HomeMy WebLinkAbout0208 CARLSON LANE - Health !08 Carlson Lane
W Barnstable P
A 110 036 - - ----- - -- - ----�
OWN B OF ARNSTABLE `
LOCATION , �� �rfSdr1 AL SEWAGE #
VILLAGE W- RAW" ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �w
LEACHING FACILITY: (type) C ' X J (size) AGlib
NO.OF BEDROOMS +
BUILDER OR OWNER Ra►� iCJ�,On��
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 leaching Facility) Feet
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
a
TITLE 5
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A `
CERTIFICATION
Property Address: 208 Carlson Lane
West Barnstable, MA 02668 pSS�SSpRSM� U?J- ((f
Owner's Name: Robert Madonna �,r10'
Owner's Address: To
Date of Inspection: July 1, 2004
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
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: July 7, 2004
The system inspector shall sub ria 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)
r
Property Address: 208 Carlson Lane
West Barnstable, M4
Owner: Robert Madonna
Date of Inspection: July 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:
2
Page 3 of I 1
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 208 Carlson Lane
West Barnstable, MA
Owner: Robert Madonna
Date of Inspection: July 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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 208 Carlson Lane
West Barnstable, MA
Owner: Robert Madonna
Date of Inspection: July 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 '/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 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 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.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 208 Carlson Lane
West Barnstable, MA
Owner: Robert Madonna
Date of Inspection: July 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?
✓ _ 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:
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)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 208 Carlson Lane
West Barnstable, MA
Owner: Robert Madonna
Date of Inspection: July 1, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 + Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 0
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): n1a [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)): Private well
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,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: Unavailable
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 8129191 -per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 208 Carlson Lane
West Barnstable, MA
Owner: Robert Madonna
Date of Inspection: July 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: 2'
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: 1500 Qal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 3"
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.):
Cement 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
Page 8 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 208 Carlson Lane
West Barnstable, MA
Owner: Robert Madonna
Date of Inspection: July 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: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level:above outlet invert: 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 and clean. 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.):
8
Page 9 of i l
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 208 Carlson Lane
West Barnstable, MA
Owner: Robert Madonna
Date of Inspection: July 1, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2-6'x 8'(1000 ag Q-per as built card
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 pits were dry. The scum lines were approximately Pup from the bottom. There did not appear to be any signs of failure. A
video camera was used for the inspection.
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.):
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: 208 Carlson Lane
West Barnstable M4
Owner: Robert Madonna
Date of Inspection: July 1. 2001
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.
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Page 11 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 208 Carlson Lane
West Barnstable, M4
Owner: Robert Madonna
Date of Inspection: July 1, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 50+ 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 g
you established the high round water elevation:
Y g
Using Barnstable topozraphic maps and water contours maps, the maps were showing approximately 50'+ 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 andlor this report.
�• TOWN OF BARNSTABLE
LOCATION ��'� / `� ./v A) 4n��r SEWAGE # T �
VILLAGEE ASSESSOR'S MAP & LOT 002D
INSTALLER'S NAME & PHONE NO. s�
i
SEPTIC TANK CAPACITY
'LEACHING FACILITY:(type)'�- (size)
--NO. ON BEDROOMS_ RIYATE SVELL R PUBLIC WATER
UILDER OR OWNER_0 - _hq
Y�
DATE PERMIT ISSUED: Q ) I
DATE COtiPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
Ny
7
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I'
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
7-C7'l.�l .------...OF....7 l'/r/�SI J4L9;�t-----------------------------------
Applira#ion for Disposal Works Tonstrudion Prrutit
Application is hereby made for a Permit to Construct (✓ -or Repair ( ) an Individual Sewage Disposal..
System at:
Location-Address or..
Lot No.
J.lJY._ �dn._...yo ... r1r� ..� 9 ............................................-.....
r
W Owne ��� �/� Address
.................... ........ ....__._. ..-4VY.......................................................................................
Address
v__ ds9
� Type of Building Size Lot... ................Sq. feet
Dwelling—No. of Bedrooms.....I..................................Expansion Attic Garbage Grinder �)
pa-, Other—Type of Building ................. No. of persons............................ Showers-(--j- — Cafeteria(- +
P4 Other fixtures
w Design Flow....Jr_�r.............................gallons per person per day. Total daily flow.__..._.`!Y.171 ..............--......gallons.
