HomeMy WebLinkAbout0294 WILLIMANTIC DRIVE - Health 2 N WILLIMANTIC DRIVE, M. MILLS
A= 103 082.001
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TOWN OF BARNSTABLE
LOCATION ��' L�r ��.��P�� SEWAGE#®10�'?�-
VILLAGE ASSESSOR'S MAP& PARCEL
INSTALLER'S NAME&PHONE NO.0"Al-4 Zeldpaeal*'
SEPTIC TANK CAPACITY eX"4 >,WF
C-
LEACHING FACILITY: (type) aR,,b, (size)
NO.OF BEDROOMS
OWNER_,g0l' ®
PERMIT DATE: COMPLIANCE DATE: '
Separation Distance Between the: ,e®,{r
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 V -* e'0257 4�01
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'f116 Town of Barnstable P 3�
• � .
' F Departiinent of Regulatory Services
• MAN& Public Health Division Date
. s'e7 200 Main Street,Hyannis MA 02601
• rfn tug t, �J
Date Scheduled / Tf nB =-Z — Fee Pd, O-0
►il iabiiity Assessment for Sew l�ispostal
Performed•By:. H " �
e. 1 Witncsscd By:
I.ocaticn Address
LOCATION& GENERAL INFORMATION
�.�
J:�> e Owner's Name y�O ��',j11
Address
Assessor's Map/Parcel: /C3 `®cQ�o®! ��ft4�� `3
Engineer's Name
NEW CONSTRUCTION REPAIR Telephone#
Land Use
Slopes(%) Surface Stones
Distances ftom: Open Water Body R _I?oselblc Wet Area
ft Drinking Water Well . ft
Dnilhage Way ft Property Line—�R Other
ft
SKETCH:(Sheet name,dimensions of lot,exact locations of test holes&Pere tests,locate etlands in proximity to(roles)
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Parent material(geologic)
Depth to Bedrock
Depth to Oroundwater, Standing Water In Hole.
Weeping Dun Pit Fnae
Estimated Seasonal High Oroundwater
Method Used: DETERMINATION FOR SEASONALIHGH WATER TABLE
Depth Observed standing In obs.hole:
DcA to weeping from side of obs.bole: Iti' Deptil l0 evil inottleet Ilt,
Index Well# Reading Date: index Well level__:_�_Yw Orntrndwater Adjustment f[.
Adj.factor _ Adj.Or'nundwdter Level
,, _
Observation PERCOLATION TEST pat® 'rinim
Hole fF
tr Time at9" tj
Depth of Pero (7p
Time at G' 0
Start Pro-soak Time @
Time(91141)
Rate Mo soak
aih./luc h
Site Suitbility
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Assessment: Site Passed 51tc Fulled:
Additional Testing Needed(YIN)
Original: Public Health Division Observiition Hole Data To Be Cornpleted 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.
QMEPTIC\PERCFORM.DOC �(
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DEEP-OBSERVATION HOLE LOG Hole
Depth from Soil Horizon Soil Texture Shcl Color Soil• Other
Surface(in.) (USDA) (Munseli) Mottling (Stnucture,Stones;Boulders.
• r sa Istcncy,�6'(3ravel)
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DEEP OBSERVATION HOLE LOG Hole#
Depth from Soll Horizon Soil Texture Soil Color Soil Other.
Surface(in.) (USDA) (Mmrsell) Mottling (Structure,Stones,Boulders.
onsi enO[avell
AAZ 9-
DEEP OBSERVATION BOLE LOG' ]bolo#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stoncs,Boulders.
Conalstanov.%Oravoll
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Sail Color Soil Other
Surface(In.) (USDA) (Munsell) Mottling (Structure,Slopes;Boulders.
C ns
IF, Insurance Rate Map_:
Above 500 year flood boundary No_ Ycs -V__
Within 500,year bouridary No :Yes k
Within 100 year flood boundary No.--. Yes _
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervI u rlal oxist in all eas observed thrpughout the
area proposed for the soil absorption system?
depth of haturall occurring aryl us matorlal?
Y�
. If not,what is the • p y g p .
Certification
I*certify that on l® (date)I have passed the soil evaluator examination approved by the
Department of Environ ental Protection and that the above analysis was performed by me consistent with .
the required training,is 's nd x rience described in 10 CMR 15.017
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Signature Datb .
Q:\S.P-PTlCkPERCF0RM.D0C
No. 1 I✓ Fee o 0 !
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es
4phratlon for 1� aY 6pstem �(Const urtlon i3erinit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) [:]Complete System Individual Components
Location Address or Lot No.c:??S Owner's Name,Address,and Tel.No.
