HomeMy WebLinkAbout0028 CONCORD LANE - Health 28 Concord Lane
Marstons Mills P
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law. r
DATE: to 1 Fill in please:
APPLICANT'S YOUR NAME/S: czc�roS S�I4ri i
" "mot ^" BU INESS YOUR HOME ADDRESS:
TELEPHONE # Home Telephone Number '"C05
NAME OF CORPORATION: r U n In
NAME OF NEW BUSINESS c a. Z^ TYPE OF BUSINESS ,� r i
IS THIS A HOME OCCUPATION? YT NO /
ADDRESS OF BUSINESS a Con car corn �9- MAP/PARCEL NUMBER — Co (Assessing)
When starting anew business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMlu%thr*
VOFFI
This individu ny p r r q ire nts that pertain to this type of business.MUST COMPLY WITH HOME OCCUPATION
RULES AND REGULATIONS. FAILURE TO
igRature** COMPLY MAY RESULT IN FINES.
MMOEN
t
2. BOARD&HEALTH
This individual has for 4eoh er r irem is that pertain to this type of business.
Authorized Si ur * - i Y WITH ALL
COMMENTS: �. r t "a
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
Ha rd us Materials Inventory Sheet Checklist
! S Date
hysical Street Address-Check database to ensure it exists
—Working Phone Number
,A,� Actual Amounts - ( ie. gas being used to fuel machines, thinner to
� ������ clean brushes all count as hazardous materials no blanks)
A/A Storage Information -location of storage, how long is storage for?
If none, note that.
/v Disposal Information -where and who? If none, note that.
Applicant Signature - understand what is listed and noted
Staff Initial -any questions, know who to ask
Vehicle Washing/Rinsing? -give a vehicle washing policy and
plain it
Attach the Business Certificate with your sign off and comments
**The inventory form should explain what the business consists of and the procedures
they are doing. Notes need to be left to explain what you discussed with them.
is
TOWN OF BARNSTABLE Date:/G/ l 115
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: _ ArGD '( c-:n+(nca
BUSINESS LOCATION: INVENTORY
MAILING ADDRESS: aK Cc^Coy L car e TOTAL AMOUNT:
TELEPHONE NUMBER: C-; - qqq- 005,1
CONTACT PERSON: �,a-to
EMERGENCY CONTACT TELEPHONE NUMBER: 01H) — q Gq - 0o 5 4 MSDS ON SITE?
TYPE OF BUSINESS:
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals(Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED -
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
Any other products with "poison" labels
NEW ❑ USED (including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables �1(\lm(X Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
-
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers&cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH EPARTMENT/CANARY COPY-BUSINESS A lic nt's Vignature Staff's Initials
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
-- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
vie AC jo 4g
Ow ner Cry ner's Name l/ /information is J�GIvl;. - / /�l� Q� �7`� �o
required for every
page. City/Town State Zip Code Date of Ospedlion
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
on the computer,
key move tab
o�r 1. Inspector: D
y y �c /sue `� � L
cursor-do not
1
use the return f I Name onspects
key.
Company Name � 9,0�
Company Address �/ 4
agora, /( U
City/Town �. State Zip Code
Telephone Nu er 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 CM 15.000). The system:
RY Passes ❑ Conditionally Passes ❑ Fails
❑ Nee Further Evaluation by the L al Approving Authority
7
Inspecto s Signature Date
The s stem 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.
d 51C�
t51ns•3I73 Title S Official ins t m'Subsurface Sewage Disposal S !am•Page t of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- �
fa Subsurface Sewage Disposaall"System Form -Not`for Voluntary Assessments
Property Address A 6 )" /j
ON ner Oa ner's Name �`), )) rr
information is AGt rS�UN `!� l/a�b � l0
required for every
page. Gty/Town State Zip Code Date of nspe lion
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E /a/ways 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 CM R 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 extiiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
"A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•3M 3 Title 5 offidal Inspection Form:Subsurface Sevage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
I`- - Title 5 Official Inspection Form
sf Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
C4 /
ON ner Cw ner's Name
information is Atli r� N� �required for every '�
page. C1ty/Town State Zip Code Date of Inspecti n
B. Certification (cons)
❑ 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 high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
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
Y
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
l5ns•3113 Title 5Official Ins pec don Form:Subsurface Sewage Disposal System-Page 3of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
la _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
ON ner ON ner's Narre
information is 1414 Qd 4 �- e7c / o
required for every
page. atyfrown State Zip Code Date of nspe ion
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections.,
Yes No
❑ 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 le\el in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins•3113 Tide 5 of Odal Inspection Form:Su bsurf ace Savage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection "Form
1z Subsurface Sewage Disposal System Form Not for Voluntary Assessments
r \,
�` ✓1 yr L—
.�
,.ems
Propefty Address
G do✓t 4
O,v ner Oro ner's Name �J�
information is
required for every ==-�
page. Gty/Town State Zip Code Date of specton
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,
❑ C?" Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ 5? 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 wateranalysis, 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.]
❑ L1d' The system is a cesspool serving a facility with a design flow of 2000gpd-
1 system
pd.
❑ Thehe system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 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.
t5ns•3/13 Title 5 Official Ins pec bon Form:Su bsurf ace Sewage Disposal S Ate m•Page 5 of 17
Commonwealth of Massachusetts
o
Title 5 Official Inspection Form
!x Subsurface Sewage
Disposal System Form0_ (OVI(or
-Not for Voluntary Assessments
1
Property Address /
.rl a
Oro ner Owner's Na
required for eve me C
information is
every T3
page. City/Town State Zip Code Dat of In pection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No '
❑ d/ Pumping information was provided by the owner, occupant, or Board of Health
❑ R 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?
❑ 2Z, 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?
