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HomeMy WebLinkAbout0044 CINDERELLA TERRACE - Health 44 CINDERELLA TERRACE A- 04 -120 • yMaxstons Mills k i _,-,. -� ,; t Commonwealth of Massachusetts W% F Title 5 Official Inspection Form ` I_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 400 �M 44 Cinderella Terrace Property Address -� Marc Verkade Owner Owner's Name / information is Marston Mills MA 02648 June 5, 20,1-5 required for every _ — page. Cityffown State Zip Code Date of Inspection c , Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information O on the computer, C.�C✓ use only the tab 1. Inspector: key to move your cursor-do not Patrick T. Sullivan use the return Name of Inspector key. Ready Rooter Excavating Company Name _P.O. Box 89 Company Address Forestdale _ MA 02644 City/Town State Zip Code 508-888-6055 S112843 Telephone Number License Number B. Certification 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority _ June 12, 2015 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 or 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Cinderella Terrace _ Property Address Marc Verkade Owner Owner's Name information is Marston Mills MA 02648 June 5, 2015 required for every — _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y,N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced witch/a complying septic tank as approved by the Board of Health. /' * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is/less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Cinderella Terrace Property Address Marc Verkade Owner Owner's Name information is Marston Mills MA 02648 June 5, 2015 required for every . page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber,pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or higp static water level in the distribution box due to broken or obstructed pipe(s) or due to a broke , settled or uneven distribution box. System will pass inspection if(with approval of Board of H Ith): ❑ broken pipe(s) are replaced ❑ Y ❑ N El ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or r placed ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required byZeh d of Health: ❑ Conditions exist which require furthon by the Board of Health in order to determine if the system is failing to protect publicafety or the environment. 1. System will pass unless Board determines in accordance with 310 CMR 15.303(1)(b)that the system is n ing in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is w' in 50 feet of a surface water ❑ Cesspool or privy is/within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 / Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Cinderella Terrace _ Property Address Marc Verkade _ Owner Owner's Name information is required for every Marston Mills MA_ 02648 June 5, 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soi absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tri utary to a surface water supply. ❑ The system has a septic tank and AS 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 d SAS and the SAS is less than 100 feet but 50 feet or more from a private water su ply well**. Method used to determine stance: " This system passes if th well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicate absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, p vided that no other failure criteria are triggered. A copy of the analysis must be attached to this for 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® 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 1/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form m' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Cinderella Terrace Property Address Marc Verkade Owner Owner's Name information is required for every Marston Mills MA 02648 June 5, 2015 .— page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is�iithin /in400 feet of a surface drinking water supply ❑ ❑ the syXtDabove tem is 200 feet of a tributary to a surface drinking water supply ❑ ❑ the sylocated in a nitrogen sensitive area (Interim Wellhead Protection Area or a mapped Zone II of a public water supply well If you have answered "yes" uestion in Section E the system is considered a significant threat, or answered "yes" in Sectio 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Cinderella Terrace Property Address Marc Verkade Owner Owner's Name information is Marston Mills MA 02648 June 5, 2015 required for every _ ________._ page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 333 GPD t5i s 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Cinderella Terrace Property Address Marc Verkade Owner Owner's Name information is required for every Marston Mills MA 02648 June 5, 2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2013= 123 GPD g ( y g (gp )) 2014= 162 GPD_ Detail.- Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate Commercial/Industrial Flow Conditions: Type of Establishment: — ;7 Design flow (based on 310 CMR 15.203)— Gallons per day(gpd) Basis of design flow (seats/persons/sq. ., etc.): - -- — Grease trap present? ❑ Yes ❑ No Industrial waste holding tank pre nt? ❑ Yes ❑ No Non-sanitary waste discharge to the Title 5 system? El El No Water meter readings, if available: 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 IIN Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 44 Cinderella Terrace Property Address Marc_V_erkade Owner Owner's Name information is required for every Marston Mills MA 02648 June 5, 2015 —_--- page. City(Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Read Rooter records: Pumped Nov. 2013 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? — Reason for pumping: - Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Cinderella Terrace Property Address Marc Verkade Owner Owner's Name information is required for every Marston Mills MA 02648 June 5, 2015 - _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Septic tank installed 1983. D-box and leach fiels installed Oct. 12, 2007. Certificates of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): - Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 5" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: -- - years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions- 8.5' X 4.5'X 5' 1000 galons 1" Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Cinderella Terrace _ Property Address Marc Verk_ade Owner Owner's Name information is Marston Mills MA 02648 June 5, 2015 required for every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 33 Scum thickness 1" at inlet .5"at outlet 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 14 