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HomeMy WebLinkAbout0040 GRISTMILL PATH - Health r 40 Gristmill Path � Marstons Mills A= 047 — 090 4 i Commonwealth of Massachusetts 0Y7 -Dyb ?L#5t�q1 �3z2 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 40 Grist Mill Path Property Address Katherine Ferullo Owner Owner's Name information is required for every Marstons Mills ✓ Ma 02648 5-23-17 I � page. City/Town State Zip Code Date of Inspection 0 rX 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, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113640 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: 0 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-23-17 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 of 17 �v� V E Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Grist Mill Path Property Address Katherine Ferullo Owner Owner's Name information is Marstons Mills Ma 02648 5-23-17 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: System was in working order at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I I Commonwealth of Massachusetts 0 Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Grist Mill Path Property Address Katherine Ferullo Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. Cityrrown 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 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 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.H 40 Grist Mill Path Property Address Katherine Ferullo Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 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 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 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Grist Mill Path Property Address Katherine Ferullo Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. Cityrrown 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 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 40 Grist Mill Path Property Address Katherine Ferullo Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. Cityrrown 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): 2 Number of bedrooms (Actual) _2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 349gpd t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Grist Mill Path Property Address Katherine Ferullo Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 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 See below 9 ( Y 9 (gP ))� Detail: "WELL WATER" Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 1 I I Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c,M 40 Grist Mill Path Property Address Katherine Ferullo Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 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: Owner- Last pumped 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °w 40 Grist Mill Path Property Address Katherine Ferullo Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: New SAS added to existing tank in 2008 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1'5" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years I� Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons (Per Plan) Sludge depth: 5" t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 11 i ` I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Grist Mill Path Property Address Katherine Ferullo Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. CitylTown 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 31" Scum thickness 2 Distance fromi top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 40 Grist Mill Path Property Address Katherine Ferullo Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 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: NA 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Grist Mill Path Property Address Katherine Ferullo Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 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.): D-box was in working order at time of inspection with no sign of past backup or carry over. 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.): NA If pumps or alarms are not in working order, system is a conditional pass. x Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 l f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 40 Grist Mill Path Property Address Katherine Ferullo Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2) 500 gallons ❑ 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.): Leaching was in working order at time of inspection. No high staining, damp soils or lush vegetation were present. 6" of standing water was present. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and co-ifiguration NA Depth—top of liquid to inlet invert Depth of solids ayer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Grist Mill Path Property Address Katherine Ferullo Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs 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 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 40 Grist Mill Path Property Address Katherine Ferullo Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 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 REAR B Al-29' 81.45` A2-47' B2.59' A3.53' B3-65` 2 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 II Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Grist Mill Path Property Address Katherine Ferullo Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page.e. Citylrown 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: No GW @126" 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: June 17 2008 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan on file with BOH. t 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 A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 40 Grist Mill Path Property Address Katherine Ferullo Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. City/Town 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 i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 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 al. 