Assessor's Map./Parcel�� AQ
Inst�a l.er's Name,Address,and Tel.No. 771 Designer's Name,Address,and Tel.No.
�
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building tlor4e�/ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided f� gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank .-a o0 Type of S.A.S.
Description of Soil
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 Certificate of
Compliance has been issued by this Board o lth.
Si / Date
Application Approved by 15TDate
Application Disapproved by Date
for the following reasons
Permit No. )= a/ 3 Date Issued
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No. � ( Fee ,,/
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: -
es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
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application for Zi8tl•sal. *pstem Construction permit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ��+Individual Components
Location Address or Lot No.ea[r"y ��L�* r/�'/ �C Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel'".0a 4R=Z 6 0 `
Instal er's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
O'o��13 t�.����.�'v.� Gam✓' -'��/�./�
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building ��� No.of Persons Showers( ) Cafeteria( )
Other Fixtures .may
Design Flow(min.required) )G+�' gpd Design flow provided � gpd
Plan Date �'1 /°,%� Number of sheets •� Revision Date
Title
Size of Septic Tank4X"sry /D 40'0 d4�4 Type of S.A.S.
Description of Soil
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 Certificate of
Compliance has been issued by this Board o lth
Si e Date
Application Approved by . Date S 7
Application Disapproved by dC V Date
for the following reasons
Permit No. Q( _ / 3 Date Issued
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TOCERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( )
Abandoned( )by
at J / �//GL/�j►j,,,�/Yj/ has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. :2 7-/3 ated 5
Installer�J/!7 �G . DesignerQ,491',e7mfJ'o — ,�-
#bedrooms S' Approved design flow ��j gpd
The issuance of th's p it shall not be construed as a guarantee that the system t c ion as designed.
Date �� % Inspecto C� 0— / f
No. 2 0 1 7 I13 Fee 1 GO -
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal *- pstem Construction J)ermit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at /�/ ��''/.C�i'/p,/jy�1'J✓ ��'✓ a2, ',�
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
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Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this per, t.
Date / 3 // 7 Approved by y , �2
From: 05/05/2017 09:23 #726 P.001/001
Town of Barnstable
��►� Regulatory Services
Thomas F.Geiler,Director
'ems Public Health Division
'°rEe3d Thomas McKean, Director
200 Main Street, Hyannis,MA 02601
Office: 508- 62- 644 Fax: 50 -790-6304
Date: rl tot Sewage Permit# o% ��� Assessor's Map/Parcel low 2
Installer&Designer Certification Form
Designer: cDO� �1 Installer: E
Address: Address:
a✓1� `TT6 , G �'
On ` ---�I was issued a permit to install a
(date) (installer)
septic system at 2L1 4WM based on a design drawn by
�'� (address)
6J1 fl� _ dated ZbE
� (designer)
/ I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.. Stripout (if required) was inspected nd the soils
were found satisfactory. H zo G"1106L.5 UT-1 UIZjW 1IN1AU0
1 certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local R '-Lions. Plan revision or
certified as-built by designer to follow. Stripout (if ra ncted and the soils
were found satisfactory. ��k OF/ygss r
01
DAVID 9c\.
(Installer's Signature) g MASON ;
9 No.1066 0 �/
isT
a1 � �
esi er s Signature)
PLEASE RETURN TO BARNSTABLE PUBL._ _fE
OF COMPLIANCE WILL NOT BE ISSUED UN i iL nv i tt i rzia r U1QI AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
q:,otlice fonns'&signerceititication fonn.doc
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
POAP
PARCEL , S$2
LOT
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 294 Willimantic Drive
Marston Mills. MA 02648
Owner's Name: Caroline Manning ,
Owner's Address: o
Date of Inspection: April 1, 2004
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Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford Z -o
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049 •• a'
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Telephone Number: (508)862-9400 r-
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CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: April 4, 2004
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 294 Willimantic Drive
Marston Mills, MA
Owner: Caroline Manning
Date of Inspection: April 1, 2004
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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
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Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 294 Willimantic Drive
Marstons Mills, MA
Owner: Caroline Manning
Date of Inspection: April 1, 2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
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Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 294 Willimantic Drive
Marstons Mills, MA
Owner: Caroline Manning
Date of Inspection: _April 1, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either`yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z 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 well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water.supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped
Zone 1I 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.