WSeptic Tank—Liquid capacitylz-5.-Pgallons Length../ . Width...,5 Diameter.___ .........
x Disposal Trench—No..................... Width_._ .............. Total Length..................... Total leaching area....................sq. ft.
Seepage Pit No.__07..�__.... Diameter.._....._._..... Depth below inlet....b........... Total leaching area.9 .sq.4t.c
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by._ ®`I' )-C.. JS................. Date.... �1 $ ............
Test Pit No. 1.....�.......minutes per inch Depth of Test Pit._f�........ Depth to ground water..../L- --------
(i Test Pit No. 2._.._Z--_-_minutes per inch Depth of Test Pit--- ....... Depth'to ground water---,Nt4.......
__-
9 --------•-------------------------------------------------•-----•....----•-----••......---------••-..........................................................
0 Description of Soil...N°.1....--- F'I v,4 ?.lL....��-/`l' L K� l p_.�'�� /J----------------
--------------------------
UNature of Repairs or Alterations—Answer when applicable................................_____...__..........___.._..__.._____..._...._..._.._...._._....
Agreement:
The undersigned agrees to install the aforedescribed Individual S age Disposal ystem in accordance with
the provisions of i ITL is S of the State Sanitary Code—The unders' ned ftvther agr not to place the system in
operation until a Certificate of Compliance has been i the bo r of li 1
Signed r
Date
Application Approved By----•---- -q ------------------------
Application
J V Date
Disapproved for the following reasons----------------•-----------...---...------...------------------------------------------•----• a.t.e-------------
` g� Date
PermitNo........,�./_.`. -52..... ............. Issued.-----..................................................
Date
It.
� ♦ t ,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�6(.c - OF.. ?q �✓l ul 04 --------------------------•--.-----
Appliratiun for Disposal Murk, Tonutrur#ion Prrmit
Application is hereby made for a>Permit to Construct (;,' or Repair ( ) an Individual Sewage Disposal
System at:
....................................
Location-Address / ��
_.IK4 rr ..._� l?:.1_V C}�� ? ._._..._orLotNo... .. --...._
W Owner Address
Installer a Address ...........................
� Type of Buildingr
g— �°< Size Lot__`'.`$e____:..........Sq. feet
aDwelling No. of Bedrooms......I....................................Expansion Attic Garbage Grinder { )
aOther—Type of Building .` .................. No. of persons............................ Showers--t-) — Cafeteria-{--�
Otherfixtures -------------......................................................................................................................................
W Design Flow.... n ................ ...........gallons per person per day. Total daily flow------- .......................gallons.
WSeptic Tank—Liquid capacity/?: __gallons Length. ,2........ Width...-5......... Diameter... ......... Depth-
x Disposal Trench—No..................... Width............. Total Length.._.......�....... Total leaching area....................sq. ft.
3 Seepage Pit No._�.Z7....)------- Diameter.....4_.......... Depth below inlet.... Total leaching area.9:5..`%-6._sq-'t!!?eP
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by_l_-.-U_2"'4.45SoeZ-1?S Date... //Z/e 5-..___....
Test Pit No. 1....�-_-_-_-minutes per inch Depth of Test Pit. ....... Depth to ground water---- -----_'4_..---._-
44 Test Pit No. 2... .....minutes per inch Depth of Test Pit._Z y`_---_--. Depth to ground water___,'..V.. ...........
P4 ---•-------------•-----------------------------...---------...------...-------...
O Description of Soil../'�4._- _........................` -7bF'f�C> l�_ ...
