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0110 WHITE MOSS DRIVE - Health
110 White Moss Drive A = 031-004-003 Mario'ns Missl - - - -- - - ------- - - - - - --- / TOWN OF BARNSTABLE LnPATION I/0 GU�/T !z/OS'S' !//^/V/a SEWAGE# VILLAGE�/�l�Y'Da/,S' mo11-.S' ASSESSOR'S MAP&PARCEL 03/-00'/-003 INSTALLER'S NAME&PHONE N0.3o8'5�20-9'73� ✓oso��s6,EyrHoS SEPTIC TANK CAPACITY /000 LEACHING FACILITY:(type) 2-SW (size) ;45-X/3 NO'.OF BEDROOMS / OWNER Q, O!'d USGi PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: , Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within . 300 feet of leaching facility) Feet FURNISHED BY �r _ u/Gi iTr' dLioSS D�/�i/_ rj,�G/c Oc-c o '�j Town of Barnstable P it /3 J et Department of Regulatory Services Public Health Division _ DateMAIK c 200 Main Street,Hyannis MA 02601 ' Date Scheduled J Time Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: �t,�e✓ 1 u--�►1�-P_Q do-1, Witnessed By: 9 L-OCATION.'&GENERAL INFORMATION' Location Address Ito W 1�t 05.5 Owner's Name 1"6AlS(<C�ns &I (LS a Address 0)0 �'l-ass fez M•)1 S y�.',� Assessor's Map/Parcel:6-3 ' _d 6,11 ^603 Engineer's Name dvAr,- (VLC-C-,� V-f NEW CONSTRUCTION REPAIR Telephone# 2 37—�'� Land Use Slopes,(%) �— Surface Stones ,, p /4- Distances from: Open Water Body Possible Wet Area��ft Drinking Water Well /i,*)---ft Drainage Way ^Jf A— ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) l p(Zj �� f ff# Parent material(geologic) Depth to Bedrock v�A Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face All l Estimated Seasonal High Groundwater -z 1 31 _ DETERMINATION-FOR.SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERtvOLATI01 TEST Date: ZIme Observation Hole# 'L j jt /` Time at 9" A Depth of Perc G Time at 6" Start Pre-soak Time @ � Time(9"-6') I ✓t S q.� End Pre-soak Rate Min./Inch cir CT/iQ/yc Site Suitability Assessment: Site Passed 'pe— _ Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTIC\PERCFORM"DOC DEEP OBSERVATION HOLE L-O.G Hole# 1 Depth from Soil Horizon Soil Texture . Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc °/Gravel 1.d-Y/Z . y "'l7i (' /�l—C 5+�,� e.�'r"✓" �� "vim DEEP OBSERVATION HOLE LOG Holeff Depth from Soil Horizon - Soil Texture Soil Color Soil Other Surface(in.) "' "(USDA) (MunseIl) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) LL 16 i f e4 L l6 ytz 'f/z. �. DEEP OBSERVATION HOLE L'OG ' Hole# Depth from Soil Horizon Soil Texture Soil Color f Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Graven 1 DEEP OBSERVATION'ROLE-LOG' Hole# Depth from Soil Horizon Soil Texture' + Soil Color Soil Other Surface(in.) (USDA) t (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) . .L. ; Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No 0< Yes _ _ Within 100 yea;flood boundary "o* Yes- Depth of Naturally Occurring Pervious Material ' Does at least four feet of naturally occu sing pervious material exist in all areas observed throughout the area proposed for the soil absorption system? �� + If not,what is the depth of naturally occurring pervious material? Certification, I certify-that'on' G (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training;pxpertise and experience described in 310 Mk 15.017: Signature `�"; r � Date Q:\SEPTIC\PFRCFORM.DOC _ y 4 1. ao.Fr' .rr�ry Pri si L�'AcX1iuG ;Pt .�dJq��. MORE Ti�AN /a►"B�LOy 4+vig TO G/TAAC; �A/V ,�iYTRA P/er ti�AVY CAS-7'./ -ON t✓O d .4' Sf/�G L B.E USE1 / COY�J�. p i�g/ FT F/A/ DR/✓El'V.4 Y � a o OF - � ® �e I o Y� P ,6 WA ST11/ :o •�J1V..�1�'-�!1 ' �DDO CAL. 1 e it . ►,ram"per .�r SPTl� 7i�8/1//t e 431 oa op o 1 1 !E zolcrI $ v WA✓���. T��S ... p O t i®' D1� Jt✓ e 1 I p KZ, ig ® �' s880 jr n in FZ VIA M. e.�,/1'.E A" .50 /C .7:4JVX !�fT. f" DU�LEJF T SZER "/C 7'.AJ4o'ff I( —2Q FT. GROUND TEJr TABLE ov���rbls �lsclreosv BOX�103•1 Fr SEWAGE ®dS'� � SKS7'4/ °f ?AQVI-A'7lDJ1I e/z/L7'.L�.�CN/NG F"tT IoZ—Z FT.: L EACH11VC- f'/T �C.4L� ��.K '° � -� ,fit V m cJ 1TE 1A Ntlr�i3�.� aT�•_�i.�a'aOMS ; 3 4., o/l��nr�i©/v G.�--F'T. SOIL. .L.00Y 6W1- 7W5�"" Ta7,4 7/l+Y,4T�U �d o/�sl _G.4L.�®� ' SOIL TEST�`/ SOIL TL�ST 2 NUMOER of L0f1CRINZc P/r �FLEt/.1QZs �_ EL�Y• ;4>AWe Off" S 0 1 L 7 46-S7` S%� ACN/NG F6 �t7 I{LPL_SQ. FT. _ ,� RED UdaTS JWl7 N�✓SI� SY T. �C/N,� ! SOT 7O/�P L�-y9CHlM�r�'.�R P/T !L—S4• /e?= .5u1� `ofL o RCG+/�T/DiV /�.AT I !y!N?I1/4 TOr iL 4RrAc�//Nis ARc�! ; �'� $41 VFT. ?