L� 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: 3
Number of bedrooms (design): Number of bedrooms (actual): J
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): v
t5ins•3113 Title 5 Official Inspection Form:su bsurf ace Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
i. E Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
roll(or
Property Address
O,v ner CW ner's Name
information is 4 0 f-�f �/ �a 6(� L 0
required for every // /_'L
page. Cityrrown State Zip Code Date of 16speclion
D. System Information
,r
Description:
� 4x
a
Number of current residents:
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 Ra"No
Seasonal use? ❑ Yes No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes No
Last date of occupancy: Gate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM R 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Title 5 Offldal Ins pec tlm Form:Su bsurf ace Sewage Disposal S Ate m-Page 7 of 17
Commonwealth of Massachusetts
_ t Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address /
ON ner Owner's Name G C��:'•�rr+
information is C��T�phS k
required for every
page. City/Town State Zip Code C)atgf of In pection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
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 S m:
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)
❑ In novati ve/Altem ati ve 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•3/13 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal S item•Page 8 of 17
Commonwealth of Massachusetts
Title 5 O p
Official Inspection Form
_
I _
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
" Property Address /0
11 el /
ON ner ON ner's Name c/ LJ
information is �fs >�� �� 3
required for every
page. aty/Town State Zip Code Date of specti n
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan): 0
Depth below grade: feet
Material of construction:
❑ cast iron 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
E
sde: feet
struction:
❑ 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: 'X I
Sludge depth: —'
i5ins-3113 Title 5 Official Ins pec tlon Form'.Su bswf ace Sewage Disposal System-Page 9 of 17
< Commonwealth of Massachusetts
ie
Title 5 Official Inspection Form
h - Subsurface Sewage Disposal System Form Not for Voluntary Assessments
l J C;�Iq CO v!r/0 r'C C--
Property Address /
Cta ner Cov ner's NameAll
information isYf ''I �it /� �required for every '1
page. Cityrrown State Zip Code bate of lvpectiah
D. System Information (cont.)
Septic Tank (cont.) /r
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
lewere dimensions determined? � 7evic-e—
How
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
C-1 00j Oeec)-ecl cy )'
RM Cavi �ee-f tV7 t/U"' C�14/t7
�
L2 i
C 1 _
1410
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
t51ns•3/13 Title50iflcial Inspection Form:Subsurface Sewage Disposal System.Page 10ot 17
Commonmaith of Massachusetts
>`- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
ON ner Owner's Name
information is A&VTk4j y
required for every �" —
page. Gty/Town Slate Zip Code Date of I pecti n
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.):
at time of inspection) locate on site plan):
Tight or Holding Tank (tank must be pumpedp ) ( p )
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.):
J
Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 Official InspectionForm:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not Not for Voluntary Assessments
Properly Address
Oa ner Ory ner's Name
information is
required for every `� f A
page. City/Town State Zip Code Date Inspe ion
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
e0 :1 Qf/iG?
SSo I c _s
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* 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:
t5ins•3113 Title 5 official Ire pec tlon Form;Su bsurf ace Sewage Disposal S ystem•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 /+ cc)0 to r.J
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address A6
J/ /C /
Cw ner ners / ✓ //�� ` [�
information is / (� A�' ✓p�b�� T 0 /
required for every
page. aty/Town State Zip Code Date of Ins ection
D. System Information (cont.)
Type:
leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
r10 Sr o �161.- ILA , ti
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
I5ins,3113 TIUe50fUdal Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
1_
Commonwealth of Massachusetts
--- ( Title 5 Official Inspection Form
�� Ia Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/ J
Property Address
ON ner O,v ner's Name
information is
required for every liL✓r —
page. aylTown State Zip Code Date b 4spec1i0h
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ns-3113 TiUe50fficial iris pec Von Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�\\ �� a coo COS �✓ ir.�,
Property Address
OAt ner Ow ner's Narr"X L
information is �s. Nf �,W
required forevery
page. City/Town State Zip Code Date 9f Inspe6tion
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 p is water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
FV 4—
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a 39-
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t5ins•113 Title 50fficial insp
ection Form:Subsurtare Sewage Disposal System•Page 15 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
�. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
t
Property Address
ON ory ner's Na
ner ACC.�
o v�
information is me
required for every 5
page. Cityrrown State Zip Code Date of nspec
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
0/
Estimated depth to high ground water: 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: pate
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
Checke with local Board of Health-explain:
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
�s 10541/
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
151ns•Y13 Tide50fficlal InspecticnForm:Subsurface Sewage Disposal System.Page 16 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Z
Property Address
Ow ner CYv ner's Name
information is /`'c�G�r f �S / Od 6 113
required for every
page. aty/Town State Zip Code Date Inspection
E. Report Completeness Checklist
Inspection Summary: A, B, C, D, or E checked
62 Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
st Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Title50fhdal Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
e, THIS IS AN ORIGINAL DESIGN
Customer /0ef-T.E ' [ f� ate
�MY tc 'h ND MUST NOT BE RELEASED �/1�/�"
says '737-�
® 6 rg O COPIED UNLESS APPLI- Address G hone
J Planning Sheer. CABLE FEE HAS BEEN PAID OR ^ CK (a—C6j,IZR:-V ' /
JOB ORDER PLACED. By _ __ _ Sheet#_. __— Of Sheets
C'.;.----- 6 8 10 12 14 16 18 20
I It
yC
_ z
z
� o
14 r
Scale: V,-," = 1' 0" (Each Square =3" All dimensions ize esi nations are su to verification on job site and adjustment to fit job conditions
w ; . THIS IS AN ORIGINAL DESIGN Customer d®� Date �_ �O�—
Kit AND MUST NOT BE RELEASED Phoned a
® OR COPIED UNLESS APPLI- Addres ei s
\; P Id►t n i n Sheet CABLE FEE HAS BEEN PAID OR /' //a
tNtio,r.rM a,ti J JOB ORDER PLACED. By _�� -S� Sheet# Of Sheets
0 2 4 6 8 10 12 14 16 18 20
i
r c ,'0X 1Z
d
F
PA-6 o.c a
q
f °
12
144-4
Scale: 1/2" = 1'0" (Each Square =3") All dimensions &size designations are subject to verification on job site and adjustment to fit job conditions
1< Date �J��j��GU{�
Kitchen/Bath AND MUST NTHIS IS AN OT DESIGNNAL BE RELEA ED Customer—�O�c/, � � � � � G J Q O
' ® OR COPIED UNLESS APPLI- Address �+ Phone-„T ''
J Planning Sheet CABLE FEE HAS BEEN PAID OR ..