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Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 294 Willimantic Drive
Marstons Mills, MA
Owner: Caroline Manning
Date of Inspection: April 1, 2004
Check if the following have been done: You must indicate`yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
v' 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 s:ptic 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:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
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Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 294 Willimantic Drive
Marston Mills, MA
Owner: Caroline Manning
Date of Inspection: April 1, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system (yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped in 2003-per owner
Was system pumped as part of the inspection(yes or no): 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed on 9126178-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
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Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 294 Willimantic Drive
Marstons Mills, MA
Owner: Caroline Manning
Date of Inspection: April 1, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of Joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 20"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 2"
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: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
7
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Page 8 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 294 Willimantic Drive
Marstons Mills, MA
Owner: Caroline Manning
Date of Inspection: April 1, 2004
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alami in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
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Page 9 of l 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 294 Willimantic Drive
Marston Mills, MA
Owner: Caroline Manning
Date of Inspection: ,4pri11, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓' leaching pits,number: 1 - 6'x 6'(1000 gal.)
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.):
The pit had 4'of water on the bottom. The scum line was at approximately the same level. There did not appear to be any signs
offailure. The cover was T below grade. The bottom to grade was 8.
CESSPOOLS: None (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: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
f
9
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 294 Willimantic Drive
Marston Mills, MA
Owner: Caroline Manning
Date of Inspection: April 1, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
l
Q O a-
30 lao
a 3y a� 3
6
3
10
I
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 294 Willimantic Drive
Marstons Mills, MA
Owner: Caroline Manning
Date of Inspection: April 1, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 40 +/- feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately
40'+/-to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
I
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 294 WILLIMANTIC DR. MARSTONS MILLS O
Name of Owner JAMES STEIDLER 1
Address of-Owner: SAME
Date of Inspection: 4/28/99
Name of Inspector:(Please Print)JOHN GRACI f,�tnir/�
l am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) GD qA "�IVE(� V0
Company Name: n/a ? 1999
Mailin g Address: n/a
OF t29 r
Telephone Number: nla
a 4*
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, --ra
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The inpection is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My inspection does
Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: , Date:4/28/99
The System Inspector shall jbmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If the system is a shared system or has a design Flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED EVERY TWO YEARS.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 294 WILLIMANTIC DR.MARSTONS MILLS
Owner: JAMES STEIDLER
Date of Inspection:4/28/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
_ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
nLa One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the
replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
nla The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
_ distribution box is levelled or replaced
nta The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
_ broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 294 WILLIMANTIC DR.MARSTONS MILLS
Owner: JAMES STEIDLER
Date of Inspection:4128/99
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety
and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nl&(approximation not valid).
3) OTHER
DLa
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 294 WILLIMANTIC DR.MARSTONS MILLS
Owner: JAMES STEIDLER
Date of Inspection:4/28/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped n1a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 294 WILLIMANTIC DR.MARSTONS MILLS
Owner: JAMES STEIDLER
Date of Inspection:4/28/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates
during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[1 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 294 WILLIMANTIC DR.MARSTONS MILLS
Owner: JAMES STEIDLER
Date of Inspection:4/28/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-=g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):;I
Total DESIGN flow: IQ
Number of current residents:)
Garbage grinder(yes or no):I11Q
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):DLO
Water meter readings,if available(last two year's usage(gpd): ]I&
Sump Pump(yes or no): hLQ
Last date of occupancy: DLa
COMMERCIAL/INDUSTRIAL
Type of establishment: DLit
Design flow: DLit gpd(Based on 15.203)
Basis of design flow: DLit
Grease trap present:(yes or no):DLO
Industrial Waste Holding Tank present:(yes or no): MQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available:DLit
Last date of occupancy: n&
OTHER: (Describe)
DLit
Last date of occupancy: n&
GENERAL INFORMATION
PUMPING RECORDS and source of information:
nLa
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped DLit. gallons
Reason for pumping: DLit
TYPE OF SYSTEM
XSeptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: DLit
APPROXIMATE AGE of all components,date installed(if known)and source of information:
THE SYSTEM WAS INSTALLED IN 1978 PERMIT#78-579
Sewage odors detected when arriving at the site:(yes or no). NQ
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 294 WILLIMANTIC DR.MARSTONS MILLS
Owner: JAMES STEIDLER
Date of Inspection:4/28/99
BUILDING SEWER::
(Locate on site plan)
Depth below grade: 1_fz
Material of construction:_ cast iron _40 PVC X other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
nCa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: i
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
nta
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Wa
Dimensions: L 8'6'H 6'7"W 4'10"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: L
Scum thickness:4
Distance from top of scum to top of outlet tee or baffle: S"
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED
EVERY TWO YEARS,
GREASE TRAP:
(locate on site plan)
Depth below,grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
Wa
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle:iVa
Distance from bottom of scum to bottom of outlet tee or baffle n(a
Date of last pumping: n&
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
nLa
revised 912/98 Page 7 of 11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 294 WILLIMANTIC DR.MARSTONS MILLS
Owner: JAMES STEIDLER
Date of Ins,pection:4128199
TIGHT OR(HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nLa
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
nLa
Dimensions: nLa
Capacity: nLa gallons
Design flow: n(a gallons/day
Alarm present: N_Q
Alarm level:jV& Alarm in working order:Yes—No—: NO
Date of previous pumping: n&
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
IVA
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert:WA
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
nLa
PUMP CHAMBER: NO
(locate on site plan)
Pumps in working order:(Yes or No): NQ
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nLa
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 294 WILLIMANTIC DR.MARSTONS MILLS
Owner: JAMES STEIDLER
Date of Inspection:4/28/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: jiLa
leaching galleries,number: jiLa
leaching trenches,number,length: Wa.