= 1—s�iz PE C©L.gTyoiv 'ATE{ o� PA U+L c�c ShNp �i0.T N .' A. L-EV ' v, No.100 ono �� LEVY & ELDREDGE ASSOCIATES. INC j PC\It 4�s 889 WEST MAIN STREET. CENTERVILLE,MASSACHUSETT FSS/ON.' �� e /Y®GIO!!Na YV'�TER E/{/GOU/YTJeEt7 fL/�EN7":�, Enl /E!� DATE: GRO LlNI? Y1/.4TE/�" A ,,4ELEK No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH pIVISION -TOWN OF BARNSTABLE; MASSACHUSETTS Yes --�k application for Misposal *pstem Construction 3permit Application for a Permit to Construct(/� Repair(411-U'pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.//0 Wh irf' W 01'1 PrIVA5 Owner's Name,Address,and Tel.No. ryf,yr3Ton,s ryf///f .0. Fo/'fjcls�l Assessor's Map/Parcel 0 3/- o o y- a o3 0- _ Installer's Name,Address,and Tel.No.,f'0j�/2 q79$ Designer's Nart}e,Address,and Tel.No.S"0� ✓oscplf 1Jt t3 rros Gngih-e-e-off works / cU 6rAll V 12,1a� Type of Building: Dwelling No.of Bedrooms _3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) '��O gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title S_ze of Septic Tank Type of S.A.S. Description of Soil Nature of/Repairs or Alterations(Answer when applicable) ;;WZg/� >: D-fox w/>Li /nr Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date Application Disapproved y Date for the following reasons Permit No.ZQ( 2. — 0 1 y Date Issued 1/°! 1201 2 No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:--tZ PUBLIC HEALTH,DIVISION -TOWN OF BARNSTABL-E,- ASSACHUSETTS Yes llt ift ation' for Disposal Epstein Construction 30ermit Application for a Permit to Construct( Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.//0 11 U SS Ur/yr Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. ,0?-V o-g736 Designer's Name,Address,and,Tel.No. Jv.��ph U� �3�:r,-os � Gr�����trrh9 v✓a,-�� ^/ "}4141i <</—,1? / i TONS N?:///t !/. Type of Building: r Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) :1Q gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil . Nature of Repairs or Alterations(Answer when applicable) /f/- fW a /� /;_,O // - -1i0 9i2 X e i i l Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed - '/ %>�; Date Application Approved by Date Application Disapproved Date for the following reasons Permit No. O 2 -- o f 4 Date Issued (�q �2 n� Z -------------- --------------------------------------------------------------------- - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( �, Repaired Upgraded( ) Abandoned( )by at Shas been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. — O 1 jdated 1 [q'7-u1 Z Installer,119, � � i4��o_s. Designer ,4:_A4q/,11.gel 1,1 f #bedrooms Approved design flow' Q gpd The issuance of this permit shall not be construed as a guarantee that the system will nct one es'gned. Date / Inspector ------------ ----------------------------------------------------------------------------. -------------------------------------------- No. --I Z— 0tq Feel /W THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction 3Permit Permission is hereby granted to Construct( ) Repair(G-) Upgrade( ) Abandon( ) System located at //l) /i/:/Ti= i `,:I> M11 ii/= and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. y, Date 1 ! °' �i�I Z- Approved by 01/13/2012 07:49 5084775313 ENGINEERING WORKS PAGE 01 Town of Barnstable Regulatory Services T 0211"F.Goner,Dhemr $ g Pubiie HeAh Dhwwn Thomm McKean,Direetor 200 Msm Street, Hygmals,MA 02601 ofaw. 308-862-4644 Fax: SO&790-630� Date: Sewage Permit# D/ Aor'r1?&p/Paroel 0 3l-- ooy_003 imagerFqm `kr rAc.JR;n*l ee T E, ` Dyer: IF--% av;r'. War 4 s,_]�. Faller: cr e•I'S � ` `J Addr+em: I? W. -c-M 1 VA Ind- _ AMrem: 8l C�c y►� -}} __ ' on �Q t � SIJ C was issued a t to ink A R (date) onsta er septic system at 11 Cl chi VX��_e, �V\4 u MA based on a design drawn by ee- -e/ r-to- dated , I A- C-L esig ) X, I certify treat the septic system referenced above was installed substantiallyy according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Suipout (if ra*tired) was inspected and the soils were found satisfWWry. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS,or any vertical relocation of any component . of the septic system)but in accordance with State dt Local Regulations. Plan revision or cerdfied as-built by designer to follow. Stripout(if required)wa ted and the soils were found satisfactory. 01r PETER T. MCENTEE (Inkallbi's Signature CIVIL ,�No.981f� 4esigner'Ces Signature) (A Design } PLEAM, RETURNT ST L LIC F WiLL NOT BE ISSUED UMM BUIMAb- BUILT CARWARE RECEIVED BY THE BAWfffABLE 'B D SI =AM YoU_ q;of oc fimLvdkIczi&M=0BCMt=form.doc r ` L W *. Y© • t .