,` —�
JOB ORDER PLACED. By r` S eet#� Of Sheets
0 2 41 i 1 8 101 1� 14 16 18 20
S ,ems' S
GC�t1NTf SIN r GO u wrin+3 o4b,PETS
�F-C(P-43 o
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12
114
Scale: 112" = 1'0" (Each Square =3") All dimensions &size designations are subject to verification on job site and adjustment to fit job conditions
`1
TOWN OF BARNSTABLE
L('?CATION ve� Pdle'd SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PTV NO.
SEPTIC TANK CAPACITY
.
LEACHING FACILITY: (type�Yr 'l (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE�' COMPLIANCE DATE: .
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility r. Feet
S
Private Water Supply Well and Leaching Facility (If any wells exist rr,
�n site or within 200 feet of leaching facility) Jx'Feet
Edg 'of Wetland and Lea 'ng Facility(If any wetlands exist
within 300 fee f 1 �n !:!�'�ty)� oFeet
Furnished kt
LQ's
a,
Uo
wale l�on9l. 1\\ � �9
6`
r
Lv \
a
i �
DATE:6/6/02
PROPERTY ADDRESS: 28 Concord Lane .
02655
------------------------
On the above date, I Inspected the septic system at t abe" addre,
This system consists of the following: ` <U
UX
1 . 1-1000 P
n se
ptic tic tank . � k
g
2 . 1-Distribution box , tiOATr��<
3 . /2-1000 gallon precast leaching pits . ( 6 ' X .-`10 ' )
Based on my Inspection, I certify the following condition NAP 1 17-
4 . This is a title five septic system . ( 78 Code ) PARCEL 5 . The septic system is in proper working order + SO
•••y�
at the present time . F LOT
6 . The septic tank needs to be pumped . Heavy scum & solids
layers are present .
7 . Waste water is 5" below invert pipe of #1 pit
an,d 60" below invert pipe of #2 pit .
SIGNATURE:_,-
Name : - Macomber
Company : Joseph-P _ Macomber_& Son , Inc ,
Address :- Box- 66
--- ---------------
--Centerville , Ma_- 02632-0066
Phone: 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P, MACOMBER & SON, INC.
Tanks•Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connectlons
P.O. Box 66 Centerville, MA 02632.0066
775.3338 775.6412
s
COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
s
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 28 Concord Lane
Osterville , Mass .
Owner's Name: Doug Carlsen
Owner's Address: 6/6/0 2
Date of Inspection:p on:
Name of Inspector: (please print) Joseph P.Macomber Jr .
Company Name:J. P.Macomber & Son Inc .
Mailing Add ress:Box 66
Centerville .Mass . 02632
Telephone Number: 5 0 8—7 7 5—3 3 3 8
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true. accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
lk,Passes j
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fai s
Inspector's Signature: Date: '��� �
The system inspector shall mit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different J
conditions of use. _
Title 5 Inspection Form 6/15/2000 page I
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Page 2 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 28 Concord Lane
Ostervi e , ass .
Owner: Doug Carlsen
Date of Inspection: 6 6: 0 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes
-d.4V- 1 have not found any information hich indicates that any of the failure criteria described in 310 CMR
15.303 or in'3T� v T3" exist. Any failure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order at the '—
present time . The tank needs to be pumped-.—,
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.
. a 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:
46 Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
4)!) 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) P s are replaced
obstruction is removed
ND explain:
2
Page 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 28 Concord Lane
0sterville .Mass .
Owner: Doug Carl aPn
Date of Inspection: 6/h/f1
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.
I. 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:
AX Cesspool or privy is within 50 feet of a surface water
40 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
?. 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:
4-14 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.
A)O The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supple.
tib The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
"The system has a septic tank and SAS and the SAS is less than 109 feet bu 50 feet or more from a
private water supple\%,ell•'. Method used to determine distance_„{�2
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and.volatile organic compounds indicates that the well is free from pollution from that facilit),and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are trigeered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 28 Concord Lane
Osterville ,Mass .
Owner: Doug Carlsen
Date of laspection: 6/6/02
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or"no" to each of the following for all inspections:
Yes :�;�jBack-up of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or por.ding of effluent to the surface of the ground or surface waters due to an overloaded or
/clogged SAS or cesspool
tatic liquid level in the di bution box above outlet inven due to an overloaded or clogged SAS or
esspool T'31
_ Liquid depth in,cosepe I is Icss than 6" below invert or available volume is less than ''A day flow
,�Rcquired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped Q
�ky portion of the SAS, cesspool or privy is below high ground water elevation.
ny 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 I of a public well.
_ y portion of a cesspool or privy is within 50 feet of a private water supply well.
riy 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 qualiry analysis. jTbis system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this forma
(Yes No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15 303. therefore the system fails. The system owner should contact the Board
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd.