leaching fields,number,dimensions: n&
overflow cesspool,number: Wa
Alternative system: n/A
Name of Technology: _nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY,PIT HAD X IN IT AT THE TIME OF THE INSPECTION.
CESSPOOLS: _
(locate on site plan)
Number and configuration: nta
Depth-top of liquid to,inlet invert: n&
Depth of solids layer: n&
Depth of scum layer. WA
Dimensions of cesspool: nLa
Materials of construction: nLa
Indication of groundwater: nLa inflow(cesspool must be pumped as part of inspection)n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nLa
PRIVY: _
(locate on site plan)
Materials of construction:Wa Dimensions:n&
Depth of solids: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nta
revised 9/2198 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 294 WILLIMANTIC DR.MARSTONS MILLS
Owner: JAMES STEIDLER
Date of Inspection:4/28/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
O �
p oD
OC
AQ 5°
AW
Ac 3l
p�3 3)
y
�c aS4
revised 9/2/98 Page 10 of 11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 294 WILLIMANTIC DR.MARSTONS MILLS
Owner: JAMES STEIDLER
Date of Inspection:4/28/99
NRCS Report name: n/a
Soil Type: nla
Typical depth to groundwater: n&
USGS Date website visited: Wa
Observation Wells checked: NO
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
X Observed Site(Abutting property,observation hole,basement sump etc.)
_ Determined from local conditions
_ Checked with local Board of health
Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS AND VISUAL-12+FEET
revised 9/2/98 Page 11 of 11
I�
if J b3 %
4 0 010
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental ProtectionCf ' �
0 Mq y
Willlam F.Weld .` Jr 1996-�
Governor (�,^
Secr Tru1!zy ECEA Coxe / � �
David B.Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ILA r
r Ip�s�e PART A
1r' CERTIFICATION
Property Address: �r�ll�uro�r o �2/ �r5)dw����S Address of Owner: Svc
Date of Inspection: S/I�/9� (If different)
Name of Inspector: STEvEA) 6111AI5610
Company Name, Address and Telephone Number: A)aCLSE EuvtfZo0ME)VTAt. $6RJ�ccS
3 PonN a o r ew ►QL/t�E
CERTIFICATION STATEMENT TVAI&5800-0, MASS 618"N
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
L� Passes ��� Of MA
_ Conditionally Pass �V yG.
Needs Further Ev.; � iongV. proving Authority
Fails CA
N
U E�1
Inspector's Signature: E�SO Date:
ANITP `
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 1D,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sen± to ',he system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D
A) SYSTEM PASSES:
_4 ' have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
i�Printed on Recycled Paper
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A �..
CERTIFICATION (continued)
C2-�Y)
Property Address:
Owner: Y4 6' T-V-o
Date of Inspection: 5—/1819�
B] SYSTEM CONDITIONALLY PASSES (continued)
_ Sewage backup or(breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
,i l n2 •�,' t r in 1, t tc
_ i flr � fc�' � .. <e >�•I�,�� i�:1i. c�-,. �G�. aJ�Orp�i��� �)'7.e1 Z i5\'r�. :1 100 feet to a surface \1'2 e SLr.r � 0.'trl U Z^: Z
surface water supply.
_ The wstem, has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_ The system hay a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The ha: a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/95) 2
s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: `L6 W11lame, f« >7rt.
Owner: S✓'Uv�S
Date of Inspection: S//F//f 6
D] SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
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 (I\A'PA) or a mapped Zone II of a
public water 5uppiy well;
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
i r
F -
• t '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 2� {�►�1rw►o-,•7�� �/` /"l�lS +y ���5
Owner: c(yc 7vk� S
Date of Inspection:
Check if the
/following have been done:.