+I �I � IMIALn Ln N M� � Postage $ �c1iS r-q CerNed Fee O Return Receipt Fee JANPO=j p (Endorsement Required) 0 Restrkded Delivery Fee (Endorsement Required) a Total Postage&Fees $ LISPS rl r-� - c3 Mr. Donald Forbush 110 White Moss Drive IL Marstons Mills, MA 02648 Certified Mail Provides: a A mailing receipt a A unique identifier for your mailpiece a A record of delivery kept by the Postal Service for two years Important Reminders: a Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®: o Certified M_aii is not available for any class of international mail. a NO:INSURANCE+COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a For an additional fee,a Return Receipt may be requested to provide proof of. delivery:To obtain Retum Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested'.To receive a fee waiver for a duplicate retum receipt,'a LISPS®postmark on your Certified Mail receipt.is required. . © For an additlonal.fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". a If a postmark on the Certified Mail receipt is desired,please present the arik cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 V A A,: 1 r , Town of Barnstable Barnstable p SHE T�y Regulatory Services Department 1'1"a.j l IIARNSCABLE, • MASS. Public Health Division YYY Cb lf'79• �� 2007 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7011 0470 0001 4525 5556 January 5 2012 Mr. Donald Forbush 110 White Moss Drive Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 110 White Moss Drive, Marstons Mills, MA, was last inspected on 12/8/2011, by Patrick O'Conner, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system" Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. I Failure to repair/replace the septic system with the deadline period will result in future enforcement action. Z DER OF THE BOARD OF HEALTH c Cean, R.S. -- Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\Town of Barnstable.doc Commonwealth of Massachusetts r Title 5 official Inspection Form Voluntary Assessments D is I System Form Not for y o Subsurface Sewage Disposal Y 110 White Moss Drive Property Address Donald Forbush Owner Owners Name information is Marstons Mills MA 02648 December 8, 2011 required for State Zip Code Date of Inspection, every page. City/Town 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 A. General Information forms on the computer,use 1. Inspector. only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name reb 189 Cammett Road lhz Company Address Marstons Mills MA 02648 rear, City/Town State Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes ❑ Conditionally Passes ® Fails ❑;Needs Further Evaluation by the Local Approving Authority. (Y� CD =� December 8, 2011 Job# 11-219 I pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 15ins•11110 Title 5 Official Inspection Form Subsurf c Sewage Disposal System•Page 1 of 17 I Commonwealth of Massachusetts _ 7 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 110 White Moss Drive Property Address Donald Forbush Owner Owner's Name information is Marstons Mills MA 02648 December 8, 2011 required for State Zip Code Date of Inspection every P9 a e. CitylTown B. Certification (cont.) Inspection Summary: Check A,B,C,D or E!always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. 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): Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 t5ins-11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 White Moss Drive Property Address Donald Forbush Owner Owner's Name information is Marstons Mills MA 02648 December 8, 2011 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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): brokenpipe(s) are re laced ❑ Y ❑ N ❑ ND (Explain below): ❑ p ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 White Moss Drive Property Address Donald Forbush Owner Owner's Name information is required for Marstons Mills MA 02648 December 8, 2011 Y every page. Cit !Town State Zip Code Date of Inspection B. Certification(cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health,. safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100"feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ® El clogged of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i ` \ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 White Moss Drive Property Address Donald Forbush Owner Owner's Name information is Marstons Mills MA 02648 December 8, 2011 required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) Yes