You must indicate either"yes" or"no" to each of the following:
(The following criteria apply to Iarge systems in addition to the criteria above)
des no�
_dd/the system is within 400 feet of a surface drinking water supply
4' a 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 11 of a public water supply well
!f you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
.�es" in Section D above the large system has failed. The owner or operator of any large system considered a
s!en,!icar,t threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
.5 :0< The system owner should contact the appropriate regional off ice of the Department.
4
Page 5 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 28 Concord Lane
stervi e ,Mass .
Owner: Doug Carlsen
Date of Inspection: 6 6 02
Check if the following have been done. You must indicate`yes"or"no"as to each of the following:
Yes No
Pumpino- 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?
_L//Have large volumes of water been introduced to the system recently or as part of this inspection ?
Z/Were as built plans of the system obtained and examined?(If they were not available note as N/A)
V/ 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,:eluding the SAS, Ideated on site?
t7 Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the b ffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
Was the facility owner and occupants if different
( p n from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes n
Existing information. For example, a plan at the Board of Health.
Determined to the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) (310 CMR 15.302(3)(b))
5
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Page 6 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 28 Concord Lane
Osterville ,Mass .
Owner: Doug Carlsen
Date of Inspection: 6/6/0 2
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): �D
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms):6�0
Number of current residents: _7
Does residence have a garbage grinder(yes or no): j10
Is laundry on a separate sewage system_�yes or no): Vb [if yes separate inspection required)
Laundry system inspected (yes or no): 5
Seasonal use: (yes or no): "
Water meter readings, if available (last 2 years usage(gpd)): 2000-104 , 000 gallons-284 . 94 G P D
Sump pump(yes or no): A1d 2001-105 , 000 gallons-287 . 68 GPD
Last date of occupancy: '
COMMERCIAL/INDUSTR.IAL
Type of establishment: AO
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.): AM
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):A)A
Non-sanitary waste discharged to the Title 5 system (yes or no):A
Water meter readings, if available:
Last date of occupancy/use: All
OTHER (describe): A14
GENERAL INFORMATION
Pumping Records
Source of information: J(lwe- A94r4,44,
Was system pumped as part of the inspection (yes or no): D
If yes, volume pumped: Q gallons -- How was quantity pumped determined?
Reason for pumping: j�'
TYKE OF SYSTEM
r/ OF
tank,distribution box, soil absorption system
41 Single cesspool
Overflow cesspool
i{J 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)
!�O Tight tank o�Attach a copy of the DEP approval
A20 Other(describe): d2d
Appr ximate ase of all components, date installed (if known)and source of information:
1 y2;2s I law
Were sewage odors detected when arriving at the site(yes or no):&?
6
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:28 Concord Lane
Osterville ,Mass .
Owner: Doug Carlsen
Date of Inspection: 6/6/0 2
BUILDING SEWER(locate on site plan)
Depth below grader
Materials of construction: cast iron Y 40 PVC A/Dother(explain): elA
Distance from private water supply well or suction line: ld';O
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight . No evidence of akag TP�he system is
vented through the house vents .
SEPTIC TANK:Zlocate on site plan) CW��'s
Depth below grade: 0
Material of construction: concrete& meta �19_ _ l�fiber
�� e e�bth r( xplain)
If tank is metal list age:Al V Is age confirmed by a Certificate of Compliance(yes or no):t# (attach a copy of
certificate)
Dimensions:
Sludge depth: 24,Le�
Distance from top sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: /1-e . �
Distance from bottom of scum to botto f outlet tee or bae:
How were dimensions determined: :744cl�,�s� ffl
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of.leakage,etc.):
Pump the septic tank every 2-3 years Inlet & outlet tees
are in place .The tank is structurally sound and shows no
evidence of leakage .
GREASE TRAP locate on site plan)
Depth below grade:
Material of construction:,4concretemetal. V fiberglass polyethylene i/.4 other
(explain):
Dimensions:
Scum thickness:_e_
Distance from top of scum to top of outlet tee or baffle: �f1�
Distance from bottom of sc to bottom of outlet tee or baffle:
Date of last pumping: Aut
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Grease trap is not present
7
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Page 8 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 28 Concord Lane
Osterville .Mass .
Owner: )Doug Carlsen
Date of Inspection: 6/6/o 2
TIGHT or HOLDING TANKA4LC- (tank must be pumped at time of inspect ion)(locate on site plan)
Depth below grade: -VA
Material of construction:AM concrete V4 metal 4)h fiberglass A) other(explain):
Dimensions:
Capacity: /9 gallons
Desien Flow: gallons/day
Alarm present(yes or no):
Alarm level: Jh Alarm in working order(yes or no): 4Z4
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
Tight are nntp rpgent
DISTRIBUTION BOX:1,2(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
Distribution box has two laterals . No evidence of solids
carry c^cr . N.o evidence of leakage into or out of the box
Replaced broken distribution box cover .
PUMP CHAMBEP /gj&_(locate on site plan)
Pumps in working order(yes or no): AV
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is not present
I
f
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Concord Lane
Osterville ,Mass .
Owner: Doug Carlsen
Date of Inspection: 6 02
SOIL ABSORPTION SYSTEM (SAS): (locate ou site plan excavation not required)
2-1000 gallon precast 1 — ing pits . 6 ' X10 ' )
If SAS not located explain why:
Located : See cage 10
Type
leaching pits. number:
.Ub leaching chambers, number: _
leaching galleries, number: _
leaching Trenches, number, length:
_ leaching fields, number, dimensions:
NO overflow cesspool, number: _ ��
4)0 innovative/alternative system Type/name of technology:2J,-� !/e,
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
Loamy sand to medium fine sand . No signs of hydraulic
failure or ponding . Vegetation is normal .