!� Pumping information was requested of the owner, occupant, and Board of Health.
(/ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
_L/As built plans have been obtained and examined. Note if they are not available with N/A.
/ The facility or dwelling was inspected for signs of sewage back-up.
ZThe system does not receive non-sanitary or industrial waste flow
(/The site was inspected for signs of breakout.
I/AII system components, excluding the Soil Absorption System, have been located on the site.
(/ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
_✓The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
t" The facilitv and occuoints. if different from owneO were provided with.information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95; 4
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: •��l I J'fir'""uw f `c /L- �"`"K y4'y d+4� �S
Owner: `y"2fF Ty-
Date of Inspection:
FLOW CONDITIONS
RESIDENTIALND
Design flow: ^W aal n
Number of bedrooms:
Number of current residents:
Garbage grinder,yes or no):_o
Laundry connected to system (yes or no):�
Seasonal use (yes or no): N
Water meter readings, if available: 4
Last date of occupancy: C uUd e�
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title s system: (yes or no)_
Water meter readings, if available;
Last date of occupancy:
OTHER: (Describe',
Last date of occupannn•:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
®W'jCA
System pumped as pan of inspection: (yes or no)*-S
If yes, volume pumped. 000 gallons
Reason for pumping. ,,cct
TYPE OF SYSTEM
r/ 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)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) S
I _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Cam¢) SYSTEM INFORMATION (continued)
/V1,/(S
Property Address: 'L �✓i��+�N �' `
Owner: L
Date of Inspection:
SEPTIC TANK:
(locate on site plan)
Depth below grade: 2
Material of construction: !/concrete _metal _FRP —other(explain)
Dimensions: �! 9
Sludge depth: < L "
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:_ y
Distance from bottom of scum to bottom of outlet tee or baffle: 17
Comments:
(recommendation for pumping, condirion of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
a
GREASE TRAP:_
(locate on site plan)
Depth belov, grade:
Material of construction: _concrete _metal _FRP _other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
r� c!a nrn j r'! ,_ .'ie, tpo �r hari�p
Comments:
(recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of ieakaec- eic.t
(revised 8/!5/95J 6
c
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
e29y) SYSTEM INFORMATION (continued)
Property Address: Z(, t,✓, 14^an (C
Owner: r Ty iiu c
Date of Inspection: 5-116-/96
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP--other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: Nd
Comments:
(note if level and distribut,c;.. a equal, e%idence of solid_ carr\over, evidence of leakage into or out of box, etc.)
Lev t
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
's PART C
SYSTEM INFORMATION (continued).
Property Address: 9 Y Jj)j/l r.N 4-1 its 0', /V I�'M
Owner: f r Tr-
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
CESSPOOLS: _
(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 a grouncivate-.
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition or 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.)
(revised e/15/95) 8
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 12_9Y IJi , ,w �,c Dn I'�vr S oh ,1)S
Owner:
�-c
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
gay
DEPTH �w e(P►ny
DEPTH TO GROUNDWATER
Depth to groundwater: feet
method of determination or approximation: C-S7//,UTL
(revised 8/15/95) 9
TOWN OF BARNSTABLE
LOCATION —l�I �JI I 1 Mqn C l.)r, SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT 103 O tc'-
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I W
LEACHING FACILITY: (type) A-7— K 0o' (size) 0�
NO. OF BEDROOMS 3
BUILDER OR OWNER C��d'1^c !'V1A/1�11nG
PERMTTDATE: 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 leachin facility) Feet
/1
Furnished by SPCy1'o^ S �o/
i
s
A �3
I
Deck, i
I '
O
a 3y a4O 3
6
LOCATION f � SEWAGE PERMIT NO.
„�- Zto W, ��wtA�rr �C. '75-51OR
VILLAGE
«s
IN A LLER'S NAME i ADDRESS
� ���
�B U I'L E R OR OW ER
N/v� 1P0 ��► �O�
DATE PERMIT ISSUED c� _� _ ►��
DATE COMPLIANCE ISSUED —� � - 7�-
r (,
.. ,� ��
�,
i
„_ � �i
�,� �1 � �
� �l.'
-�ov S �.,
No .......6p�............ ic Yu ..........V..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_0._7 LOA...........OF...... ......................T
......... .....
Apphration for Dispoiial Works Towitrurtion ramit
Application is hereby made for a Permit to Construct X or Repair an Individual Sewage Disposal
System at:*
....7 ...6 t ...................