No ❑ ® 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 well. El ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen,and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow,of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ 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. l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 110 White Moss Drive Property Address Donald Forbush Owner Owner's Name information is Marstons Mills MA 02648 December 8, 2011 required for every page. CityrTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 White Moss Drive Property Address Donald Forbush Owner Owner's Name information is required for Marstons Mills MA 02648 December 8, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. 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 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 — _ I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 White Moss Drive Property Address Donald Forbush Owner Owner's Name information is required for Marstons Mills MA 02648 December 8, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract . ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I - Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 110 White Moss Drive Property Address Donald Forbush Owner Owner's Name information is required for Marstons Mills MA 02648 December 8, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance date: 1/9/87 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material of construction: 0 concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5' long x 5.2'wide- 1000 gal. 2„ Sludge depth: t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 110 White Moss Drive Property Address Donald Forbush Owner Owner's Name information is required for Marstons Mills MA 02648 December 8, 2011 every page. Cilyfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 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 13" 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.): Liquid level was found at bottom of outlet invert, baffles were intact. Observed solids on baffles indicating tank had previously been full to top. 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 l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 White Moss Drive Property Address Donald Forbush Owner Owner's Name information is Marstons Mills MA 02648 December 8, 2011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 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 15ins•11110 P 9 Po Y g i Title 5 Official Inspection Subsurface Sewage Disposal System•Page 11 or 17 i i _�J Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 110 White Moss Drive Property Address Donald Forbush Owner Owner's Name information is Marstons Mills MA 02648 December 8, 2011 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert 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.): Observed solids and staining to top of box. Unused knock outs were rotted through causing box to leak. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 I f i J Commonwealth of Massachusetts . Title 5 Official Inspection Form _ +.. As Not for Volun Subsurface Sewage Disposal System Form rY. Subs g p Y 110 White Moss Drive Property Address Donald Forbush Owner Owner's Name information is Marstons Mills MA 02648 December 8, 2011 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Type: . One 6x6 pit. ® leaching pits number: ❑ leaching chambers number`. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Probing of soils in area of leaching pit found damp soils. 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 El Yes ❑ No ISins•11/00 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i I _ Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 110 White Moss Drive Property Address Donald Forbush Owner Owner's Name information is required for Marstons Mills MA 02648 December 8, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 14 of 17 i 1 Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 110 White Moss Drive Property Address Donald Forbush - Owner Owner's Name information is Marstons Mills MA 02648 December 8, 2011 required for —__.-----------------_._._.__...._._._...._....._.___....._.._... -- State Zip Code Date of Inspection every page. CityfTown D. System Information (cont.) 