--•---. `!-----La,�l ,�s ,5�11�..__.%-5�. s� (v L....S':/s"
W
x -----------------------------------------------------------•--••---------------••--------------------•-•--------------•---------------------------------------•---•------------••------•--------..-•-•--
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
----------------------------•----------•---•---------------•------------------------.....--•---.--•-•---•-----•------------------•-----------------•---------•------•-------------------------......----
Agreement:
The undersigned agrees to install the aforedescribed Individual age Disposal ystem in accordance with
the provisions of iITT: 5. of the State Sanitary Code— The under 'gned f rther agr s not to place the system in
operation until a Certificate of Compliance has been ' the bo r of h It
Signe ----- . ....... -----.•. -. / ...I^ ... '•-
Date
Application Approved BY E - -+« - c�V--
Date
\ Application Disapproved for the following reasons----------------•-•-------------•----•------------------ :..�
--------------•------•-------------•----•----------•--------....--•------------------•--------•--•------------•-•-•-----•--------------------------------------•--•------------------..................
Date
Permit No......./9.L.312.,...................._ Issued........................................................ -
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
// g fly
Trrfifiratr of Tontplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( +/S or Repaired ( )
by................ ------ +✓ _ ------------------•-------------------------------------..................
. ------------•--
Installer
62!_�c--- t�-• ----7�L/ :r to I/�,��vS
has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the
application for Disposal Works C nstruction Permit No.___,1:... ._ .',......... dated-......... ....................................
THE ISSUANCE OF THI CE TIFICATE SHALL NOT BE CONS D A ANTEE THAT THE
SYSTEM WILL FUNCTIO 1 OILY.
DATE... ----------------
Inspector_.. -----.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.../..l..i,?-a.?, .......
. ........C:.....ti........oF.A.... . .Lf-=........................
FEE../Q.Q...........
Dispoo Works Tontrnr�ion rrntit
Permission is hereby granted............--- -- --------- !� =� ----"=.........................................................
to Construct �) or Re air ( ) an I ividual Sewage Disposal S stem
at No.......................�-o�rl -----ea*.� - s ------•------
Street
as shown on the application f /Diosal Works Construction Permit N4. .� .... Dated.... ..... .........................
.................................A ------------..._Board of Health
DATE-------•-----------------•----- •- ---FORM 1255 HOBBS & WARREN• PUBLISHERS
-'p
r
0 90 2 2 3 13 5 13 POLAROTDO 6"
No...1951�I.P.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
XWN....................._OF..... ................................................
App iratiou for Ui"ooal Works Tontrnrtion Famit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: p
....-. -L oT /'� C..4-Q•C..o!V .riN e ...__ S1?RF.(5l1...._r"5.......-----•---•-•----•--------------------
•• ocation-Address or Lot No.
......................shl. ._.r-.....I.-C..---------- .......l<T-_/.34 �KN.L .............•----.....---
Owner LAdl ess
.gl!... ,1✓ .--•---------------------------------•--------•-•-. --.....���! ��?-/. y..----��'� / c •-•---------------------
Installer / Address
dType of Building Size Lot...43.6_,5`�__.-Sq. feet
Dwelling—No. of Bedrooms........A&1�......................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type of Building No. of persons............................ Showers — Cafeteria
P., Other fixtures .............................. ..
W Design Flow........../_/0..........................gallons per person per day. Total daily flow------44.0...........................gallons.
rr
WSeptic Tank—Liquid capacity)-FO..gallons Length----./O...... Width-----5-.i „........ Diameter................ Depth_ _r- .....
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......Z-.-_-__.... Diameter.._.... ........ Depth below inlet.._...9.......... Total leaching area---..�A2.sq. ft.
Z Other Distribution box (x) Dosing tank ( ) /loS EFFEU-1
aPercolation Test Results Performed by....... ...._ OVIC7,(4EfEC/.K__q........ Date....4-/Z�495
Test Pit No. 1---4-2 -minutes per inch Depth of Test Pit.....1(4......... Depth to ground water.K164C._&.JC0VNTEAED
fz, Test Pit No. 2................minutes per inch Depth of Test Pit-----1.4........ Depth to ground waterVOWC.F-N�'uionlTCe-f'O
................-...........................................................................................................................................
O Description of Soil.........#1.........0 50ASPLL......................1Z.....---6:n 4...-(-0ht''I��Ut�o��-------------------
v -------------------------•--••-•---•--....---------3_1'¢....-h4eV.,.54iVV----••-------- ..............4-5......Cv."moE'7L..............................