4
Location Address Lot N
................ ....... .....ox 16&y L
r_e.. 6 Y caner
Address
.w...vr_�VE_
................ 6 rl
Installe AddressType of Building Size Lot...dt..0, ..Sq. feet
Dwelling—No. of Bedrooms---------------- .......................Expansion Attic Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers, Cafeteria ( )
Otherfixtures .....................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow.......:3.3.0....................gallons.
Septic Tank—Liquid*capacity.1.000gallons Length................ Width______--_-_..__- Diameter--.----_--__-___ Depth...._...........
Disposal Trench—No--------------------- Width._.___....._._.... Total Length.......... Total leaching area....................sq. f t.
Seepage Pit No.--___-_-.!._--___-_ Diameter-----)0----- Depth below inlet.... .. Total leaching area.=. ,._sq. ft.
Z Other Distribution box ()Q Dosing t nk ( )a . 2a. ......
Percolation Test Results Performed by.... /A........... Date---St
Test Pit No. I.......2--minutes per inch Depth of Test Depth to ground water.....
Test Pit No. 2................minutes per inch Depth of Test Pit__---_-_-.---____:-_ Depth to ground water.._.._....._....._..__..
................ ................................0 -------------------I.....................................Description of Soil........... .t _5C>_t4 ........... -A
.3 ��.n -3....
1
............................................ ......o_o,&r,_&F.......5-:AA)b............................................................................
U
W -- ----
................. --------------------------I ----
�ii A_ .Y...............................................................
U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------- .........................................
..............................................................................................................................................................------------------------......_..._------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL IT T-Z'j 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been jsjogled
Yby he oard'oY16Ith.
1*. -S'gn-d.. ................. .. ...............
Application Approved By...... T ----------- .....9 X.�Jv-�� -..........................
Date
Application Disapproved for the following reasons:................... ...........................................................................................
........................................................................................................................................................................................................
Date
Permit No....................... Issued------ 7�4- , I
----------------------------------- ..................................
Date
No. .�... '~ ^. ..
Fzcs.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C?.. .............OF....... / ?..�.Rr 41.----..................._.
. ppliratinn for Uhip a al Vorkti Tomitrnrfi,an ramit
Application is hereby made for a Permit to Construct (><,) or Repair ( ) an Individual Sewage Disposal
System at
Location-Address or Lot N�
.� . . ................ c!. ,nt ..
Owner Address
,`►°1. . ,Pa�C' .................'S4..1<
Installe Address
Type of Building Size Lot._ .vy.UCz..Sq. feet
U Dwelling—No. of Bedrooms................. ._...Expansion Attic (Xj Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Otherfixtures ................................ --------------------------••-------------•--------------------------------•------------•-•-----------•-•---------
W Design Flow............................................gallons per person per day. Total daily flow....... ....:.....gallons.
GG Septic Tank—Liquid capacity..O(X-)gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No. .................... Width._._ Total Length..........____.... Total leaching area....................sq. ft.
Seepage Pit No..........I......... Diameter.._..�f�?.".C� Depth below inlet....(-i.. --- Total leaching area.Z6&=....sq. ft.
Z Other Distribution box ()Q Dosing tank ( )
Percolation Test Results Performed by.... ' ,�_....._..��� -.�!�_.___.__-_. Date...s ....2:..�?....._�L..._......
�-a Test Pit No. I....._.2 _..minutes per inch Depth of Test Pit.1 .".U. Depth to ground water......
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-----------------------------------------•-----••#- -------- .-- , 9 -.-
. .. ...----_..----'P-._.--.---•.-----------_.-.----...--
O Description of Soil....---...-C �c�--•--- ./?�?,1'¢).- �zr'� r !�- ��� 1�� �--� ' !31? .'V..S��JI,
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 TIT L;,,. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been 's ed by th oard o ealth.
q _
Sig d _... --- .� --
Application'Approved By.. { ...... � .Date
Application Disapproved for the following reasons-----------------•--------•--•----------.....--•------•-----•------••............••---•---- •-•••••............
-•-••••.........•-•-•---••--.........-•-•---••••••--•••.••-•--•---•••-•-•----•-•................••••-••••'..............•••••..•-•-•-----••------........................•••----.... ••••....._....
Date
PermitNo......................................................... Issued----------------••.....................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.... .!- ..� �......OF...... 1Z! a. !Q ........................
Cnrrif irtt#e of f�niYtlittnrr
THIS' TO CERTIFY, That the Individ al Sewage Disposal System constructed or Repaired ( ' )
by ... ?. !