How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet concrete baffle and outlet PVC tee in place. Liquid level at outlet invert. Pumping not needed at time of inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ Iberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form `4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Cinderella Terrace Property Address -- -- Marc Verkade _ Owner Owner's Name information is Mrston Mills MA _0 required for every —a 2648 June 5, 2015_ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal / fiberglass ❑ polyethylene ❑ other(explain): Dimensions: — Capacity: gallons Design Flow: — gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Cinderella Terrace Property Address Marc Verkade Owner Owner's Name information is Marston Mills _ MA _ 02648 June 5, 2_015 required for every _ page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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.): One inlet, three outlets w/speed levelers in place. Very light solids carryover. No high water staining over outlet inverts. Riser brings cover within 10" of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamb , condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: L15,ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Cinderella Terrace Property Address Marc Verkade _ Owner Owner's Name information is required for every Marston Mills _ _ MA 02648 June 5, 2015 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: — ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1-30' x15' x6" ❑ 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.): SAS located and inspected with camera. SAS has 3 lateral lines in a stone field. No sign of standing water in Imes at time of inspection. No sign of past hydraulic failure. All lines tied into vent at end of system. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System For -9 p y m Not for Voluntary Assessments a. 44 Cinderella Terrace Property Address — -- Marc Verkade Owner Owner's Name - — information is required for every Marston Mills MA 02648 June 5, 2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids -- Comments (note condition of soil/, igns of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 44 Cinderella Terrace Property Address Marc Verkade Owner Owner's Name information is required for every Marston Mills MA 02648 June 5, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below_ ® hand-sketch in the area below ❑ drawing attached separately I V 7 � 1 i �i o `3 a = 3 4 0 a / t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Cinderella Terrace Property Address Marc Verkade Owner Owner's Name information is required for every Marston Mills _ MA _ 02648 June 5, 2015 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >5feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record _ If checked, date of design plan reviewed: 09/24/2007Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database-explain: mays_massgis.state.ma.us/oliver.php You must describe how you established the high ground water elevation: Test hole in 2007 to 10' (elv= 83.5) found no ground water. Base of SAS at elv= 88.5 per engineered plans. Slope to East of property drops below base of SAS. Accessed local ground water contours and topo mapping. No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �,. 44 Cinderella Terrace Property Address Marc Verkade Owner Owner's Name information is Marston Mills MA 02648 June 5, 2015 required for every M _ page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Town of Barnstable P# Department of Regulatory Services Public Health Division Date r" •63A �� s�� r ,'1 00 M�in'itreet,Hyannis MA 02' Date Scheduled "'��//» ' % imef Fee Pd." Soil Suituh : sty Assessment for Sewage Disposal Performed By: JALu'J C, �-c.li R•S, S,t� Witnessed By: D.2#ymA t� i(pp.AJt1 LOCATION& GENERAL INFORMATION, Location Addressst ' , /___. / I Owner's Name V h h0 W n y. l.l Y� tre tk K M c e—, A , Address f ore c oso re— Assessor's Map/ParceL• 04/7 /2p Engineer's Name ��C. E l li 5 t�r NEW CONSTRUCTION REPAIR Telephone# 0 385 aaa Land Use fit.: Slopes M S�lOX Surface Stones _ j Distances from: Open Water Body 04 ft Possible Wet Area N ft Drinking Water Well 0-0—4 ft _ Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) C tN D�ReZv+, �7t JLA cct' 13 Z.s'9 -67 iMBLE 12: 33 13V Parent material(geologic) IMmkA-C' 'Si0N___��" � � ) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: N 1/� Weeping from Pit Face N �h Estimated Seasonal High Groundwater "Z.0 '} DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level..a Adj.factor- Adj.Groundwater Level,,.e Observation PERCOLATION TEST Dide Time I o1uc Hole# '� Time at 4" Depth of Perc Time at 6" Start Pre-soak Time @ 01.00 15me(9"-6") End Pre-soak 1.I:00 Rate Min./Inch Site Suitability Assessment: Site Passed_,� Site Failed: Additional Testing Needed(Y/N) AJ Original Public Health Division Observation Hole Data To Be Completed on Back----------- ' ***If percolation test is to be conducted within 100' of wetland,you must first notify the, Barnstable Conseli'vation Division at least one(1)week prior to beginning. Q:ISEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# 1 Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. n istenGravel) Z.o ' CF Fist �,�st_ `1.3 g ara l o A. 9"/L C_ N��c SAID l �512 6�6 Lao S DEEP OBSERVATION HOLE LOG _ Hole# Depth from Soil Horizon. Soil Texture Soil Color Soil Other r Surface(in_) (USDA) (Munsell) Mottling (Structure,Stones,-Boulders. r I ) onsi ten %Gravel) . N 3.O- 13 C,os>ti 4,-,iN 10 14tv54 „✓— !Ow' C_ l� Sa: 104rt.6/ C.o�sP r DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) Mottling (Structure,Stones,Boulders. } _ _ Consistencv.%Gravel) , I DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil F Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. a .r Flood Insurance Rate Map: •, Above 500 year flood boundary No— Yes i Within 500 year boundary No x Yes ' Within 100 year flood boundary No x Yes ( Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? YIF1 If not,what is the depth of naturally occurring pervious material? Certification I certify that on d (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required traini pertise and experience described in 310 CMR 15.017. z Signature Date 7 �LAe( Q:\.SEPTICIPERCFORM. J �„� CL/—,% S•�. TOWN OF BARNSTABLE LOCATION `kA_ Z M SEWAGE# VILLAGE V\As ; i I C_, ASSESSOR'S MAP&PARCEL(rY=70 I]V�'S NAME&PHONE NO. )y SEPTIC TANK CAPACITY LEACHING FACILITY:(type)(. C te, (size) x �� x G NO.OF BEDROOMS OWNER T_y_\.4J- G PERMIT DATE: COMPLIANCE DATE: b CS Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) / Feet FURNISHED BY i V tys i 3 j 1 � A � � 6 " � o 0 TOWN OF BARNSTABLE V LOCATION ���-�ZrX �L C SEWAGE# ' VILLAGE yjjf ��SSESS.OR'S MAP&PARCELr9T I INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY 1490 LEACHING FACILITY:(type) 5,8o / L (size) /t NO.OF BEDROOMS _ A OWNED_ PERMIT DATE: COMPLIANCE DATE:.: Separation.Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �'� Po 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 facili ) "Feet FURNISHED BY ' 1 _� � � � � � v _ A , � _ . �„� .- t . , µ ., .. ., �- 7 � t � ., a..,' t Aas �dO9�a / A �. � -. � L , �. �� � � « � 1 Fee _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,-MASSACHUSETTS Yes pplicatton for -�Miqoal 6p!5tem Cougtructfon Permit Application for a Permit to Construct O Repair(L< Upgrade O Abandon O ❑.Complete System ❑Individual Components Location Address or Lot No. 1_,(* t Owner's Name,Address,and Tel.No 4Co► 11 L-1)Q ?&r j Assessor's Map/Parcel g-' ��� " ��y� _ ®A.z 1i V o%tv r ,)& _TT; jw I taller's N e,Address and Tel No. % 5.n 51 "' Designer's Name,Address and Tel.No. N v t 0�N;. -' r V,"2 5 t�,QS1 4 tea 191.1 611,LR M O—J4 6;' 1 S N �P acr QnWA� 0-3-c 3 f Type of Building: Dwelling No.of Bedrooms Lot Size :),oil 10.X sq. ft. Garbage Grinder ( ) Other Type of Buildings IV.91 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 3 3-3 gpd Plan Date Number of sheets t Revision Date /tom-A •e�) Title y Size of Septic Tank i 'geloy E-1 Ci35i N e: Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) /, C.� C 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 Bo o alt4. Signed -� Date Application Approved by- DMAK Date 2 Application Disapproved by: Date for the following reasons Permit No. aO 0� ` W Date Issued Z _ _A . . ,. •/�� V r,W Fee 300. _ THE,COMMONWEALTH OF.AMASSACHUSETTS Entered in computer: PUBLIC kLEAL�TH DIVISION - TOWN OF BARNSTABLE;-MASSACHUSETTS Yes ZIpplication for �DiOpo5al 6p5tem CoYCg ruction Permit Application for a Permit to Construct( ) Repair(Lo< Upgrade( ) Abandon( ) ❑.Complete System Individual Components Location Address or Lot No. 60 Owner's Name,Address;and Tel.No.co C' 4 7 IT yy i do ✓e lla T-t y✓ c-�t � ,,� a�e �. s�►revs xWc Assessor's Map/Parcel V,'7 PCL. I Id ' %� IN 1 0 AT 14 e O%A T 'A, . V I i taller's N e,Add I� ress and Tel.No. �.37 S W-1 Designer's Name,Address and Tel.No. A v l � � O% i;1,14, 69,Lrma 4% Deb 53 Bm ;a 1 S a ti Pw► �c 3 t . Type of Building: _ Dwelling No.of Bedrooms Lot Size'' a O! I0')6 sq.ft. Garbage Grinder ( ) Other Type of Building 4w"go No.of Persons Showers( ) Cafeteria( ) Other Fixtures f Design Flow(min.required) 4 to '` gpd Design flow-provided 3 gpd u Plan Date - pR d"7 Number of sheets Revision l6ate /b-A •67 !Title F y Size of Septic TaStk_ '• vqaL, &(.C1S�iN C Type of S.A.S. Description of Soil { L'-i Nature of Repairs or Alt'e"rationsv($An wer whlehfd�olicable) X Date last inspected: = t , Agreement: The undersigned agrees to ensure the construction'and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of . Compliance has been issued by this Bo 75valtb. � � s ' Signed � Date � C5 Application Approved by `'°�., Date Application Disapproved by: Date for the following reasons ) - P&rmitNo. �(� 4W f Date Isgued Z THE'COMMONWEALTH OF MASSACHUSETTS J •, BARNSTABLE, MASSACHUSETTS Certificate of (Compliance r THIS IS TO CER -tat the si a Sew ge a isposal System Constructed ( Repaired ( ) Upgraded ( ) Abandoned( )by rh `at L/ ri h K tom. Ina &00 has been constructed in accordance " b / . L with the provisions of Title 5 and the for Disposal Syst inConstruction Permit No. dated` �� dated Installer Designer ' y' #bedrooms Approved design flows The issuance of this permit hall n be construed as a guarantee that the system i�ction as de _n O G Date Inspector l;/, —————————————— ————THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS �Di5pogal 6p5tem Construction Permit Permission is hereby granted ted to Construct ( ) Repair (� Upgrade ( ) Abandon System located at l l: L /, G Ae, L and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Con tructi n must be completed within three years of the date of thi Date Approved by Town of Barnstable °FT"ETOh' Regulatory Services Thomas F. Geiler,Director w BARNSrABLE. 9�A 6 9 �0� Public Health Division 'Ft639. ° Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Dater dZj Sewage Permit#o��D - W Assessor's Map\Parcel PC� `�® Designer: -+1� �E$iCj/@� Installer: 0 Address: Gv,�- ��`�� Address: On was issued a permit to install a (date) (installer) septic system at LA 0�k4 j�,L jjkWbased on a design drawn by (address) L 1S V'96�L� dated C"::T (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 and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if required) was inspected and the soils were found satisfactory. H G � OF Pf,y�S�C o� JASON (Installer's Signature) o� CHRISTOPHER ELLIS U) No. 1126 n GISTER�o l`l• E S S'INITAR\N gne ' ature) (Affix Desigrer"'s Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 03-09-06.doc C f���-�LLd� �j=�-P-P�C�`y _ �917 J r t A13 AA LLA l5' Coo J.C: ELLIS DESIGN COMPANY INC. SEPTIC SYSTEM DESIGN&ENGINEERING—SEPTIC INSPECTION— SITE PLANNING—WETLAND CONSVLTATION&PERMITTING P.O.BOX 2152,BREWSTER,MA 02631 PHONE 508-385-2228 FAX 508-385-2328 EMAIL jcellisdesign@verizon.net Certificate Of Compliance October 12, 2007 Barnstable Board of Health Barnstable Town Offices 200 Main Street Hyannis, MA 02601 Dear Board, An inspection was performed of the newly constructed septic system at: #44 Cinderella Terrace,Marstons Mills Map 47 Pcl. 120 and it has been determined that this system substantially meets the requirements as set forth in 310 CMR 15.000(Title 5) and the Orleans Board of Health Regulations. An� .S. J.C. Ellis Design Co.,Inc. A THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) (�Y� L IMA DATA ®•U - . . . i of Barnstable ru flatory Services F. Geiler,Director p Postage $ I \�� p Certifted Fee Health Division p Return Receipt Fee �"z P° (Endorsement Required) - Her.. as McKean,.Director p y Restricted Delivery Fee �, itreet, Hyannis,MA 02601 ra (Endorsement Required) Total Postage&Fees $ ,�, ui Fax: 508-790-6304 0 Seto , p -et A�°WE -- orPoBox to O, 30 �3 �`"srare,a �A Compass Realty Dev. Corp P O Box 2384 Mashpee, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located at 44 Cinderella Terrace,l UM11Y e, MA was last inspected November 14th.2006 by Michael Dedecko, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system"Fails"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: System is in hydraulic failure. You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALT DEPARTMENT Thomas A. McKean,R.S., C.H.O. Agent of the Board of Health Town of Barnstable �O*IHE. Regulatory Services snxwsrns Thomas.F. Geiler,Director �$A 039. •� Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 January 10 2007 Ms Hiedi M. Harnois c/o Wells Fargo Compass Realty Dev. Corp P O Box 2384 Mashpee,MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located at 44 Cinderella Terrace,NU&JR2e, MA was last inspected November 14th 2006 by Michael Dedecko, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system"Fails"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: System is in hydraulic failure. You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALT DEPARTMENT Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M ,•.