W ••••---------------•-........------•-----••-••------------------•--•--------------------•--•-----•---•--• ------------------------ --
UNature of Repairs or Alterations—Answer when applicable______________________________________•---.-___-______-________-__-___-_________•-•_-.-----•--.
-•-------------------------•----...............-•---------•-•----•-•---------------•.....-•-•••••....-•-.....--------------•----•---•---------•-----••---•--------•---•-----•......----••---•-•••--••-•-
Agreement:
The undersigned agrees to install the aforedesc ndividual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary o — e undersi ther agrees not to place the system in
operation until a Certificate of Compliance has been ' s b the d o ealt
Signed. `.......................�.,--.--- -- ._......
-- � Date
Application Approved By............. -•-•--••• `.�
Date
Application Disapproved for the following re ons:-----•-•••••••------••---------------------------------------••-••--------•---------•........................
---------------------------------------------- ------------------•-------.............-----•---........--...................................................................... Date
Permit No....... $•--4 4-0 Issued- - - ......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Trrtifiratr of Tomplianre ,
✓. TICS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
f/ S�o Installer
at...40.7..... �4..---... 1P.C4 P. ...........Liwif--------------•---•-------•--•------------•--••---•--•----•-•---------------•---•-•.._..--•----------•--
has been installed in accordance with the provisions of TITLE, 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----------------------------------------- dated__............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
FEB 50
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
....::.... .................OF............................_..........-----
Appliration fur Diipn,al Works Tonotr irtinn rantit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address or Lot No.
......................--.......................................................................... ---------._.._..-•---•--•-............•---....._._....••-•-..........._.._............•-•-•---•---
Owner Address
W
Installer Address
UType of Building Size Lot............................Sq. feet!
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder
'k Other—T e of Building ____________________________ No. of persons._.___.__._.____.___________ Showers Cafeteria
Otherfixtures -------------------------------------------------------•-•----•----•--------•-------•-------•---•----•-----•---•----•••---•-•------•-....__....----
W Design Flow___..........._.............................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity______:::__gallons Length................ Width---------------- Diameter---------------- Depth................
x Disposal Trench—No_ ____________________ Width-------------------- Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( -) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date......................----------------
Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
<s, Test Pit No. 2.................minutes per "inch Depth of Test Pit.................... Depth'to ground water........................
P4 •-•-••-•--•--•-•-------------------- = --------------------•----------------•---••--••-•-•-•----......==-•----•-..........-•----------............-•------
0 Description of Soil----------------------------------••----•---------._...-----•--...-•--------------•--•------•---•----•...----------•-=---•-•-•-----•--•-•------------•-------------•--
"�
V _;
W
-------------------------------------------------------------------------------------------------------------------------
--------------
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
.. ... ....• ------•-•-•-•-----•---••--------•...................................
Agreement:
The undersigned agrees to install the aforedescr' dividual Sewage Disposal System in accordance with
the provisions of TITLE, 5 of the State Sanitary od — e undersi -ther agrees not to place the system in
operation until a Certificate of Compliance has been ' s y the o ealt�
t
Signed- _ ...... ----•-------------•--- .
Date
ApplicationApproved By---•---•--------------•••-•----•--• -• -- ------•-•------•---•--•••-••----•----------- ----R-VS
Date
Application Disapproved for the following re ns:---••---•-------••-•----•----•--•--••-----------•••--------•-----•-•-----------••---•-•-•---•---------------•---
..............................-•-•--•• ----••---•-••---------•---••-------•••. ------•------•------- - ------••--• ---•---------
y Date
Permit No.._... S ¢ - Issued:.' ��
''Date
THE COMMONWEALTH OF MASSACHUSETTS,"'
BOARD OF HEALTH
F..... ............
Trtfifiratr of "Toutplianr
TH IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ------------•----------------------------------------------------------------------------------'--------....--
Installer
at....4-d_7-......4-6Y--.........C-t9A4,SD_1_y...........-A4074vit-----------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in"the
application for Disposal Works Construction Permit No_________________________________________ dated................................................
THE ISSUANCE .OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL,-FUNCTION SATISFACTORY.
DATE............... ............................................. Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-C
..r. . FEE..__._....'
Dispoli l Warkii 01nnitrnrtion Virrmit
Permission is hereby granted..........