Install
at_......... = .... �:�_. ! ti1T� "-- f Z-=••----..VIIA(_' --1_dw)s.-•----�-RA-�` ..................................
been installed.in accordance with the provisions of T(T- 5 of The State Sanitary Code a described in the
application for Disposal Works Construction Permit No.----- ': -7 `......------•.._ dated: _. .".. :... ._`_______________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE COVSTUEDS /�y Gfll�►R�►NTHAT THE
SYSTEM WILL FUNCTION SATISFACTORY.-DATE__... ..... Inspector � `R%�1/1/1' ..... .........
I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........�C. _Mj......OF.......... { .)S�- 1 1.. ..............
No......................... FEE........................
Disposal Workii T.omVudion rmi#
Permission is hereby granted.......-- kA..6-_----._- �1__ 1 ��.�C_ _.__. _ LCA....2-/wa'.1=1.i
to Construct,K) or Repair ( ) an Individual Sewage Disposal System
at No.... ....... ..... -------- A-4757'-k.C<`\S-•... �.l.sj- .........................
Street
as shown on the application for Disposal Works Construction Per` it No. ._ . Dated.... __-_ .• _ ...___
. • ..........' 'L ' ---------------------•------
DATE -
(•'f 7� y oar of Health
'-67......-----•---------------4------'--•-•..................•--......... /
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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ROBERT
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EXISTING SPOT ELEVATION Ox0 CERTIFIED PLOT PLAN z `
EXISTING CONTOUR - p -- G c� 7 ZG N/,�c /rt�.4i►%Tl c D/Rdver�,,
FINISHED SPOT ELEVATION 0.0 t
FINISHED ..CONTOUR . 0 ... / :-IZ57-0/1/S
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APPROVED : BOARD ' OF HEALTH r
�A III 1A9 9,o'MASS �
DATE AGENT SCALE :- � F/- 40 : DATE s
L DREDGE ENGINEERING CO. .ING�! _ - t l��,^✓c-r; _�._.
—.---._.- mm CLIENT ___. ... _ _._ I CERTIFY THAT THE PROPOSED
EGISTERE REGISTERED JOB NO. ��_�c�.3�- BUILDING ,,SHOWN . ON. THIS PLAN
CIVIL LAND DR. BY '�, ��'�' CONFORMS TO THE ZONING LAWS
F
ENGINEER SU_RVEYOP, — �— OF BARNST, LE MA, :S.
'F.f33 N0' ,MAIN ST 712 " MAIN ST. CH. BY: .--"- - —--..-. V71
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IS0:1`'YARMOUTH, ;MASS.{ HYANNIS, MASS. SHEET OF Z_ DATE REG., LAND '"SU_RVEY.OR ''
E/TNER TNT SEP.T/G TA'IV OtrQ
aO FT . p r �E�RGN/n/G. P/T`AIVE MORE.:.77HA/V / ELOJV
`OW MI. GRAOE PO 0A91A W A=7WV CONCRETE R
CODE
SNA L[ _B.F B A?0 Ua V T 'TO rm/?A D, ( A N RFXTRA
.;F 4"PIiC s P/P2
„J•IERVy CAST be OW .CO!/L=R
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B O �g p AvaR FT !
- !F/N ..DR VEyI/A y
_ g70MiN, /'' CONGRLt'TE
14 a C,R.40E / CO ✓Efz CLEAN .SA/VO•
_.� BACKS/LL
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M /VTLN ' ST oaao 1 • s • s • • • � po c +
4 A S HFD S70N -E :
SEPTIC TANK D/ • . • • • • • • . • • ; , a
:.I BOX p • I 8 e • • • • ncry
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• a • • DEPTt/ • • !` • o 4'ASHED STaiyB ..
o • • • • • • • • tr o c o
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o vs c • •. o.., • • • • p a•y - PRECAST SEEPAGE
ff • o r • • • e .• a a • ' a o P_ !7 OR EQU/V.- ...
/NI/BRT E'LEVAT/DNS P b a
INYE)?T AT ffZ1Z4D/NG '9 6 p FT. -
INZET .SEPTIC TANK,
OUTLET SEPTIC TANK M,3-FT. '
INLET D157R,B!/T/ON BOX 9 S'O FT GROUND WA7,ER TABLE
OCITLETD/STR/BLITION BOX-9't•9 F7 SECT/ON O F
SEWAGE O/S'POSA L SYSTEM
INLET LEA CHlAlCr o/T' 945FT 7A,6411-ATlDN
LEACH//VG P/T t vIMENsIoA/ A 4 FT.
SCALE 14.j a /: 0'•
DE$/GN CR/T��/A D/,d/ENS/aN $ FT.
3 / 7: //✓
It/UNJ8ER OF BEDROOMS . D MENS/ON C�-F
GARSACZ D/SPO•SAL UNIT SOl L>. LOG SO/L TEST
TaT.4L ESTIMA-TED FLoaV 330 6.44../DAy' TEST . SOIL TEST2 .