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 3 281 12 27 Crr'a)qe / r f / r / / / / r f r / i :• / / / / / / / / i / / r / r / r r / /`•r r r / / / ! / / Water Service White Moss Drive i Commonwealth of Massachusetts : Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 110 White Moss Drive Property Address Donald Forbush Owner Owner's Name information:is Marstons Mills MA 02648 December 8, 2011 required fo- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high round water: N/A P 9 9 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: 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 White Moss Drive Property Address Donald Forbush Owner Owner's Name information is Marstons Mills MA 02648 December 8, 2011 required for State Zip Code Date of Inspection every page. Citylrown E. Report Completeness Checklist ® Inspection Summary: A, B, C. D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 17 of 17 TOWN OF BARNSTABLE Y LOCATION �o I� I�J�;�e �a 5 5 �J SEWAGE # $7- Z H 6 VILLAGE M-1 0 L\^S K+:\1 s ASSESSOR'S MAP & LOT a3/ - Qo 4NSTALLER'S NAME & PHONE NO. •� d�c'5ca�, a SEPTIC TANK CAPACITY LEACHING FACILITY:(type) aG�^ Q (size) NO. OF BEDROOMS 3 PRIVATE WELL O PUBLIC WATE BUILDER OR OWNER G � d�'�`C pavt(, DATE PERMIT ISSUED: _ j'•7 9 7 DATE COMPLIANCE ISSUED: O - q 7 VARIANCE GRANTED: Yes No / 1:J - n 4 i qSSESSORS MAP NO: PARCEL NO.: _001 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -' ,,-'---n is hereby made for u Permit to Construct ` *�' or Icnui ` ' ao Individual Sewage Disposal Owner Address Installer Address � Type of Building Size Lot. feet I}��l' --��o. u6 8cdroov�y--.-.-.-. ��-_--------' �n� Attic /m&« Garbage Grinder �^�» Other—Typeof Building ............................ No. of persons............................ Showers ( ) -- CafeteriaPA ( ) ^� ~~^^^ fixtures ...................................................................................................................................................... Design Flow.......... a��........................ ��gallons per y�csoo per �u�. Total daily flow.-.----�����---------�PDoos. 04 Septic Tank—Liquid id ./�8�'.gu}oou Length................ Width................ Diameter------- Depth................ Disposal Trench--No..................... Width.................... Total ................... Total leaching area....................sq. f t. Seepage Pit No.------- Diameter-------------------- Depth below inlet.................... Total leacbingurcu-----.---aq. h. Z Other Distribution box ( ) Dosing tank ~~ Percolation Test ]leonita Performed ' , .����[/� �-���� ���� _ D��-'-'�2�������------ ^� ` . v ' � ]��z Pit No. l---*�~_roioutcs per inch Depth of Test Pit.................... Depth to ground vrutec.-----_._.. [� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----.................. O . ``----`------------------ -----------------`�---''-----------`'- -------------------------------------------~-=-......._ -------- -----~------------------------------------------------------------------------------------------------------------------ U Nature of Repairs orAltcrud000--Anuwerwbeo -_.----_-'___-'--_'_--.--._.__--_- � ...................................................................................................................................................................... '`,'-_-__. The undersigned agrees to install the uforcdescribcd Individual Sewage Disposal System io accordance with | He provisions ofI2Il� �� the State Sanitary Co de The undersigned further agrees to oplace system� in | operation until a Certificate of Compliance has been issued by the board of Signed` '''-'- '`"--------' ---- bate�'r-'--- ,^' icutuo Approved By'--' -..a. --'-_-------------'- -------���'v���'=-��'-� `~ _ -I Date Application Disapproved for the following reasons:.............................................................................................................. - ......................................................................................................................................................................................................... Date Permit Date No. v ... 7.6, Fins.... ...�" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH A ? r , r ......OF......�m .FL.f_ : 4 ............................ Applira#ion for Uhipasal Warkii Tatuitrnrtinn ramit Application is hereby made for a Permit to Construct (�') or Repair ( ) an Individual Sewage Disposal System at .. r �... = r .. ............ Loc tion-Address 4 or Lot No. ....... r: ---------------------------- ='_�.