A` "If?/�f�/`r"jllDfl�
to Construct ( or Repair ( ) an Individual Sewage Disposal System
atNo.. y...... _sty,Cpl?r..... <.3� ....................................................-----------------•------------•--------------------------..__.............
�.4 Street
as sh-ow s on the application for Disposal Works Construction Permit No.., d �� .... �15
S-4g _ ._. _ .. ......
..........................--
Zi
Cad of Health
•
DATE.... ............
f
FORM 1255 HOBS & WARREN. INC., PUBLISHERS
sue. r
Massachusetts Water Resources Commission/Divi'sio urces
WXTER WELL COMPLETION 'REPORT
WELL LOCATION
Address �L,�
City/Town e( ,%& nc
G.S.Quadrangle Map
Grid Location
Owner
Address
LL USE CONSOLIDATED WELL
Domestic Public ❑ Industrial ❑
Type of Water-bearing Rock
Other Water-bearing Zones
METHOD DRILLED 1) From To
Rotary(type) Cable ❑ 2) From To
Other 3) From To
4) From To
CASING /� Depth to Bedrock
Length_Diameter
Type. UNCONSOLIDATED WELL
STATIC WATER LEVEL Water-bearing Materials
Feet below land surf ce—A Sand: fine❑ medium❑ coarse❑
Date measured q& Gravel: fine❑ medium coarse❑
GRAVEL PACK WELL Screen: 7�L
Yes No ❑
Slot length from0to
❑
Split Screen(or 2nd screen)
WATER QSJALITY TESTS MADfK Slot>f length from to
Chemical Bioloqical u/ Depth To Bedrock
PUMP TEST
Drawdown feet after pumping days hours at&6GPM.
How measured Recovery feet after hours.
LOG of FORMATIONS COMMENTS: (On well or water)
Materials From To
0
DRILLER
Firm
Address \
City
Registration I o.
t Operator's Signat
Please print firmly
1 OM-8/81.164843
e
SHEET 1 OF 2
7 .
s
�o .
EXIST.
96 X WELL
LOT 13 98
(VACANT) I O T 1 4- e X o
43,659 S.F. 95 X 9
X3
N
91X4 95X7
r o +
57' 93 X 6 16 <<
91 X 1
B,Q,yy' 1444 ,s (R�
Y� 2 R
90 x 1 se X 7 oF�� 6 D. BOX C.B. fn d
♦o �y��- 27' 21' ZO �.
�� �' C.B. fnd
O °pv° ' +- O
1250 GAL. PREC. CONC. SEPTIC TA
89X9 � � 6 n �..
279.1 s
\ N CD
S
\ 7 X 3 2 6'-0" X 8'-0" EFF. DEPTH LEACHING
PITS W/ 1-O" OF STONE ALL AROUND
\ LOT 15 O
I m
r
O
NOTE: TOPOGRAPHY TAKEN FROM A SITE AND SEWER PLAN
FOR BODEFISH MARKETING INC. DA TED 4125185 „ p, „
BY DOYLE ASSOCIATES — - - - -- - SI TE CMG SEWER PLAN
FOR
WILLIA c\ ,
W RI CHARD JO Y
4 L 0 T 14 CARLSON LANE
0
BA RNS TA BL E, MASS.
PROFESSIONAL LAND SURVEYOR
ZONE: OF Scale: 1 "=40' Date: 8127191
ASSESSORS MAP: 133
BENCHMARK DATUM: SEE NOTE
FLOOD ZONE: NON—HAZARD "C" Wm. M. Warwick & Assoc. Inc.
Panel No: 250001 0011 C
PLAN REF.• PLAN BOOK 389 PAGE 5 213 0/d Main Road Box 801
WA TER SOURCE. WELL North Falmouth, Mass 02556
(508) 563 — 7777
'DISC. JOY JOB. 1 'DWG.• "JOYSS" BY- GSL
r • '
�Sr ,
TYPICAL SYSTEM PROFILE SHEET 2 of 2
21'CONE. MANIf01E C'OVFP WAIFRITWIT
1 ST. FL. OR C.I. rRAMr& (,OVER IF PAVEV r.C.
BY IANR RI5ER(S) OR(TRICK &MORTAR mil/ D
COURSES AS ROD. r0 RRING 70 CRADr. y
nNISIf r.RADE
4 PVC sch.90
_ r10w UNE sch.e0 4 P VC
sc/1,40 4'�VC
bb 7Ff - - - - - _ Q - --
t C7�O RUD. ,.H_ .• 7 E• ._
1 — r10w UNE
; •••••�
LOADING
U-BOX e70 ;
SEPTIC TANIt •••• LOADING '•'
:.<....... ...•.