.� NUMBER QF 40ACHING R/TS r`-E-lu- ,OA7"E_OF SO/L O TEST
S/OE LE NG
ACH/ PEi?P/T SQ. F7� RESULTS h//TNE E SSD BY 1�• T3uiVi K i S
—Z r
BOTTOM 4494CN/NG PER SQ. A7; . 4LO,4Mj Tu dSVL. f'tRCOLAT/ON RATE At/ _ — M//VII NCH
TOTAL LEACH/NG AREA . .26 b SQ. FT. Z' -3 ' PWICC0L/4T/!JN RATE/ 2 MIN.�INCN
< 9A R S7 E
RESER{/EGE,4CN/NG AREs1 �°6 SQ. FT. . -„/A' -
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aE sA�vo fi ^�: C2/✓E2 [.t-/M.4n/Ti L DR.i E
N OFM" ,`. SAL C4-A LOT 26 w/
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SIC ASSESSORS MAP : Ao--_22 _
L� PARCEL : Z - TEST HOLE , LOGS`
-- --- — 1) The installation shall corripf with Title V airy) Town of Board of
01\ '' � SO I L EVALUATOR: I or 0j C �
� FLOOD ZONE: �OT �-1� � f fealth Regulations.
r I% . -- --- WITNESS : Q Wl 1 g
2) The installer shall verify the location of utilities sewer inverts and septic
I
REFERENCE: components prior to installation and setting base elevations.
1�L _ l .____ ___.�'� DATE.
7�IC � I PERCOLATIO RATE:
Ca___ � �__.. _-- • , lr•.� �+ 2' l 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per Foot. The first
. tl Y, �� i2 two feet out of the d-box to the ieaching shall be level.
�� 4) This plan is not to be utilized for property line determination nor any other
- TH- 1 TH-2
n purpose other than the proposed system installation.
C �31
5) All septic components must meet Title V specifications.
'2 Y'j 6) Parking shall not be constructed over H10 septic components.
f j rlle,7,
7) The property is bounded by property corners and property lines.
104 �' 8 The ro shall review
/ ! ) property owner design considerations to approve of total '
LOCATION MAP 1ul- �� �jlV Vb design flow and number of bedrooms to be considered for design. Receipt
7 I � 16 27 of payment for the plan and installation based on the plan shall be deemed
approval of the design flow by the owner.
9) The existing leaching or cesspools shall be pumped and filled with material
C1i 6 per Title V abandonment procedures. Those within the proposed SAS shall
? q be removed along with contaminated soil and replaced with clean sand per
Title V specs. i
p 10)System components to be 10 feet from water line. Sewer lines crossing the
- water line shall be sleeved with 4 inch SCI140 PVC with ends grouted if
_ � r ► �✓�J
applicable. The proposed SAS is being installed below the water service
V L�� -T �. 79 R i t/C ' line. The line is to be sleeved as aforementioned and maintained in place.
S E P T I C SYSTEM DES I G N 11) If a garbage grinder exists it is to be removed and is the responsibility of the
owner to ensure such.
9 3_ � FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such exists.
BEDROOMS AT GAL/DAY/BEDROOM 4J b GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer
�(
t lines exiting the dwelling•prior to the installation.
SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting
I �• Title V requirements.
`jGAL/DAY x 2 DAYS GAL i
5�6 > -- 3s,' i USE [CE GALLON SEPTIC TANK
_ a4woelQ Wol- l�bl�
3t 3 Z a_
o I th SOIL ABSO PT I ON SYSTEM -
ouNUA71uN ^ Z
4� Al2 OF 11,14
Its
LID L1
t`✓ ' SIDE AREA: �( .�" I2� X ,CM11 - 11 N7 4� D B.
Cc'
1 \` BOTTOM AREA: i k u-1 MASON
/,
l0 MIME ) v No.loss o �y
b
�Q
l
SEPT I '', SYSTEM SECT I ON `~"' `'
Af 32042- 3S"w Ap-
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u
Li
IL
GAL ��j,l I g2,� i
SEPTIC TANK!!�w Wv
7u
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=ri��7T
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r�� I t 1�bt v�( b �i '� ' - V,70 O I I - ---�
f S 1 TE AND SEWAGE PLAN
LOCATION : Z�j
20 PREPARED FOR :
0
'An.
ALE
DAV I D B . MASON R6 D
Z
DBC ENVIRONMENtfAL DESIGNS
DATE HEALTH AGENT EAST SANDWICH . MA
( 508 ) 833-2I77
i