• . ..j . Owne A dress 'ami-It-t�----------i�'J .............................. .........5V4 � --------------------------------------------------------- Instalier Address r d Type of Building Size Lot......... •f - er ,(�) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) W Other fixtures -------------------------------- . W Design Flow.......... .........................gallons per person per day. Total daily flow----_........: `l_.._.................gallons. 04 Septic Tank—Liquid capacity.// :...gallons Length................ Width Diameter---------------- Depth................. Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area-------------------_:_sq. ft. 3 Seepage Pit No---_---------------- Diameter.................... Depth below imlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosintank ( ) t a Percolation Test Results Performed by. r' _ U........ &t i� _ 1 1- Date_........ �l�r�. ............ T, - �..._... d. i Test Pit No. I.......... _minutes per inch Depth of Test Pit .................. Depth to ground water. __ ................... (% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ..........: ...:----------•--•--•-----............-------------------•----•--•....--•--•-••-.....----••---•-•-----••--------------------•-- O Description of Soil = -----------------------------.................................................................. 1% U -•••-------•-----•----•----•-•-------•---....w_r-.ra: 'I-�- ------. ---------------•-------•-----...........---•---•--------------...----------------•----•--...-•-----•----------. . . 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 TyTI E of the State Sanitary Code— The undersigned 'further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health �Signed .� .� � � .� ..�� --•-Dat-e-l .......... � Application Approved By..... �.---�...`"`` •----•----- -------------•--•----•---•-- Date Application Disapproved for the following reasons:..-----•------------------------•--•---------•-------••---•-•--------------------------------------------•--.- -----•-•--------•---•---•-•-•-••-•--•------------------------------•--••-----------.........------.....V................................................................................................. 0 -7 _ Date PermitNo.._.......-•......- ----------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH „r................ Tntif irtttr of Tuntplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X or Repaired ( } by .......... -� Installer Ayt at A'`"L" � , t=�}2�? i`Y3�: �r t'!�!5 =� f? ;R t a=- ;r,�� f _4 has been installed in accordance with the provisions of T?T1E j of The State Sanitary Code as described in the application for Disposal Works Construction Permit Noo.? �.y4t.............. dated__..--___-___-__---_____-.-------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................. �> �.. cr.-.........!a ...................... Inspector........------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH NO......................... ...... Disposal Workii Tnnotrnrtion fautit Permission is hereby granted..------..1 r 4- ,_' ... ........................ ........................ to Construct ( slorl Repair /( ) an Individual Sewage Disposal System � } at i�TO. rf� -f E:.Fi i¢� e ........... ..„=:_... ry � �-�-1 .vml r f t�l.. ..! .................... -• •-- /f Street as shown on the application for Disposal Works Construction Permit ------- Dated.......................................... ............. . :0•-Board of Health•----•----•-----------•--_..... DATE..............=................................................................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS `t AAID DBE �(0 Ito ` b 3 } f` Io o. D ��t f °°o 1 5 Iz I Lo i. yf s GG NA , LEGEND I EXISTING SPOT ELEVATION 0 PROPOSED SPOT ELEVATION ] ��P gss9i EXISTING CONTOUR ---0— —— ��� P AU L �ZN Sc PROPOSED CONTOUR - 0 = (7-V` of 4_LEVYNOTE= THE LOCATION OF ANY UNDERGROUND ROSINSEWERAGE,WELLS, OR OTHER UTILITIES SHOWN ON �° ioo5o NTHIS PLAN IS APPROXIMATE ONLY AS DETERMINED �/s FROM RECORDS AND/OR VERBAL INFORMATION. �`s�ONA' L THE CONTRACTOR IS RESPONSIBLE FOR THE VERIFICATION OF THE EXISTING LOCATIONS IN `'° : ILL L L�cao�� � THE FIELD. N I R x e LEVY EL®RE®GE ASSOCIATES,INC. CL9ENE pf : F PL r , ENGINEERS- LANDSCAPE ARCHITECTS MB NO./a I`::PLANNERS — LAND SURVEYORS , 4�� �/ a' ' /V r DR. BY 4 '889'WEST MAIN STREET': : CH. -BY, CENTERYILI.E, MA. 02G32FfEET z_• ` DATE ..L ., SCAL.E= .. � r, � y , I COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Sign ture / �� item 4 if Restricted Delivery is desired. b //) /' 11 Agent ■ Print your name and address on the reverse a Gll ❑Addressee so that we can return the card to you. B. Received b (Printed N e) C. Date of Delivery ® Attach this card to the back of the mailpiece, or on the front if space permits. . Isrdelivery address different from item 1? ❑Yes 1. Article,:Addressed to: If YES,enter delivery address below: ❑ No MTD--'onald"Forbush 110 White Moss Drive Marstons Mills,MA 02648 3. Service Type ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise I ! ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes i I 2. Article Number 7011 0470 0001 4525 5556 1 (Transfer from service labeq PS Form 3811,,February,2004 Domestic Return Receipt y-102595-02-M-1540 i i UNITED STATES PqRV .,. ' tSPS r. u^ Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • Town of Barnstable Public Health Division I 200 Main Street i Hyannis, MA 02601 i IIjj }} i fj ff jj {{ { yj � IIIiIIIJI1113I 4i1111[11I1JIIIiIJ�IiiJ1dIM 1y1111J11iILI `•:� S'4..;'�� £�r�a- �,�s'n:'�±r xSrye'�`ti; Z �:.n i �_; '� ro•5 t ,.:-.t 4. � �'� _ •Yw�'... '4' _.;,; f —,r-a k..g. iF Lt; '�`�.�.�p �*":=a _,y, e7e„�:",.'� . '.- '�.'''"° - — - _ - -- ' h " >6... IV07,6 !G EOTHE�'' THE.S�P�/C Ti�iN aY f' r.�/ �`x .Fr •s ° �M� .. ! CEf�cH G �! i41�'F dF' 4."D/.ED r°d7/:e4/WF%'.E .CQ/yCaE'.�7' ®6/C/�* } SchfzzwL.&40 S�i.�Z �� 50004a"7' rP 6fri4 Z>�.64N ,EJR'pRi� w P V.c: P/P= -. x C®NCFd 'F:E NZ=-4Yy CAS7''lRG9NDE !/SE.[7 !F!N Za,T/VEWAY CD►��Fc' Cz EAV SAfi/� 6'� v foes Q "�„ � . ,�,. � ,,fir a � c B �. 0 ! �����/dam • p ♦ �. !�' . '' �� •� ;'. i 1� ASN�P`✓�''di4/�` / u./, d =/1,3�otr�p:' a go� a e:� ®. ® ® oe • Dwap PRE3"S��P�1GEw 1 A9�/C ' 44 EVAVONS /NVE 7 AT ffu/LD!/✓6 In i o. _ _ xa/tea : I! 4e7 ..W�'!� T.4/i//a r�l,�ar C e$E�r u �-lv�,� t�/��.E�'s���ic T.a/v1•s/moo�r ' ! /o �r GROuAI® W,4 rEA TABLE /ir o / ® ,TZE�dal�7•R/,�t/�'i®N�Xf /hVl�T.LE.�CR1JVa �»- /0Z_7 O'Fr S�1�Vs�� ®/S'®�A�. �1�.5�".�ia°1 -rAouLAT1o)V L. CHI/�I� AP07'' f�ES16N CX17'� fA ®/�lENS10%1 .WT. - d1PLl ��� P7:• �, TOTAL ,--7r1MA-'�d7 FLoE�i/y��.38... Ga3L.lAoAV SOIL TEST' 0/ SO/4 7—"'ST R . NUI.18E • OA•ZA-ACMINa PITS f°�LE�!d FLAY .DATE aF S®/L TffS7- S/6? �AC/0/NG P�iF P/T G2�_Sl� F3: o-i tz�P REa[/L7S it/ITNE�SE® dY T, 807'7'OA9 LE-9CN/NG®0 Fd P/T !�3 SQ p y S u�3 'o/L P-CR C0AA-r10N MATO AEI 2 !e'9lIV�/i4+C/5f 7-0;r,4L L,fiCN/Nlr AREt4 �'4 SQ. F7. /-�4�t Jul C8LA7'/ONI��y'E �� !"llN.�lNCN. 1,. R��ERP1E LEW-NIN6 AREA 2(` 5Q. PT. \�H OF MAssq S%Z'�!3 o� PAULSl�Np A. ,GOT �� 14111172 � ss f�/yF LEVY i No.io0s0 o LEVY & ELDREDGE ASSOCIATES. INC. Cif A9p��G15T ��� C�-• 889 WEST MAIN STREET CENTERVILLE•MASSACHUSETTS 02632 Cif sS1uN� `��c N®GMOUNO kV,4rC EVC0VMTglz�© c6/�ivr:��E�i.lEe/E,� PA7"45 j+ L • c. ——150—— EXISTING CONTOUR x 100.98 EXISTING SPOT GRADE N W EXISTING WATER SERVICE G EXISTING GAS SERVICE U UNDERGROUND WIRES LCC 37858 g 1;� TEST PIT BENCHMARK + 94.20 N o6.00'OO- W LEGEND LOCUS rx i 115 Aso Meigs Rd a wool Stree o m 3Q //APN 0 �� -004;�003 LOCUo SMAP CALE 810fS.F. / o a� EXISTING LEACH PIT CONTRACTOR SHALL PUMP, FILL W/ SAND AND ABANDON. 134.77 ' +• + 105A4 ,' EXISTING SEPTIC TANK (TO REMAIN) ' 104, +�� 104.79 TOP OF TANK, EL.=106.37t r TP-2 25��_ 1. 7- INV.(OUT)=105.04f(VERIFY) o i. 27 �:'•PREP :!4-, ' 93 No rn TK N ...r 105.61�,'106.4 -® o . & -1- 104.:38 z 106,7 +:io7,481,, ,,� BENCHMARK C r C1; OUTSIDE COR./BULKHEAD �e� o• EL.=108.45 (Assumed) x 107.'%( r + 108.12 o. DECK i r x i -t- 106, 107.19 ,EXISTING HOUSE(#110) G o T.0.F.=109.4f q, 108.5 I � I y 0 I o , 10 54 I x G x 108.51, 108.28 a I 0 0.00 ��� F 108.27 . �� - 0 PA VED � G I DRl VEWA Y. L=9.86, o ELE� x J08.37 R_721-g7 00 G� 96 pp' i1- 108,32 �a•46'OCr W, x 08.34- / -- 486--N �� _ 108,30 108,15 F��� OF SS -x6 08,E/ ent ` 108.10 VE PETER T. TEE 108-- - ovem RI o MC CIVIL of 107,57 SS o. 35109 OWNER OF RECORD edge 1•' O A REPSZE��� FORBUSH, DONALD R & 107.0 ' I TE t 0 E PATRICIA R & BRUCE A WH 110 WHITE MOSS DRIVE MARSTONS MILLS, MA 02648 Engineering by: SCALE DRAWN JOB. NO* PROPOSED SEPTIC SYSTEM UPGRADE PLAN Engineering Works, Inc. 1"=20' P.T.M. 273-11 t 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET No. 110 WHITE MOSS DRIVE MARSTONS MILLS MA (508) 477-5313 1/4/12 P.T.M. 1 of 2 Prepared for: Bruce Forbush, 110 White Moss Dr, Marstons Mills, MA 02648 NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL: 103.0 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. INSTALL RISERS & COVERS OVER INLET INSTALL WATERTIGHT RISER & PROVIDE TWO ACCESS MANHOLES TO WITHIN 3" AND SETT TO 6" OF FINISH GRADE. OF FINISH GRADE FOR INSPECTION PURPOSES T.O.F. PROVIDE ACCESS TO GRADE OVER OUTLET COVER COVER SET TO 6" OF GRADE EXISTING F.G. EL.