CESSPOOLS,4Lt*esspool must be pumped as part of inspect ion)(locate on site plan)
Number and configuration: a
Depth — top of liquid to inlet invert:
Depth of solids layer:
Depth of scum laver: r9
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Cesspools are not present .
PRIVY4"(locate on site plan)
Materials of construction: ItIlf
Dimensions: /
Depth of solids: _
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Pri my—Ls S nnt• nracant
9
IE
l
pav 10 0( 11
OFFICLA.L rNSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM TNFORIYLATION (continucd)
Properry Addre)s:29 Concord Lane
s ervi e ,
Owoer:Doug Car1sen
Dstc of Inspcctioo; 6 6 02
SKETCH OF SEWACE DISPOSAL SYSTEM
PTow o< 1 of the
ocncrvnuki. scwl:c disposal syslcm including tics to it Icast two permancni rcfcrcncc Ianwnarko or
Lo Lo<atc ill w01) within 100 (cct. Locatc whcrc public watcr supply cnicrs the bviloing.
Sir v 1A_
P�
S^ L� � � u �0 � •Z
32'6�►
Ift�2y6tr \ \ Ja
b
i
10
Page 11 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Concord Lane
Osterville , Mass .
Owner: Doug Carlsen
Date of Inspection:6/6/0 2
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check)all methods used to determine the high ground water elevation:
Obta' s stem design s on record - If checked, date of design plan reviewed:
bserved site abutting pro e / bservation hole within 150 feet of SAS)
D hecke with local Board of Health explain: 16/¢
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain: hhn : II town . barnstable .ma . u . s .
You must describe how you established the high ground water elevation:
Used ; Gahrety & Miller Model . 12/16/94 Grond water elevations nhnvP
sea level .
Used . USGS : Observation well .data _ .Tuna 199?
Ysed ; USGS : T —
ouo
water e evations . January 1992
Leaching
Pit `T.� 'eet
17
Groundwater: Feet Below Bottom of Pit Pigh Groundwater Adjustment 1.8 ft per Frimp(er Method
Therefore, the vertical separation distance between the botto }
),of the leaching pit and the adjusted groundwater table is
feet.
11 i
T.nrr.-R'tT�Tt-lilt�JR••A TiR rJ'TrTrr.rr..r.:-.Tr.1mr:+IT"t.rn nrnty t'7a'C•rcr.rr.1 .TT`rJ•••r-.Titer•-..
TOWN OF Barnstable BOARD OF 11EALTII
SUIISURFACF SEHA(;F DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
.•••�•�.T••.••.•f—�.1I��.�T.T.71I.1I:l.Tt TT TTlT T.1T.T1'�'.'1 r•1 t'TR�T'RRr1"ft'ITT'R�Af RrTTRi'.TTRT1
• MMR-rRrr"VTVP'tTTT.TP�T.•.�I'l•T'TT•�1• •�..
-TYPO OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRES$ 28 Concord Lane Osterville ,Mass . '
ASSESSORS MAP , BLOCK AND PARCEL # 122-106
OWNER' s NAME Doug Carlsen
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P.Macomber Jr .
COMPANY NAME J. P.Macomber & Son Inc-:` '
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City' Stat• i1P
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 _ 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Chec one :
System PASSED t
The inspection crhich I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or Lhe environment as defined in 310 CMR 16 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I have con trcted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature - Date
ne copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or11,operator shall u
within one year of the date of the inspection , unless allowed dortrequiredm
otherwise as provided in 3.10 CMR 15 . 305 .
partd .doc
wav? 3
20
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assr2BORTOLOTTI CONSTRUCTION, INC.765 WAKEBY ROAD,MARSTONS MILLS,MA 02648508-771-9399 508-428-8926 FAX: 509 428-939900
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
PART A 6
CERTIFICATION
Property Address:
.r9,?dX6e/zd 4/1v_ OOZI
Date of Inspection: 0 Inspector's Name:
O)Vqer#s N e Address:nV
CERTIFICATION STATEMENT*
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection. The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal terns. The System:
Passes
Conditionally Passes
1 Needs Further Eval o B e Local Aproving Authority
Fails
Inspector's Signature: Date:_
The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- -
ty(30)days of completing this inspection. If the system is a shared system or has a design now of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional
office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECTIONSUMMARY:
A)SYST)E;,IiI PASSES:
v I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated'
i below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair,passes inspection.
Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If
"not determined",explain why not.
The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or 4
exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water.level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
G
V
F
}
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A '
CERTIFICATION(continued)
Broken pipe(s)replaced
}► . ' Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection,if(with approval of The Board of Health):
Broken pipe(s)are replaced:
Obstruction is removed
C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by The Board of Health in order to determine if
the system is failing to protect the public health,safety and the environment.
1)SYSTEM WELL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT,FUNCTIONING,IN A MANNER WHICH WILL PROTECT THE '
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within SO Feet of a surface water
Cesspool or privy is within 50,Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE.BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM`IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH,AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public '
water supply well.
The system has a septic tank and soil absorption system and is within 50•Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 5.0
Feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less\
't*S --
D)SYSTEM FAIILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR45.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent 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 clog-
:ged'.SAS.or cesspool;.,,
' Liquiddepth_in cesspool is less than.G"below,invert.or.available volu nj is less than 1/2
day flow.
Required pumping more than 4 times in the.last year NOT due to clogged or obstructed
pipe(s). Number of times pumped
-2-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. if the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant.
threat to public health and safety and the environment because one or more of the following
conditions exist:
The system is within 400 Feet of a surface drinking:water supply, ,+
The system is within 200 Feet of a tributary to a surface drinking water supplyi.