°°• 44 CINDERELLA TERRACE Property Address WELLS FARGO Owner Owner's Name information is required for MARSTONS MILLS MA 11/14/06 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. III Im rtant: When filling out �° A. General Information I_ forms on the 1 computer,use 1. Inspector: only the tab key to move your MICHAEL DEDECKO cursor-do not Name of Inspector use the return key. COMPASS REALTY DEV. CORP Company Name +� P.O. BOX 2384 Company Address MASHPEE MA 02649 City/Town State Zip Code 508 221-5003 Telephone Number License Number B. Certification 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 SectionJ5.34Qof Title 5(310 CMR 15.000). The system: t : t 6�k ✓ ❑ Passes ❑ Conditionally Passes ® Fail s r c ❑ -Needs Further Evaluation by the Local Approving Authority, - z 4. .• 'czs • 11/14/06 " •� Inspector's Signature Date 11�\ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 44 CINDERELLA TER MARSTONS MILLS•08106 Title 5 Official Inspection Fomr.Subsurface Sewage Disposal System•Page 1 of 15 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 CINDERELLA TERRACE Property Address WELLS FARGO Owner Owner's Name information is required for MARSTONS MILLS MA 11/14/06 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 44 CINDERELLA TER MARSTONS MILLS-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 5 44 CINDERELLA TERRACE Property Address WELLS FARGO Owner Owner's Name information is required for MARSTONS MILLS MA 11/14/06 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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. 44 CINDERELLA TER MARSTONS MILLS•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 CINDERELLA TERRACE Property Address WELLS FARGO Owner Owner's Name information is required for MARSTONS MILLS MA 11/14/06 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ® ❑ 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. 44 CINDERELLA TER MARSTONS MILLS-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal'System Form - Not for Voluntary Assessments M 44 CINDERELLA TERRACE Property Address WELLS FARGO Owner Owner's Name information is required for MARSTONS MILLS MA 11/14/06 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no",to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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. 44 CINDERELLA TER MARSTONS MILLS•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M s 44 CINDERELLA TERRACE Property Address WELLS FARGO Owner Owner's Name information is required for MARSTONS MILLS MA 11/14/06 every page. City[Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board'of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? . ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size.and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 44 CINDERELLA TER MARSTONS MILLS•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 44 CINDERELLA TERRACE Property Address WELLS FARGO Owner Owner's Name information is required for MARSTONS MILLS MA 11/14/06 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): N/A Sump pump? ❑ Yes ® No Last date of occupancy: N/A Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No I Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 44 CINDERELLA TER MARSTONS MILLS•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 I Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 HIGHFIELD DR Property Address WASHINGTON MUTUAL Owner Owner's Name information is required for SANDWICH MA 11/20/06 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1983 Were sewage odors detected when arriving at the site? El Yes No 9 9 44 CINDERELLA TER MARSTONS MILLS•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 CINDERELLA TERRACE Property Address WELLS FARGO Owner Owner's Name information is required for MARSTONS MILLS MA 11/14/06 every page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 FT feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): JOINTS TIGHT,YES VENTED,NO SIGN OF LEAKAGE Septic Tank(locate on site plan): Depth below grade: 1 FT feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 GAL Sludge depth: 6" 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 12" Distance from bottom of scum to bottom of outlet tee or baffle 91, How were dimensions determined? MEASURED 44 CINDERELLA TER MARSTONS MILLS-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 44 CINDERELLA TERRACE Property Address WELLS FARGO Owner Owner's Name information is required for MARSTONS MILLS MA 11/14/06 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): INLET AND OUTLET TEES INTACT, STRUCTURALLY SOUND, LIQUID LEVEL EQUAL WITH OUTLET INVERT,NO SIGNS OF LEAKAGE. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): 44 CINDERELLA TER MARSTONS MILLS•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts . Title 5 Official a Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 CINDERELLA TERRACE Property Address WELLS FARGO Owner Owner's Name information is required for MARSTONS MILLS MA 11/14/06 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ® Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert EQUAL WITH OULET INVERT Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-BOX IS LEVEL AND DISTRIBUTION EQUAL WITH OUTLET INVERT,NO SOLID CARRY OVER, NO EVIDENCE OF LEAKAGE. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 44 CINDERELLA TER MARSTONS MILLS-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 44 CINDERELLA TERRACE Property Address WELLS FARGO Owner Owner's Name information is required for MARSTONS MILLS MA 11/14/06 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-6x6 ❑ 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.): SOIL IS SANDY GRAVEL, YES SIGNS OF HYDRAULIC FAILURE, PONDING IS FULL, YES DAMP SOIL, VEGETATION IS OVERGROWN 44 CINDERELLA TER MARSTONS MILLS•08/I6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 CINDERELLA TERRACE Property Address WELLS FARGO Owner Owner's Name information is required for MARSTONS MILLS MA 11/14/06 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool' must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 44 CINDERELLA TER MARSTONS MILLS-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 CINDERELLA TERRA;,E Property Address WELLS FARGO Owner Owner's Name information is required for MARSTONS MILLS MA 11/14/06 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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. D 3 2 P �vJT r 13 . '�,k - 35`t R-L-2° 5 44 CINDERELLA TER MARSTONS MILLS-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M s 44 CINDERELLA TERRACE Property Address WELLS FARGO Owner Owner's Name information is required for MARSTONS MILLS MA 11/14/06 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: +25' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: HA 692 HYDROLOGIC INVESTIGATIONS You must describe how you established the high ground water elevation: ESTABLISHED BY USGS MAPS AND SURVEYS 44 CINDERELLA TER MARSTONS MILLS•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 _ r �1 pz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH —/a0 \. >w. csF..............� � 1..c��� ,... � -1 ... S 4 Appliratiott for Diopogttl Nforkri Cnonstrnrtion Vermit Application is hereby made for a Permit to Construct (L)or Repair ( ) an Individual Sewage Disposal System at: .--•-••--- •••... •----•-•••-••••••••••-----••-••••.Location-Add ss r Lot-No. or Lot No. owner .____._..... W t n /� Address Installer U Address Type of Building Size Lott�._�? �--�_---•Sq. feet ., Dwelling—No. of Bedrooms..__._.._3.................. .....Expansion Attic ( ) Garbage Grinder (�)� G4 g No. of persons. - Showers ( ) — Cafeteria p, Other—T e of Building ( ) d Other fixtures ........ - W Design Flow........ ---- ----------_---.-......gallons per person per day. Total daily flow..............3.�.� ................gallons. WSeptic Tank—Liquid capacitA.D.a-.gallons Length................Width................Diameter................Depth................ x Disposal Trench—No.....................Width_------••----__--Total Length....................Total leaching area-------------------- ft. Seepage Pit No..................... Diameter.................... Depth below inlet-_-.--..__---__--.-_Total leaching area..................sq. ft. Z Other Distribution box ( ' ) Do in tank ( ) 11 .a Percolation Test Results Performed by. ....__.r•-�4)--• Date.... '1-y•=_ ••`�•.. Li..a Test Pit No. 1.........__..minutes per inch Depth of Test Pit........ ......... Depth to ground water..............__........ . Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Description of Soil..... -----------•----------- ••-•---.... ______________• --- --- •----------------------------- •----------------------- --- ........•-__.•... AM•_ U -------••-------•---------------------------------_....•--•-•-----_.....---•--...•.........__......._.•--------••-............--••--............................................................... W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ---------- greement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Si a a'"�----•-•--••-- `O••�1��.�3... Application Approved By.......................... .....)........................... /p-� ....... y .....................a eR Application Disapproved for the full ng easonS:...........................:.......................................................... Date ................••----•--•-••---_.--•'-.........-•----......---•---------•--•----•-----•----..----•--•••----•--..._......-•___._.___ Date PermitNo..................................._............... - Issued_................................ ...................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH u..,�.^............OF............ .. e--........................ (Jrrtifiratt of Tomphatta THIS IS TO CERTIFY, That e Individual Sewage Disposal System constructed ( tom/"or Repaired ( ) +,C_h c:,n__a-------------- rJ<a__.........-----:.._._.....-•---------=- 1 Installez •M ••- at...__... ham- '............... �__ � 3. ......._..�5'/tic'.t_.__......__._._._. :.1.._.t..f�•_________-______- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code �dej ibed in the application for Disposal Works Construction Permit No.- "�_:_. _ ./..._..._...... dated Z. J................. THE ISSUANC OF HIS CERTIFICATE SHALL NOT BE CONSTRU S A GUARANTEE THAT THE SYSTEM WILL F CT � SATISFACTORY. DATE..........Z/4 --•---> .................... Inspector... ...___......_._...__..._._._-•-------'-._.._._.____.__'-.._..__._.... THE COMMONWEALTH OF ASSACHUSETTS BOARD O�Fi HEALTH Q /.. FEE........................ Disposal Workii Tonotr_ ton Vermit Permission is hereby granted.....:. ............... :1------ .................................................................. to Constrict (v�or Repair ( ) an Individual Sewage is osal System rn M atNo... .�-..:s:.. :_�.._._...C......................................'f!:"-•-..............`..'C�..... Sa............-----... Street as shown on the application for Disposal Works Construction Permit No:,,, ...... .... Dated-.-............-------------.-.----..._.__- i �� Board of Health DATE....� - ... .._....-------------------------------------------------- cnv� 1745 p M CI II KIN INl' An CT('1N TOWN OF BARNSTABLE LOCAT'iON 0 7' aC&4-LV4-, �°`'�- SEWAGE # !~LLAGE ;�WLoe" hu-i4 ASSESSOR'S MAP & LOT ,, ; moo c� o� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) NO. OF BEDROOMS BUILDER OR OWNER • L` -d PERMTTDATE: 'tV1MPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwat rj ble 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 LOCATION SEWAGE PERMIT NO. LU o; C fot perEcc-/. - "VIL'LAGE Oq7 dap tir�rsm� s M/(- L-,5 11 INSTALLER'S NAME A ADDRESS �3dc'ti47 ,Q'GF 3 U I L D E R OR OWNER J, 6 Af «N DATE PERMIT ISSUED DATE COMPLIANCE ISSUED /�� 40 7/ eell .1 ` •� d. t� i#� 1.�.�r `f A �(' P THE COMMONWEALTH OF MASSACHUSETTS y� iQ �� ^f oZ= BOARD OF HEALTH /� 0 ,, ...................... S� A11411iratilft for DhipuiiMl Workii Tonstrurtijan Vrrmft Application is hereby made for a Permit to Construct ('l,)"or Repair ( ) an Individual Sewage Disposal System at: ........... - ...... .......... . ..................... ..---.........--.------.---....._................... Location Ad ss or Lot No. ..... ..._... ._..... ................elm._�..�`•.----•--_..... ............................................. �Z Owner Address /� .a !.) ................ ............................. ......_....--•-••...........--•---••-•------Address........_..............