.:........ .....
.......... GAL. ............
NOTE: FOUNOAPONTOBf •••••••••• '•••••.•••
DESIGNED BY 07HERS. SET TIC TANK &D-BOV TO OE .... '•.••••.•.
INSTALLED ON A LEVEE, SIAG7:E BA5r. 24"CONC. MANIIOI E COVER WATERRGHr ':••••• LEACH BASIN •"••'
or, r.� I NAME &COVER Ir PAVED I:G. :i..• •••••.
BY IANI(RISLR(s) OR PRIC/C &MORTAR �'7�1 p �•...•. ":;......
LEACH BASIN SECTION '•
-/ GOIpi.SE'S AS POD. 70 IIRINC TO GRADE.
NOW: MUSr DE' TO rrAsr IF'Or.SIGN """•"
ErltllMr IS > THAN 2000 C.P.D. •'
I Ih7SN CRADE'
Al
dd �Qm
_ — .... / �� Al 3O~
— nuw LINE — 2" OF 118 TO 112" _
WASHED PEASIONE, -
FREE OF IRONS, FINES, &
�DUST IN PLACE
9.0 &'b
"SPECIAL NOTES"
3/4" TO 1 112" CLEAN
WASHED CRUSHED STONC �Z � 6 PIA 711N6
FREE OF IRONS FINES, &
LEVEL BASE DUST IN PLACC. ��
J FT 6 FT. I I F7
8 FT.
ErrfGPVF CIAMUER
(Nor TO EXCEED J TIMES CEPfCRVF DEPTH)
GENERAL CONSTRUCTION NOTES
SEPTIC TANK, DISTRIBUTION BOX, & LEACH BASIN TO BE "ACME" STD. PRECAST REINFORCED CONCRETE UNITS
OR EQUAL.. CONCRETE: 5000 P.I.S. 28 DAYS, STEEL: AST44--A• 615-68 GRADE 60. H-10 LOADING UNLESS NOTED.
ALL SEWER LINES TO BE 4" P. V.C. SCH. 40 PIPES, GLUED JOINTS, INVERTS TO CONCRETE TO BE PARGEO &
WATER TIGHT. MINIMUM PIPE PITCH TO LEACHING UNIT: I/4"/FT UNLESS INDICATED OTHERWISE. A
ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE TO THE STATE ENVIRONMENTAL CODE, TITLE V,
THE MIN/MUM REQUIREMENTS FOR THE CONSTRUCTION, SUBSURFACE'
TO BACK FILLING, OFOTHE BOARD OF SANITARY
SEWAGE EFFECTIVE
AT COMPLETION OF CONSTOF HEALTH SHALL BE NOTIFIED FOR AN
INSPECTION. ( WM. M. WARWICK & ASSOC. INC. TO BE NOTIFIED IN SOME TOWNS.)
ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH & WM. M. WARWICK & ASSOC. INC.
SOIL & PERCOLATION DATA TEST PIT # 1 TEST PIT # 12
U
EL. 0, EL.
PERC. RATE: Z MIN,/IN. Lds `; �Sve>S0 6 v
41
3, •� G,4ii VEL 85.
TEST PIT ELEV.: D•� PERC. UEPTII,
�L Iyg0
DA TE. ��Z �85 /�, D 519/vp
TEST BY. Y�OG �JSSG�i�l TES
WITNESSED B Y.•
HEA L TH A GEN T, B.0,H. EL y EL.. 76•b
DESIGN DATA GROUND WATER WAS ZVO ENCOUNTERED AT A DEPTH OFIFT.