The system is located in a nitrogen sensitive area Interim Wellhead Protection Area1'F
(IWPA)or a mapped Zone II of a public water supply well:'
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.'00 and 6.00. Please consult the local-...
" regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check"e following have been done:
V ping information was requested of the owner,occupant,and Board of Health. .
None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
-built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow. '
The site was inspected for signs of breakout.
system components,excluding the Soil Absorption System,have been located on site.
The septic tank.manholes were uncovered,opened,and the;interior.of the septic tank.was in-
ATh
pected for condition of baffles or tees,material of construction,dimensions,depth of liquid,
epth of sludge,depth of scum.
e size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3-
s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
t PART B ,
CHECKLIST(continued) -
The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
! PART C ,
SYSTEM INFORMATION
FLOW CONDITIONS '
Design Flow:S5 gallons Number of Bedrooms: Nun r of Current Residents., �
Garbage Grinder:_,Q() Laundry Connected To System: f/ Seasonal Use:,��
Water Meter Readings,if 'table: -
Last Date'of Occupancy:
•*,w
Type of Establishment. '
Design Flow: sallonstday. Grease Trap Present: (yes or no)
Industrial:Waste Holding Tank Present:
'`'Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informationW","""z a Z&ka -6L44.�
System Pumped as part of inspection: ALL If yes,volume pum �>allons
Reason for pumping:
TYPE OF SYSTEM:
_Septic Tank/Distribution Box/Soil Absorption System .
Single Cesspool
.l Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records,if any)
- Other(explain):
P OXIMATE AGE of all components,d to installed(if known)and source of information:
^' Sewag „odors detected when arriving at the site: 4.26
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
/
Depth below grade: Material of Constructions concrete metal FRP_Other
Dints ons:1L.5`,E )e S Sludge Depth: Scum Thickness:
w. Distance from top of sludge to bottom of outlet tee or baffle: 3 ��
Distance from bottom of scum to bottom of outlet tee or baffle: .r/Art e .
Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation outlet'evert, structural inte rity,evidence of le age,etc.)
//
i
GREASE TRAP: A)o
Depth Below Grade: Material of Construction: concrete metal FRP Other
j (explain) — — — —
Dimensions: Scum Thickness:
`•. Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and'outlettees or baffles,depth of liquid
level in relation to outlet invert,structural integrity,evidence of leakage, etc.)
_ 7.
TIGHT OR HOLDING TANK: A,,�
Depth Below Grade: Material of Constnuction:_concrete—metal_FRP_Other(explain)
Dimensions: Capacity: gallons Design Flow: gallonstday
Alarm Level:
Comments: (condition of inlet tee, condition of alann and float switclies. etc.)
DISTRIBUTION BOX: t/
Depth of liquid level above outlet invert:
Comments: (note if 1 el and distribution is equal, viden o solids carryover, vidence of leaka into
or out of box,etc.)
PUMP CHAMBER:�(� _
Pump is in working order: -
Comments:(note condition of pump chamber,condition of pumps and appurtenances,etc.)
_5
41
i
- < Z t,
,
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTIf JN FORM
PART C
SYSTEM INFORMATION(continued)
SOIL ABSORPTIOk SYSTEM(SAS):
(Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive
methods) j If not determined to be present,explain:
Type:
Leaching pits,number-Q Leaching chambers,number: Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Commen :(note condition-of soil,signs of hydraulic failure level of ponding,c6nddion of vegetation,
et
- z • ,�
4
i
CESSPOOLS: 'ju ..
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(cesspool must be um as art of inspection)
( ,� pumped P Pce )
Comments:(note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
i
PRIVY:
Materials of construction: Dimensions:
Depth of Solids:
Comment:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.)—
-6 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1'
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
e-
DEPTH TO GROUNDWATER:
Depth to groundwater: Z y Feet /J
Method of Determination or Appro ' do
u
-7-
Sewer Permit No.
Marne ---
(_.a / ,
Location
Installer's Name and Address
Builder's Name and Address
Date Permit Issued:
Date Compliance Issued: �—
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NO ... .. Fss ......................
THE COMMONWEALTH OF MASSACHUSETTS
;I
BOAR® OF HEALTH
z,Aj
.... .....BOARD
.....OF............ .1z IJ.STAc$ .��r.
?]�j Applutt#aun for 11aupuu�al Works Tonu�rn.r#iun amit
01 Application is hereby made for a Permit to Construct (4} or Repair ( ) an Individual Sewage Disposal
System at:
A ,, Location-Addres�ep G 1 or Lot N .
--M.A4,L....................
Own 7 Address
' !.br. ....S_.L S-1....................... ......._._............--......----••-•----•.Address ......_... ...
Installer
Type of Building Size Lot feet
Dwelling—No. of Bedrooms.... .. ..................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QOther fixtures ...--••-•----------•----------------------------•-----...---------•-----------------------------._.....-- Ig
W Design Flow.._..r'.���' ..........................gallons per person
�er day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacityl�. 04.:..rallons Length.....�JWidth................ Diameter................ Depth................
x Disposal Trench—11 No. .................... Width.................... Total Length.................... Total leaching area--_---_..-__....__sq. ft.
Seepage Pit No...4.. .Z.. Diameter.....1C2........ Depth below inlet..?.:!✓Z..... Total leaching area..r. ;9.2..z-.42.?q. ft.
Z Other Distribution box Dosing tank ( ) /
aPercolation Test Results Performed by.�?-..?Cw�.A....7. �_C Date.....���1-_!3Ze¢-je>..
Test Pit No. i...�.....minutes per inch Depth of Test Pit----1.-�.......... Depth to ground water.._...__"'_-..........
fs, Test Pit No. 2...I...........minutes per inch Depth of Test Pit..__..[ �_._.. Depth to ground water........................
dk1 .............1---------.....................................................