- Installer d Type of Building Size Lot ��-_..R. _cD....Sq. feet U Dwelling—No. of Bedrooms......... ..............................Ex Expansion Attic j p ( ) Garbage Grinder (j)v aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QOther fixtures -------•------------------------------••----•---•-•---................................. Design Flow........ __\.1�. ........................gallons per person per day. Total daily flow..........__....... ................gallons. WSeptic Tank—Liquid capacitv1C29t-.gallons Length................ Width................ Diameter................ Depth................. x Dis osal Trench—No. .................... Width.................... Total Length.................... Total leaching area...__...__.,____....sq. ft. Se page Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area......_._.____..__sq. ft. z Other higtribution box ( ) Dosing tank ( ) 11 '' a Percolation Test Results Performed by... .a11� -!......k..N._. °�__........ ._. ... Date_... ..' -y.- -. •-. Test Pit No. 1----------------minutes per inch Depth of Test Pit........(/....._.. Depth to ground water........................ fs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..................... ............... -- ---•----•------------- -------------.............. •........ ___.........._.... Description of Soil Q_n - Q.M...._.....k_••----•• �-, '-� -----•--•------ x U -------------------------------------------------------•-------......-----....----•--------•--•-......._.....---•-•----.....----••--•---•-------•--•----••-•-----•---•----....__-------...--•--------•-- W x -----------•----------------------------------------•--•--...-------------•------•--•-----•-------------•- ----------------------•.............--------- 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 iIIL U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Si ne (Y '—� 1l - te� Application Approved BY.................--•-----. ..--- •---....:......_.....---..................................... �7-__.. ..�..-•-- Date Application Disapproved for the f oll ing easons: .. ..........................,.............................................................................................................................................................................. Date PermitNo......................................................... Issued..----...-•----------------.._.............. Date .. No.11 _ Fm3.....�tf� ............... .. ......_..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH AVV iratiun for DhiVuiitt1 Works Tonitrurtion "permit Application is hereby made for a Permit to Construct ( L. or Repair ( ) an Individual Sewage Disposal System at: . _......._... ` . _. .....< ..0. ......... .......... ........()-.r.................................................. Location-Address' � ---•-'•--••-•----••-.--•--••••.•_-•----.-.or Lot No. ........................................... Owner ''� Address ?...... ... �-,•.................• •--•---•--•-------•----.....--•--...-----..........---.......----.................--•••-•-••-..... Installer Address d Type of Building Size ....Sq. feet Dwelling—No. of Bedrooms..........-'..............................Expansion Attic ( ) Garbage Grinder (Q)v aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ..---••----••-•...--••-•-••-••• - -- Design Flow---••-•..•- W g �.Q)........................gallons per person per day. Total daily flow...................::.__..................gallons. Septic Tank—Liquid capacity�.QPI.galIons Length................ Width................ Diameter................ Depth................ W 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 ( ) `-' Percolation Test Results Performed by... .1v.. ..... ............. Date._.__ Test Pit No. 1................minutes per inch Depth of Test Pit.........J...... Depth to ground water-........__..........._. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... O Description of Soil------...O `2", --• •�-� `---•-----•-t .---• ..S .�ca '� x ................ U ,. W x ----•-----••--- ---------------•-----------•----•-----••-•---......•••--•••••---•-•••-•---••--•-••••-----••••••••••••••--•••••-•---•-••••••••-•-•--••--•••••-•--•------••••..................•-•-•...-•- 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed- ! . ` . -�_..A� 4. p ate Application Approved BY /D = . . _ JDate Application Disapproved for the follo ........... .._......_ ...---------...--.-----...- - --.._. .....................................•-••••--•-••••••••••••-•.........••••-••-••----••..........•-•-•--••.........••...............••----•••-•-•....-•-••••--•••-••---••--••-••••-•••••••••----•••-•----- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tnrtifiratr of Tom phatta THIS IS TO CERTIFY, Thate Individual Sewage Disposal System constructed ( tey"or Repaired ( ) a r' -•t5 I staller CA f�n -----------•.-• //......... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code desefibed in the /o i !� application for Disposal Works Construction Permit No._�.��_."__�_�./................ dated.... ........__r.�.,l�__......_.___... THE ISSUANC OF HIS CERTIFICATE SHALL NOT BE C /NSTRS A GUARANTEE THAT THE SYSTEM WILL F CT � SATISFACTORY. DATE............ ..f....... Insp;ASSACHUSETTS or.... ....•-•-........... 1 THE COMMONWEALTH OF BOARD OF HEALTH J. .......... va^ O F............. .CtJ�-n-� <� .......................... .................r ............ L No....3... .. FEE........................ Uiipog\a1 Iforkii Tonotrion remit Permission is hereby granted.._..:'.V..L'� ."6. '1..`.......................r.Q-�. to Constrpct (t,,,' or Repair ( ) an I dividual Sewage is osal System at No..........-.c, .._.4........... .... n �- �Il.A 1 Street as shown on the application for Disposal Works Construction Permit No. .._._. .... Dated.......................................... ....... � .. ....... DATE.2n .................................................. Board of Health............ 6LFORM 1255 A. M. SULKIN, INC., BOSTON J � � I NO.Y--••-....-•921 Fick T,THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �. LJ '✓�...........OF................ .GL . ...... ......................... s 4 ggAppliration for Mipusal Works Tonstrur#inn Errant Application is hereby made for a Permit to Construct (1,) or Repair ( ) an Individual Sewage Disposal System at: ....................... ! :4.......... e .. .......... ........... .. ........ ..................................................... Location•Ad ss or Lot No. - ... . gym- `-- - ........... ........-•... - --------- \ ' Owner Address A-;................. �,..------••......... .........•---••...-••---....._._.....-•---••-••--..............._................................. Installer Address U Type of Building Size ....