT PUMP MALFUNCTION "� NUMBER OF DRYWELLS 3 D.ALARM ON AT HIGH WATER LEVEL 4.ALARM CIRCUIT SHALL BE SEPARATE FROM THE PUMP POWER CIRCUIT • to off : S.PUMP CHAMBER SHALL BE EQUIPPED WITH (, � .,� � � 'ta'i� � -.. •• ' •.!� RISERS AND A MANHOLE COVER WITHIN 6" {_: r �� - U {,' • =L � L OF GRADE d ` * y •a 43.8' 2 o C //t r /mod...'0o " � (1 1 L a lto �3'..: /C/e 67 roan d w ,r r EOP /r 44.2' y EOM,,... 45.5' o s< /,P �' > f 11(�ntb ` BVWA7 , 44.9' -+ 9 /',' .yam..,✓ ���- i���j s r "�j p�K� `� 44.0' 45.3'EOP BVWA3+ BVWA2 a . r 45.2' Pend" BVWA1�.i D / ,• ram• -,�n41:1 ..Lawlw-nur sn7 c .nwi>.,,,r 5.wnn'vw un.nura,:: . 43.8 EOP " h o " GENERAL NOTES: 7 7 , +78.9' o 1. ELEVATIONS SHOWN ARE BASED ON NGVD ' r NL o 2.ALL PIPES IN THE SYSTEM.!�:1UST'BE CAST IRON OR SCHEDULE 40 PVC. 3. HEALTH AGENT/CAPE & ISLANDS ENGINEERING \ MUST BE NOTIFIED WHEN CONSTRUCTION IS OBSERVATION PIT � W�.� PT•• COMPLETE PRIOR TO BACKFILLING. P-751 /, i �,� 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED 'PERCOLATION RATE: < 2 MINJIN DESIGN DATA / BY CAPE & ISLANDS ENGINEERING AND THE BOARD WITNESSED BY: R.GIFFORD OF HEALTH. �o 0 5. MATERIALS AND INSTALLATION SHALL BE IN BARNS. BOARD OF HEALTH' ' -vs a G s-,r ,� COMPLIANCE WITH THE STATE SANITARY CODE � DATE: SEPT.28,1981 � 2 NUMBER OF BEDROOMS 4 +7s.s' [TITLE V]AND LOCAL APPLICABLE RULES AND a) orl arre :o) sr►c p � REGULATIONS. GARBAGE DISPOSAL f�Q_ �''` 6. NORTH ARROW IS FROM RECORD PLANS AND IS LOAM DAILY FLOW 440 GPD. s3.3' +83.2' w � n s' NOT INTENDED FOR SOLAR ENERGY PURPOSES. SEPTIC TANK REQUIRED 1500 GAL. K GAS GAS 7. WATER SUPPLY: PRIVATE WELL SEPTIC TANK PROVIDED 1500 GAL. / V�G '+ 8. FLOOD ZONE C [NON-HAZARD] _-sue bso , ( LEACHING REQUIRED 440 GPD. \` '�' oAs �� 9. THIS PROJECT DOES NOT INVOLVE ANY PHYSICAL �- GROUND DISTURBANCE OR VEGETATION REMOVAL SOIL ABSORPTION SYSTEM CALCULATIONS: ` WITHIN 1 00' OF WETLANDS,INLAND OR COASTAL 48° 4s" BANKS OR FLOOD HAZARD ZONES. C./a.. h + + Y SIDEWALL AREA 186 SF, � .5 83.5' 84.1 GAS 1 TL GAS 66 " 186 SF. X .74 G/SF. = 137 GPD. BOTTOM AREA = 441 SF. � 83.4' C 8LE `� MEDIUM SAND 441 SF. X 0.74 G/SF. = + HSE ,, 8G 326 GPD. �., 83.2' 83.2 E.s 11 HSE AR LEACHING PROVIDED = 463 GPD. 77.2' P �' OP OAS 0,83:5' \ \+83.1' �. �lOP�_ e33' l� i�� 8 " No GROUNDWATER (70,0) \ E.OP 6 86.8' \ $ C 9•0 168 144 \ ( GAR / \ •1' EOP 8 .9' 5.4' IS.FO' }`87.7, E E P OP \ LE E P GAR., GAS + +77.2' ✓�- 6.3' 6.6' �� 88.4' 87.3' • OP LE �` CBD 86.0' EOP EO HOLLY8 8.3'J 9 �^ 8.0' OP 89. LEGEND 1 EO ABLE �. AS 88.9 l a n s.2' 52 PROPOSED CONTOUR OP LE 90.1' 0 A EOP D +8tr Eop EOP s8.a' po` --- 52--- EXISTING CONTOUR rr�.. �%,� ; �-.� ,✓ EOP E.8' / $� / ,---foP ► �1 OBSERVATION PIT CABLE CFss �' PROPOSED SEWAGE DISPOSAL SYSTEM 87.4 EOP EOP 92.9 _ 9 . EOP ELEE.r k ❑ DISTRIBUTION BOXtl• PREPARED FOR v 1F14 t 11 a° 93.9' SEPTIC TANK l ► .L_� EVELYN HANLEY fiy� � l A + EOP r ,�� F , ,d. HSE.NO. 347 WHEELER ROAD 91.5' +sPaK2' SOIL ABSORPTION SYSTEM MARSTONS MILLS,MASS. s 94.9 E � q� ►P 95.0' N RESERVE RESERVE AREA EOP PLAN N0. 110404 SCALE:AS NOTED 22.26 PIPE INVERT ELEVATION J,���_r_.• \�' - FILE NO. 307BA DATE: NOV.4,2004 EOP ! � �A*„� .. SEPTIC FILE NO. 75 PCS FILE. wheeler347 t;t-tAHL ES }1' PLOT PLAN � sr'�r►i :�� , 2so= 5 �` CAPE & ISLANDS ENGINEERING SCALE: 1" = 30' o 0 0 ,% 82 2.2 B 347 N � src � 800 FALMOUTH ROAD, SUITE 301C MAP SEC PCL LOT HSE �c LAW MASHPEE,MA 02649 (508) 477-7272