-
O Description of Soil-.-----�•� '�{'.--T ! + ---dc�r' 4�4- 1
7 v SAD
U - .. . ---------
W •---•-------•----•-------- �Z�... =Z-r•.�- T s�?I�S ?�-f Z-S�-"l � 1 5?(V1UL..SAWD..
Y
VNature 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 iITHE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
OP a ' n un '1 a rtificate of Compliance has been ' oard of health.
Signed.... .......... ---- --------•-••---. ---------- ---
n Date
Application Approved By. ,; ............--. •--
----
----...-- ---- -------------
Date
Application Disapproved for the following reasons' ------------•------•-••--•---•-•----------------------------•---•--•-----------•--.........-----•--.........
.................•--^-•----------------....-•----------�-•--•-.....-------�----------•----.....---•...-•---------- -------•----•----..................----...Date....................
PermitNo.... ----•--. Issued......................................................-
No. �. Fnz......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
`v ''J----------------OF............ ? o ! - --°--A.�L .......
App iration for Disposal Works Tontrudion Vrrmit
Application is hereby made for a Permit to Construct (>-.4 or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address
11 or Lot Iv o.
�,Ga—G C'.Ga. (n ---•---Gv�c. �-7 �Ci �.U t C. /V\ F•�e
1 c .
_... .............. .... ...... c
Owner _
-.---.•-------Address
�
a -•- GQ / ------------------------ --•-•-----•-......---------- ----••---------.....------------....------.
Installer Address
UType of Building Size Lot..-.. ..��..:`+...�.Sq. feet
�., Dwelling—No. of Bedrooms....-4."-J..................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................. No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures -----------•---------------------------------•--------••--•-•---••---•-----------•------------••-••-..-
W Design Flow........ ..........................gallons per person per day. Total daily flow.......................
-..........-_..-•._.. ions.
WSeptic Tank—Liquid capacityl.2.-.�.=gallons Length.�-T_F-.--�'Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No....... '_.. __ Diameter-----L� .__..._. Depth below inlet..•!...f�aI..... Total leaching area.:w4_�sq. ft.
Z Other Distribution box ( )4) Dosing tank ( )
Percolation Test Results Performed by. .T _v _ ►. :.�.Imo.-..,.--...� ..........: Date................................f>..-
Test Pit No. 1.... '......minutes per inch Depth of Test Pit...1.Z2........... Depth to ground water......-.—_.__.....__.
tz, Test Pit No. 2.... .......minutes per inch Depth of Test Pit......}?? Depth to ground water------
-_____________
a '% --•--•--------------------------------------------------•---------------....._......--------••-•••--..................................
O Description of Soil---•-- l� - t��"� /-=` G .-'�-� 1-7 N E���=M S At"11��
x -7'- 175' �� C-t l�,l �l D
v ------------------------------,-- --------------•------------------------•-- _
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
opera ' n un '1 a rtificate of Compliance has been ' oard of health.
��� � �
Application Approved B Signed_
Date
PP PP Y 7 ........................................
Date
Application Disapproved for the following reasons -•-•--••----••-•-------•-•--••--•-•--•--•-•---••-•••--•--••'---•--------•'-••--•..................•-•.........
--------------------------------------------------•---...-----.........---------•-------....-------------•-••.._....-•-----•-----••---•--•-----•-•---••••.------•-•--•••••-•--•-•-•-••-••--•-•-•--•---
' Date
Permit No E.- _43------- Issued. - •---- ...
Date
i
THE COMMONWEALTH OF MASSACHUSETTS
OARD OF EAL H
.............1 ( / ......OF........
...... ...... . . ....:.. :" .. .....
(Intif irtt#r of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
by.......... T -
/ o� ta (/ ::.
--------------------------------------
Installer
A
has been installed in accordance with the provisions of TI 5 of Th State Sanitary Code as escribe in the
application for Disposal Works Construction Permit No.----0-0--_----- ��... dated-------/-/�t�_r�' �,'
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.........................3-^.-I.W T...................... Inspector...................... . .0.............................................
THE COMMONWEALTH OF MASSACHUSETTS
Q BOARD OF HEALTH
N tl ...—./.�J.. �.. .�, � �' / L.6 .............. ... •----• FEE ........
Disposal Works Tonstrujio# Prrutit
Permissio is hereby granted` C�(------.T- �/O� �....... .......
to Construct or Re air ( ) an Individual Sewage Disposal em
at No...._.
Street J
as shown on the application for Disposal Works Construction Permit Now __._:14 Dated....��.._ai /
j
..............•-••-------•......... ......••.....----•----•••---
---
oard of Health
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DATE................ ' '.._��cl------------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
b-001-
Eck �^ tx
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`r'"� rY SITE PLAN SHEET / OF 2
SCALE: /"= 30'
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640tF
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56
`I LOT 22
54 -7
-1C006.9L.LE,4CM h/7'
7' 2'5TONE. 44 D � 56P7-/G TANK
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No. 19771 `z
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9fCISTI
DA V/P Mac L �f
FOR
REGISTERED LAND SURVEYOR
L-07 Zz C0/kbf09ID LA IV E7
ZONE — �x TEf UILL� , A4A
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PLAN .REFMs4P z44 Lc;-r- DATE N42VC- MPSW /5, /� E5 tl
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jBENCH MARK DATUM IYM. M. WARW/CK 8 ASSOC. , INC.