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (W)U aOther—Type of Building ----------------------- ---- No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ---.-----•-------•... ........... W Design Flow........�..�-........................gallons per person per day. Total daily flow................. ......................gallons. WSeptic Tank—Liquid capacity1.Oq...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 biatribution box ( ) Dosing tank Percolation Test Results Performed by.. .aIJ�G- ........_k-..N... Date.___ W Test Pit No. l................minutes per inch Depth of Test Pit........ ----._- Depth to ground water.....................--. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .................... ................................................. ......................... x O Description of Soil..----..0 ....... oQM .......................................... - .................. -------•---------------------•-----=----...........------------------•-•-••-------------•-------------.•.....-----------....----•--•----•-------------•-••••----.....-•--••............----•-............ 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 iITL1 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of Health. Seeasons: 11/L3? _...... �,. .A __.......... Ci o p� '.t�'�7. ate ^� Application Approved By.......................... ......................... �1- ..-•............................ ...... Date Application Disapproved for the foil i •....:..............................•------•---•--•-----.......................................... .................•......-•9•-••-------------.................................... -- •.................----.........-----................____....•---_____. ........_•.. ___..._.......-- Date PermitNo......................................................... Issued.........-•---...................--•--.......----...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ .........OF............. . . .. . . ........................ Trdifirate of Tnntplianrr THIS IS TO CERTIFY, That- a Individual Sewage Disposal System constructed ( or Repaired ( ) I staller ......-... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code des ibed in the application for Disposal Works Construction Permit No._ �-�_"._ ->?./............... dated.../© . _ ' _..r ._....._......._ THE ISSUANC OF HIS CERTIFICATE SHALL NOT BE CONSTRU S A GUARANTEE THAT THE SYSTEM WILL F CT SATISFACTORY. DATE............��.......................•-•--.......................-•--....... Inspe ctor ..._..............._..•--•-•-•--••-•-.....-•-................-•-..... THE COMMONWEALTH OF BOARD OF HEALTH 3 . F............ No Wit.!�n................O ................ .... /a FsE........................ Disposal Norks Tnnotr t'ntt rruti# Permission is hereby granted....... `�--Q- ' " `.. -.-------- '---..4:��... to Constr>ct (hI� or Repair ( ) an I dividua.� Sewage is osal System � c at No.----. v--- .K---...... ........................................................... ............A --.-----------------------•... Street as shown on the application for Disposal Works Construction Permit No.... ...... .... Dated.......................................... ........................ jn Z Board of Health DATE..Z.... 1�..... ................................................... FORM 1255 A. M. SULKIN, INC., BOSTON - =r1� �30� 15 :� • �L�?ra 6-P0- r ' Jt se>- - ----- -- -...- ;- -- ---- - ... . -._- -� ---- - - - ---- - 1 ... -ro-r'j&� ' =St�s�1 = 25 .p ca. _ 1 f1GD{6T1C�tJ O&Y _ : 1N SM 10,O1Z IE-SS.RP �t . ,c.✓z�, Lyg 00. ww zc M/N En- �t";jTi¢�79 . • _ _ _ . (r'�, ' 9 0 -row 9-7 Y 1'•, . ... _. 4j(�_: i. . _ < ...:.. `st'PF�° i ooc� lug .. •yr - �.. - . . .�. �... -Box CB tnty . . 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GQ (:�� lc*" b -t- 83 : F3/S.�CTCtit .cu'!E t�.lG. - RGGtS'It2�D 1-At.lC� 5tJ2vGYatZS '('NIS ht_Ati-1 IS UoT ZA-zlr.'D 06-1 A oSTi=Cvt�LL o �1rtAS�,. tr�Sc'ev�nGw; �.u�:•i�Y Y�te.. o�c,�r�. 5alowt.a APPL_t cAl--l-r t-br ec u�>c� ru i��TG�M�w1t� LO-v -LICE:5 LOCUS MAP SECTION DETAIL _ COMPONENTS TOP OF FOUNDATION - i NOT TO SCALE - SOIL ABSORPTION SYSTEM EpD EL,92.0'f qcF ,: EL. 95A' SEPTIC TANK DISTRIBUTION BOX (1) 30' x15 x 05 DEEP (EACH FIELD _ � � •�. 11=1 I T=1 I CI 11=1 11=1 I I-1 I CI 11=1 I I-1 11=11 CI 11=1 I I-1 11=1'r=I I - III I I F-I I I I I I I-�I =1 II II I IJ I I-1 Ii II IL=..III-1 II IME" 2- of 1 8' TO 1 2' II ICI II II IiI_IfI iLII II II tiJ ] . DOUBLE WASHED PEASTONE�I 2g 0.5' N EL. 89.45' DusnNG 1000 GALLON EL 88.83' �C�yoRN LOCUS SEPnc TANK EL. 89.0' EL. 88.7' `V •" INSTALL GAS BAFFLE AT OUTLET =89.2' 3/4'TO 1 1/2' NOT TO SCALE VENT DOUBLE WASHED STONE EL 88.05' DESIGN CALCULATIONS ,h : / \ FLOW RATE •�•� d � \ `�O• , 3 BEDROOM DWELLING = 330 G/P/D REQUIRED Y;• / , 97 (110-G/P/D PER BEDROOM x 3 BEDROOMS) NO GARBAGE GRINDER ALLOWED �4 5' EXCAVATION NOTES SEPTIC TANK. "���'` / 96 PCL. 121 \ 330 G/P/D x 2 = 660 G/P/D REQUIRED TOWN WATER \ 1. ALL PRECAST COMPONENTS TO BE H-20 RATED. USE EXISTING 1000 GALLON SEPTIC TANK �, 0b. e� / \ / 2. ELEVATION DATUM. IS FROM USGS QUAD MAP. ' h / 3. MUNICIPAL WATER IS AVAILABLE. SOIL ABSORPTION SYSTEM: P ` C1`� / PROPOSED FIELD 4. ALL CONSTRUCTION TO CONFORM WITH 310 CMR 15.000 95 LEACH PERC RATE = <2 MIN/IN -- CLASS I SOIL / AND ALL OTHER APPLICABLE LOCAL, STATE AND FEDERAL / \ /DISTRIBUTION BOX CODES AND REGULATIONS. BOTTOM: (30)(15) = 450 S.F. s� LEACH FIELD \\ J/ 5. INSTALLER/CONTRACTOR TO REVIEW & VERIFY ALL (450)(OJ4) = 333 G/P/D. PROVIDED �V 94 DISTRIBUTION LINE ELEVATIONS AND DETAILS AND REPORT ANY DISCREPANCIES USE: (1) 30' x 15' x 0.5' DEEP LEACH FIELD �(/ 0 ® / ETAIL TO DESIGNER PRIOR TO CONSTRUCTION OR ASSUME ALL 9$: 1 / �} / / S.A.S.SASRESPONSIBILITY. AS SHOWN IN DETAIL / / / / \/ 93 6. INSTALLER/CONTRACTOR IS RESPONSIBLE FOR MAINTAINING J c \ EXISTING SAFE WORK AREA, VERIFING ALL UTILITIES AND NOTIFYING 92 LEACH PIT DIG SAFE PRIOR TO CONSTRUCTION. // (ABANDON) 7. ANY CHANGES TO OR DEVIATIONS FROM THIS PLAN MUST DEEP HOLE DATA / / 91 BE APPROVED IN WRITING BY J.C. ELLIS DESIGN CO. AND 90 PCL 10-004 BOARD OF HEALTH. ` •' '_' ,': j / 8. FINISH COVER OVER COMPONENTS IS NOT TO EXCEED 3' 1 PERFORMED BY: JASON C. ELLIS, R.S., S.E. 98 • ,��' / �y _ / / , \ / �/ / 89 PER 310 CMR 15.000. j WITNESSED BY: DONNA MIORANDI, BARNSTABLE BOH 9. ALL ABANDONED SEPTIC SYSTEM COMPONENTS TO BE I TEST DATE: SEPTEMBER 24, 2007 PUMPED DRY AND FILLED WITH CLEAN SAND OR REMOVED -9 - //// AND REPLACED WITH CLEAN SAND. I DEPTH # ELEV. DEPTH #2 ELEV. HYD. _ - i _ 1 ��`' / / / / / 88 10. ALL COMPONENTS TO BE PROVIDED WITH WATERTIGHT 3 O.00' g2.5' 0.00' 93S' 96 _ i ) ( / p� �� �. i / / / / ACCESS PORTS WITHIN 6. OF FINISH GRADE. CP A v O / / 11. ALL SEPTIC TANKS, DISTRIBUTION BOXES AND PIPING TO so I FILL LOAMY SAND 95 ,/ / / - - ��O�pcgb v / // / S7 BE INSTALLED WATERTIGHT. I 2.0' 90•�' 10YR4/2 94 ® _-v �}`�•�,� �G; EXISTING / // / i 12. NO KNOWN EXIST WITHIN 100' OF PROPOSED i A 93 SEPTIC TANK/ / t LOAMY SAND 0.5' 93.0' 92 i'- \ / // // 86 13. EXCAVATE ALL UNSUITABLE SOIL AS NECESSARY 5' AROUND 10YR4/2 91 _ \ \ / AND UNDER S.A.S. DOWN TO C LAYER AND REPLACE WITH 2 3' B 2SAND. ' LOAMY SAND / / \\ /////i '' 14. PROVIDE VENT WITH CHARCOAL FILTER ON S.A.S. LOAMY SAND 10YR5/6 90-- / �`\\ 1ms/6 APPROX. / / \ \\ ` //// 85 4 3' c 88 2' 3 0' c 90 5' WELL LOCATION(USE FOR IRRIGATION ONLY) is 89 r \\\` //// PCL 25-002 MEDIUM -' MEDIUM - `�3 LOT 28 I , ` 84 0� TOWN WATER COARSE SAND COARSE SAND 6 88 -20,102 S.F.t / I \ -// i83 ry 10YR6/6 1OYR6/6 / / I .