=106.8t F.G. EL: 106.0t F.G. EL 105.5t MAINTAIN 2% GRADE (MIN.) OVER SA.S. ' L = 6. L _ 5. ® S=1% (MIN.) ® S=1% (MIN.) 4"SCH40 PVC 4"SCH40 PVC 6" 10"1 as $ as 14" 8 130000 am ammm EXISTING 48' LIQUID aaaaaaa LEVEL ADD 4' 5.2' 4' GAS BAFFLE INV.=104.62 PROPOSED INV.=104.47 INV.=105.04t D-BOX EFFECTIVE WIDTH = 13.2' EXISTING INV.=102.50 ELt EXISTING SEPTIC TANKS (FIELD VERIFY) 2-500 GALLON LEACHING CHAMBERS SURROUNDED WITH STONE AS SHOWN H-=10 RATED TOP CONC. ELEV.=1 �` A BREAKOUT ELEV.=103.06 NOTES: INV. ELEV.=102.50 saes mama aBaaa 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE 6006 eases INVERTS, PRIOR TO INSTALLATION. BOTTOM ELEV.=100.50 4' 2 X 8.5'=17.0' 4' 2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE 5' MIN. ABOVE BOTTOM OF EFFECTIVE LENGTH = 25.0' - ON A MECHANICALLY COMPACTED SIX INCH CRUSHED T.P. EXCAVATION OR G.W. STONE BASE.. AS SPECIFIED IN 310 CMR 15.221(2). LEACHING SYSTEM SECTION 3),INSTALL INLET & OUTLET TEES AS REQUIRED. NO GROUNDWATER, EL.=94.6 - 4)_CONTRACTOR SHALL INSPECT EFFLUENT FILTER ON 3/4" TO 1-1/2" DOUBLE OUTLET TEE AND REPLACE IF NECESSARY_ IWASHED STONE SEPTIC SYSTEM PROFILE 3" LAYER OF 1/8- TO 1/2- DOUBLE WASHED STONE r N.T.S. (OR APPROVED FILTER FABRIC) GENERAL NOTES: SOIL LOG 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL DATE: JANUARY 4, 2012 (REF# P-13,508) BOARD OF HEALTH AND THE DESIGN ENGINEER. SOIL EVALUATOR: PETER McENTEE PE 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS WITNESS: DONALD DESMARAIS R.S. OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE HEALTH AGENT LOCAL RULES AND REGULATIONS. ELEv. TP-1 DEPTH ELEv. TP-2 DEPTH 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 106.1 0 105.6 0 TO INSPECTION AND-APPROVAL. BY THE,BOARD OF HEALTH AND THE -- ' '- DESIGN ENGINEER FILL' FILL 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 105.1 A 12" 104.8 A 10" FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN SANDY LOAM SANDY LOAM ENGINEER BEFORE CONSTRUCTION CONTINUES. 104.7 10YR 4/2 16" 104.4 10YR 4/2 14" 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. B B 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF SANDY LOAM SANDY LOAM, THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 10YR 5/4 10YR 5/4 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 102.8 40" 102.6 36" ' 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. C. C 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS M-C SAND M-C SAND AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE 2.5Y 6/4 ' 2.5Y 6/4 DIRECTED BY THE APPROVING AUTHORITIES. 5% GRAVEL 5% GRAVEL 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY 95.1 138" 94.6 138" THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. PERC RATE 2 MIN/IN. IN SAND (PERC ON FILE, p#6145) 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS NO GROUNDWATER ENCOUNTERED lNL THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE h INSPECTED BY THE DESIGN ENGINEER PRIOR TO BACKFILL. ®®®® ®®® 13. THIS PLAN IS'TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. ®®®®®® ®®®®® 33" w ®®®®®® E3®®®® DESIGN CRITERIA N Z ®�»®®® ® ®®®® NUMBER OF BEDROOMS: 3 BEDROOMS SOIL TEXTURAL CLASS: CLASS 1 102" DESIGN PERCOLATION RATE: 2 MIN/IN (9/10/86, P#6145) DAILY FLOW: 330 G.P.D. 4" KNOCKOUT DESIGN FLOW: 330 G.P.D. GARBAGE GRINDER: NO 20" DIA. COVER EXISTING SEPTIC TANK: 1000 GALLON CAPACITY 4" KNOCKOUT / 4" KNOCKOUT 62" LEACHING AREA REQUIRED: (330) = 445.9 S.F. 0 .74 USE 2-500 GALLON LEACHING CHAMBERS IN SERIES 4" KNOCKOUT SURROUNDED BY DOUBLE WASHED STONE-ALL SIDES SID-EWALL AREA: 2(13.2' + 25.0') X 2 = 152.8 S.F. BOTTOM AREA: 13.2' x 25.0' = 330.0 S.F. 500 GALLON CAPACITY, H-10 LOADING TOTAL AREA:..............................................................482.8 S.F. CHAMBERS DESIGN FLOW PROVIDED: 0.74(482.8) = 357.3 G.P.D. N.T.S. Engineering by: SCALE DRAWN JOB. No. PROPOSED SEPTIC SYSTEM UPGRADE PLAN Engineering Works, Inc. NTS P.T.M. 273-11 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET No. 110 WHITE MOSS DRIVE MARSTONS MILLS MA (508) 477-5313 1/4/12 P.T.M. 2 of 2 Prepared for: Bruce Forbush, 110 White Moss Dr, Marstons Mills, MA 02648