,DOMESTIC. WATER SOURCE MPS&J \,OA rr--(�=. BOX 80/ - NORTH FAL Al0UTH
FLOOD,ZONE. MASS. 02556 - (6/7) 563 -26,38
I
SHEET 2 OF 2
TYPICAL SYSTEM PROFILE 4 � .y�M ,g •
" 5• ; {. 21'CONC. MANPOLL COVER WATERTIGHT
f' OR Gl. FRAME& GOVER IF LAVED FG
,jk}� ! .• F: BY TANK RISER(S) 04 BRICK&MORTAR
COURSES AS ROU. 10 BRING TO GRADE. C 1 O
O FlNISN GRADE
*PVC seh.40 /
$
ch.Ip 4P
lEE VC �
o r srh.40 4 PVC
t� TFE
E z.d LOADING 51.20 — SLOW—LINE — .•.•••;•�
I s a`� GAL. 05 U-BOX
trx},;, � � "�� ;�`�,)ti•.< SEPTIC TANK 5 � ::':: '7�-lo:, �•:�:•• '::
;• L OAD/NG
+�x 7 .'.
p c k:y,�,� i 4l ,+ NOTE•"FOUNOA PON TO BF ...;...;�; �,p 02:� /�� ..........•.•.
OESICNED 11Y OTHERS SEPTIC TANK&D-BOY TO at .......... GAL. •....:.•:..
I r•� s i � INSTALLED ON A LEVTL, S/ABtt BASE ?I'CONC MANI+OrE COVER WATERnCNT
i ••• LEACH BASIN ••••�••••
OR CA TRAMS &COVER If PAVED F G '• ';���;��;�;
x n r BY TANK RISCR S) OR BRICK &MORTAR
{ '� LEACH BASIN SECTION ( z �E� D :•:::•::
COURSES AS ROD. TO BRING TO GRADC. '� �•
NOTT: MUST BC TO GRADE IF DESIGN ......:
EFFLUENT 15 > TWOV 2000 C.P.D.
....... LEVEL BASE :.......
t} ti , FlNISH CRADE -
t
3 5,
FLOW LINE 2 u OF 118
ro 12„ ti
r� l ••••••;••• •;••• WASHED PEASTONE
a} t�j) iY+ ..........•• EKES OF IRONS, FINES, &
4tf •i.l A. • • •••••• •
' .••......•
� 4��;d;` t . ... .. .......... DUST IN PLACE,
r CAI�. q lP .. 55 . ... •..•:.....
• . •.•• .••.. • •.
..:• •.. .•. SPECIAL NOTES
` ••••• 314" TO. l/2 CLEAN
•••• WASHED CRUSHED STONE ��
t '..... .... .....
Oy-r L Jc- P( SrA
•":" '•: ••••• •'•• FREE OF IRONS. FINES, &
LEVEL BASE •; DUST /N PLACE. t '2 L f3yTL<D" �SL
y J-,'ly I'• /tr'-1 I_�1..L.r r liG• V V�l�
z FT 6 FT, Z FT, -BIZ t C M fJ►MUM F
t r 4 FT.
ErrECn!1r DIAMETER
(NDT TD Exam J nM£S EFrccnvr DEPTH)
GENERAL CONSTRUCTION NOTES
SEPTIC TANK, DISTRIBUTION BOX, & LEACH BASIN TO BE "ACME" STD. PRECAST REINFORCED CONCRETE UNITS
OR EQUAL. CONCRETE: ._5000 P.I.S. 28 DAYS, STEEL: ASTM-A-615-68 GRADE 60. H-10 GOADING UNLESS .NOTED.
ALL SEWER LINES TO BE .4" P. V.C. SCH. 40 PIPES, GLUED JOINTS, INVERTS TO CONCRETE TO BE PARGED &
WATER TIGHT. MINIMUM PIPE PITCH TO. LEACHING UNIT.• 1/4"/FT. UNLESS INDICATED OTHERWISE.
ALL SYSTEM COMPONENTS SHALL BE.INSTALLED IN ACCORDANCE TO THE STATE ENVIRONMENTAL CODE, TITLE V,
THE MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF SANITARY SEWAGE EFFECTIVE ON JULY 1, 1977.
' AT COMPLETION OF CONSTRUCTION PRIOR TO BACKFILLING THE BOARD OF HEAL TH SHALL BE NOTIFIED FOR AN
INSPECTION. ( ftf. M. WARWICK & ASSOC, INC. TO BE NOTIFIED IN SOME TOWNS.)
ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH & WM. M. WARWICK & ASSOC. INC.
s Jt } SOIL, & PERGv,;s 'T ION DATA TEST PIT #' 1 TEST PIT # 2
r
1 _
710 8
r� s 0� EL. 0, EL. 513.
C. RATE: �- ,MIN./IN. �t�/Sc>�saSC-.
ilk
e 4
� t TEST PIT ELEV.: t S(-kxyr.lPERC. DEPTH. 1 ►.�lADSvM SAI.1D
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HEALTH AGENT R.O.H.
tl 7
GN DATA - GROUND WA If WAS ►�d NCnUN T-RED AT A DEPTH OF 3 FT.
NUMBER OF BEDROOMS:
_a � ,.,; 'GARBAGE DISPOSAL:
TOTAL DAILY EFFLUENT 0 GPD. 1� SITE & SEWER PLAN "
r J.r SEPTIC TANK REQUIRED- GAL.
FOR
� f(; + iR :•SEPTIC TANK PROVIDED: 1.20o GAL.P a5+.
r4 'a DAV I � � DIGL_ C— A �
r SIDEWALL AREA Z' GAI../SO.FT-
��y BOTTOM AREA (;AL./SQ.FT. L��" 2z. CotilGc�t2 l-- fit-1
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01
` Scale: As Shown Date � � / 14
74355�,c.�.O �
;! Wm. M. Warw 'ckJ & Assoc. Inc.
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BRIXt 213 Old Main Road Box 801
ter
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North Falmouth., Mass 02556
(617) 563 - 2638
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