� SEPTIC SYSTEM UPGRADE PLAN PERC ® 60' PERC RATE I BENCHMARK <2 MIN/IN <2 MIN/IN TOP OF CONC. FNDN. 87 i // / /i �/�82 J.C. ELLIS DESIGN 10.0' 82.5' 10.0' 83.5' EL 95.0' M.S.L.t NO WATER ENCOUNTERED NO WATER ENCOUNTERED 86 / / / i81 SUBJECT: 85 // j 44 CINDERELLA TERRACE PCL 119 84 MARSTONS MILLS, MA 02468 I �P�ZN OF a� SS TOWN WATER 83 / ® PREPARED FOR: I, s0'J yG 82 CITIFINANCIAL SERVICES, INC. o CH' ISI ER 81 1 1 11 NORTHPOINT DRIVE, SUITE 100 --L[S cn COPPELL, TX 75019 0. 1 6 P.O. BOX 2152 ASSESSOR'S gA/17- PROPERTY OWNER AND BREWSTER, MA 02631 MAP 47 PARCEL 120 SCALE: 1 30' CONTRACTORS TO VERIFY (508)385-2228 ALL WATER LINES AND GAS JASON C. LIS, R.S. UTILITIES ON PROPERTY. Em0i1: jcellisdesign®verizon.net DATE: SEPTEMBER 24, 2007 REVISED: 2, 2007 SHEET 1 OF 1 LOCUS MAP o4y, e N �yORH LOCUS NOT TO SCALE G _ t V I w •' �o� PCL. 121 as h� TOWN WATER Q-a �A' P �6 LEACH FIELD Q`w 'c" o� a� ;:LEACI P;• PCL 10-004 O —D—BOX G SEPTIC TANK O I . 1 PCL 25-002 LOT 28 i s3`�6• 20,102 S.F.t ��pa TOWN WATER i PCL TOWN WATER SEPTIC SYSTEM AS-BUILT PLAN J.C. ELLIS DESIGN SUBJECT: 44 CINDERELLA TERRACE \ MARSTONS MILLS, MA 02468 �� (N a ;y.• ® PREPARED FOR: JAS CITIFINANCIAL SERVICES, INC. ��� . o 'RiS P R 1111 NORTHPOINT DRIVE, SUITE 100 I c 19 COPPELL, TX 750 j N . 12 F ��3 P.O. BOX 2152 ASSESSOR'S S sTE PROPERTY OWNER AND 47 • PARCEL 120 SCALE: 1"= 30' 4NITA1-4 CONTRACTORS TO VERIFY BREWSTER, MA 02631 MAP ALL WATER LINES AND GAS I (508)385-2228 i Email: jceltisdesign®verizon.net DATE: OCTOBER 12, 2007 JASON C. LLIS, R.S. UTiUT1ES ON PROPERTY. SHEET 1 OF 1 LOCUS MAP SECTION DETAIL - COMPONENTS TOP OF FOUNDATION NOT TO SCALE ITMFTrm I, SOIL ABSORPTION SYSTEM EL. 93.0'± SEPTIC TANK EL. s2.o'± (1) 30' x 15' x 0.5' DEEP LEACH FIELD f DISTRIBUTION BOX Z 1=1�=1 r I = III ,,,1-11-11 „ II „ III�ILII „ II „ II-11W1-/-IFfII-I-II-IlfII�IIe 1I-I�I�II- 2• of -II2I-' co DOUBLE PE/TO NE11-11 „ II-III-1I Z O <v v �� Q�Q e�C V NEL. 89.45 ETNo0GO EL 88.83' SEPTIC TANK EL. 89.0 LOCUS EL 88.7' IA/ :''" INSTALL GAS BAFFLE AT OUTLET !EL. 89.2' 3/4 TO 1 1/2' NOT TO SCALE VENT DOUBLE WASHED STONE EL 88.05' DESIGN CALCULATIONS FLOW RATE j 3 BEDROOM DWELLING = 330 G/P/D REQUIRED ••/ ( � \ (110 G/P/D PER BEDROOM x 3 BEDROOMS) / 97 NO GARBAGE GRINDER ALLOWED �� ,. / 5' EXCAVATION -� \\ NOTES SEPTIC TANK: r-' ��'� / 96 PCL. 121 \ 330-6/P/D x 2 = 660 G/P/D REQUIRED :' �a• ,oh/ ! TOWN WATER \ 1. ALL PRECAST COMPONENTS TO BE H-20 RATED. USE EXISTING 1000 GALLON SEPTIC TANK �QL �y �. e / \ / 2. ELEVATION DATUM IS FROM USGS QUAD MAP. 3. MUNICIPAL WATER IS AVAILABLE. SOIL ABSORPTION SYSTEM: / Q / PROPOSED 4. ALL CONSTRUCTION TO CONFORM -WITH 310 CMR 15.000 PERC RATE _ <2 MIN/IN - CLASS I SOIL / -� 95 LEACH FIELD �\ / AND ALL OTHER APPLICABLE LOCAL, STATE AND FEDERAL BOTTOM: (3 = <2 = 450 S.F. / i \ /DISTRIBUTION BOX CODES AND REGULATIONS. Gv (450)(0.74) = 333 G/P/D PROVIDED \ O.Q �✓ ,�O ERG LEACH FIELD \ / 5. INSTALLER/CONTRACTOR TO REVIEW & VERIFY ALL J` DISTRIBUTION LINE ELEVATIONSS AND DETAILS AND REPORT ANY DISCREPANCIES 94 �+ TO DESIGNER PRIOR TO CONSTRUCTION OR ASSUME ALL USE: (1) 30' x 15' x 0.5' DEEP LEACH FIELD / // S.A.J. DETAIL RESPONSIBILITY. AS SHOWN IN DETAIL a / \/ §3 6. INSTALLER/CONTRACTOR IS RESPONSIBLE FOR MAINTAINING EXISTING SAFE WORK AREA, VERIFING ALL UTILITIES AND NOTIFYING 92 LEACH PIT DIG SAFE PRIOR T CONSTRUCTION. 7• ANY CHANGES TOORDEVIATIONS (ABANDON) FROM THIS PLAN MUST // DEEP HOLE DATA , / 91 BE APPROVED IN WRITING BY J.C. ELLIS DESIGN CO. AND BOARD OF HEALTH. ' 90 PCL 10-004 8 FINISH COVER OVER COMPONENTS IS NOT TO EXCEED 3' PERFORMED BY: JASON C. ELLIS. R.S., S.E. i / / i \ J j �/ / 89 PER 310 CMR 15.000. WITNESSED BY: DONNA MIORANDI, BARNSTABLE BOH / _ / - / / 9. ALL ABANDONED SEPTIC SYSTEM COMPONENTS TO BE TEST DATE: SEPTEMBER 24, 2007 / PUMPED DRY AND FILLED WITH CLEAN SAND OR REMOVED - 1 //// AND REPLACED WITH CLEAN SAND. I DOH #1 ELEV. DEPTH #Z ETV. 9 HYD� - �� i ��� _ / / / / / 88 10. ALL COMPONENTS TO BE PROVIDED WITH WATERTIGHT s o.00' 92.5' 0.00' s3.s' 96 ACCESS PORTS WITHIN 6" OF FINISH GRADE. v O / / 11. ALL SEPTIC TANKS, DISTRIBUTION BOXES AND PIPING TO Fl LOAMY SAND 95 / i (- - ����0�� / // / 87 BE INSTALLED WATERTIGHT. I 2.0' 90 7' 10YR4/2 94� / 0 `- - -- - +�t��,� . G� EXISTING / / / i 12. NO KNOWN WELLS EXIST WITHIN 100' OF PROPOSED i A 93. 92/ --- �`' O�`' \\SEPTIC TANK//// // 13. EXCAVATE ALL UNSUITABLE SOIL AS NECESSARY LEACH AREA. 5' AROUND 1 LOAMY SAND 0.5' 93.0' AND UNDER S.A.S. DOWN TO C LAYER AND REPLACE WITH tO1R4 2 91 ,�_ \\\ \ jj// // / 86 CLEAN MEDIUM SAND. / 90.2' L� �D // / r \ / //� 14. PROVIDE VENT WITH CHARCOAL FILTER ON S.A.S. I LOAN SAND 10YR5/6 1 OYRS/6 APPROX. 90-- / / / / / 1\\\\ `/////i 85 III 4.3' 86.2' 3.0' 90.5' WELL LOCATION J i \\ \\ c c- MEDIUM - (USE FOR IRRIGATION ONLY) 's� 89 - LOT 2 8 1 �- \\`%/ 84 PCL 25-002 COARSEDIUMSAND COARSE SAND 36 88'� -20.102 S.F.± / -�//i83 0� TOWN WATER 10YR6/6 10YR6/6 �' / - N SEPTIC SYSTEM UPGRADE PLAN PERC 0 PERC RATE BENCHMARK - <22 MIN/IN <2 MIN/IN TOP OF CONC. FNDN. 87 // / , -- -- '82 J.C. ELLIS DESIGN 10.0' 82.5' 10.0' 83.5' EL. 95.0' M.S.L.± / NO WATER ENCOUNTERED NO WATER ENCOUNTERED 86 / / // // / /i81 SUBJECT: / 44 CINDERELLA TERRACE 85 PCL. 119 / / MARSTONS MILLS, MA 02468 TOWN WATER 84 i N OF^�qSS c 83 i j/ ® PREPARED FOR: o� JASOI �yG 82 / CITIFINANCIAL SERVICES, INC. s IST -R 81 1111 NORTHPOINT DRIVE, SUITE 100 COPPELL, TX 75019 No. 1 R� P.O. BOX 2152 _ sTE PROPERTY OWNER AND ASSESSOR'S SgNI TE CONTRACTORS E VERIFY - BREWSTER, MA 02631 MAP 47 f?Ak2CEL „12p SCALE: 1"= 30' j - ALL WATER LINES AND GAS (508)385-2228 JASON C. LLIS, R.S. UTILITIES ON PROPERTY. 1 Email: jcellisdesigndPverizon.net DATE SEPTEMBER 24, 2007 REVISED:OCTOBER 2, 2007 SHEET 1 OF 1