NUMBER OF BEDROOMS:
GARBAGE DISPOSAL:
EST. TOTAL DAIL Y EFFLUENT 9`�'D GPD. " SITE �c SEWER PLAN "
SEPTIC TANK REQUIRED: Z60 GAL. FOR
SEPTIC TANK PROVIDED: /Z 50 GAL. 141 ,Ij41�7p O
SIDEWALL AREA Z• GAL./SQ.FT: L OT ,i�'L.S01V L A A 1,r—
BOTTOM AREA / GAL./SQ.FT. ����J�7', L, f/;),a
77_ 0
---- Scale: As Shown Da t e: f IZ-71y/
_.- � �E„ Warwick & Assoc. Inc.
'� 'OF
213 Old Main Road Box 801
E.
V North Falmouth, Mass 02556
3417 q
D�r�S/O rrAL a�' (608) 563 - 2638
SAIL LOG
N0. 2SITE PLAN
i
" S✓G_sod L. Z .{ ✓o
3
4 --- - - Ez R 1
S
TOP Or FOUNDATION El.:
7
- .... Mcv✓M
Mevit/M
I N.E t. �_ - Mi,►/. /' CovFe 10 IN D
IN.Et f8.4 l IN.Et. aa, —._ 2'. Ccvre /�8 -�%g' V/A NiE0 S1ewF 11
IN.EtB.s J IN.Et. ��� !��— 8G ? 25
016 W/ sump e ° c a o
4' LIQUID LEVEL Y . • ° ' �� T4 7 1 3 i �L 7
.► iv.14
w,+�a
• $'Err
• - c 1 ° O f• t �o Y vi1K CNGUN7 r - 15
�,��c�; EA'N/wry r/ems PERC TEST RESULTS
PRECAST SEPTIC TANK WITH � _� . _... ___ PERC RATE :
� Z
�`" �T lvC tf
i CAST tiN PIAC_ :IyLET AND -ra _:�_._ _._ _ ' ° ' ,ve, z_ � zC G'°,,• " � �,F r •�
E •, n- , „. ,a . AA-v-A.0 WHITNESSED IT:
OUTLET T 'S PER TITLEC 'S ' BOARD OF HEALTH
�. -- • . �. : _ HBO R T
SIZE . _ : DATE: --- -
x
s�3
PROFILE OF PROPOSED SEWAGE SYSTEM
SYSTEM DES16NEu' SiTHE TOWN OF RE61ILATIONS AND
STATE TITLE Y FOR SUBSURFACE DISPOSAE, OF SEWANE . SCALE
2101
< -13 GS9 5F LGT /3 - Y•^ E
1. ALL PiFE SiiALI 6L SCNEBYLE 48 P.Y.C. SEWER PIPE
PER FOOT
2. ALL PIPES SMALL BE S LIFE B 4y EXCEPT FOR -
�.
THE FIRST 2 FEET OUT Or THE 1 ; R WHICH SHALL BE LEVEL p67
3. DESIGN! FLOW CC UACitS b I GALDAY PER 6R. 4� GAL- A - �`� x a�
G'Q�� D�sT. O
SEPTIC TANK SIZE X SAL, ��'<25. � 91-4
`
USE i_. 6 AL. W l oc�r 1ARBAll DISPOSAL
LEACNiN6 SYSTFM US' T1.
P/Ts W/ ILO^ GF 570MI 04-iL Jrli:'4Li..ji
Pg.�
EFFECTIVE AiEa /�- � � . s . _ „a :-� ;,.�/"�� Q / 'PILO
7- //' > 4>' y I.G� _ U=J I.i f. - • . (''y
TOTAL FL-DW____.
IOTA l R T�i °D FLOW X 446 Wl GARBAGE DISPOSAL.
RP.0 9
x �S-7 95
AESERVE GAL/BAY
c ti
77,
REFERENCE PLANS : _' � �j`N �� s362
APPROVED R Y , _
BOARO OF HEALTH � 33
PRE ERTY OWNER _ : , .t � �-r, .z,��. 1
FOR
:t, + BEOAOC V' SINGLE ;* DAILY DWELLING
S k06E8T �1 u
++
ASSO�i� �ES A. LMOUTH , MAS
S ,
.
_DO _ __