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 �A required by law. I DATE: 4"`7`t Fill in please: �t APPLICANT'S YOUR NAME/S: i cLe1 reri1��� i tl{ " BUSINESS YOUR HOME ADDRESS: L4 0 me,4 m�A\ �.a 1: Mrxr�.i.5 l`1;1�� , l�1•Q.. �b4� -�, ����� � Q�-a'q1"3�3d TELEPHONE # Home Telephone Number LZ 4h 't•�s_krrr' 5 f; NAME OF:CORPORATION. �.rtg F BUSINESS ( im eV t NAME OF NEW BUSINESS ���\\o` R�,�c��.e, TYPE O I HOME'OCCUPATION? YES AD RE S OF BUSINESS, n MAP/PARCEL NUMBER (Assessing) When starting a new 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 COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual has bee rmed of the per require is that pertain to this type of business. ut orized Signature* COMMENTS: 3. CONSUMER AFFAIRS (LICENSIMG AUTHORITY) This individual has b inf the licensing requirements that pertain to this type of business. Authorized Signature COMMENTS: Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: �Q BUSINESS LOCATION: 4Gr e �`� °�- INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: I CONTACT PERSON: I-Yk cLaziA EMERGENCY CONTACT TELEPHONE NUMBER: S�C''�� 'F5OL MSDS ON SITE? TYPE OF BUSINESS: Y jn. 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 materials 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) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants I' Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. 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 Misc. 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 (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) 4 Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS )TOWN OF BARNSTABLE LOCATION,y� �,� /� SEWAGE# VILLAGE///-A ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. (�s� /p ® ,�✓ y�?Y 8�j�� SEPTIC TANK CAPACITY LEACHING FACILITY:(type)S-QQ Z�Cl l/� .�✓C1� (size) NO.OF BEDROOMS 02 OWNER t,;,1 • PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ✓¢ Feet Private Water Supply Well and Leaching Facility.(If any wells exist on site or within 200 feet of leaching facility) lad Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Dnw,/ �4/ �lsryj � �_ �`` � � V a a ,{ .� �,}r � �� NO.Jc� a`"� THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF /EALTH OF 46, APPLICATION FOR DISPO,W SYSTEM CONSTRUCTIOY PERMIT Application for a Permit to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) - ❑Complete System ndividual Components yyner'sNap�a�/�9� Map/Parcel# r d s�s S h yGD `77 7 J j o[# Telephone# D17�'/Ol7`. �tif �?io��'"`/ ��/'� �q®l G�t1f«s�rs.oy rr'sName�� �yT� ,fesigner's�� Address Telephone# !d Telephone# Type of Building: Zes7C4 Lot Sizea 7011 r Sq.feet Dwelling—No.of Bedrooms CZ Garbage Grinder (rid Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow required) o7v70 gpd Calculated design flow 3 gpd Design flow provided gpd Plan: Date Number of sheets / vision Date Title 77 z' T S. 14,7 ©-,Z Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS�s/ � The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a j�s not ace the ystem in operation until a Certificate of Compliance has been issu by the/oard of Health. A Signed Date Inspec . s FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH .J,- / flff✓ OF APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair (X) Upgrade ( ) Abandon ( ) - ❑Complete System dt Invtdual Components / Locat/ Map/Parcel# y/ � ds�s h VrlJ %$ dre7 7 of# / Telephone# Vr.7i j3jv ys Nam a� /`(//s ner's Addr s �( Address T— fTelephone# Telephone# Type of Building: 1"07C f pR Lot Sizea 70� Sq,feet Dwelling—No.of Bedrooms o9. Garbage Grinder (4�d Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(!Rin.required) C y7O gpd Calculated design flow gpd Design flow-provided 3�?gpd Plan: Date Jule e /7,/CV g Number of sheets 1 Revision Date Title 7?' /s s` s,Ae -"/�s17 o 04' 6►J Description of Soil(s) -e 1`41,01 Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS �1�''''" ��J�^► 0>�"� /°�� t ` - The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further 5agpesnot to-place the ystem in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspection_q s 1Q t FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 Q— No. C �" THE COMMONWEALTH OF MASSACHUSETTS FEE a_,g5 xfj4- BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: EI ?ndividual Component(s) ❑Complete System The undersigned hereby certify that the Sewa/ge Disposal System;Constructed( ),Repaired( ,Upgraded( ),Abandoned( ) at �0 , r A �� P4- /4 0 /,)/,e 115 has been installed in accordance with the provisions of 31 CMR 15.00 (Title 5) and the approved design plans/as-built r s-� 9 plans relating to ap lication No.accordance 9r�y Approved Design Flow- '' (gpd),. ' Installer _d 1� 01"�`� M>1�s i0 t Designer: �iJun! l_-.�iJ'� ''�5 . Inspect�r Date � �0 a The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. THE COMMONWEALTH OF MASSACHUSETTS FEE lie BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Constjuct � epair !/Upgrade ( )�bandon ( ) an individual sewage disposal system at `/Ca �"f -A //�, / �st4 / i`1 t as described in the application for Disposal System Construction Permit No.C. dated /2 Provided: Construction shall be co pleted within three years of the date of `h si perr�'ii-t 11`local conditions must be met. Date Q Board of Heal I".L__ 1 ___._..•� FORM 2 - DSCP DEP APPROVED FORM 5/96 VIMLFORM 1255 (REV 5/96) H&W HOBBSB.WARREN'" PUBLISHERS- BOSTON Town of Barnstable � o Regulatory Services Thomas F. Geiler,Director 'MWSTABM MAS& Public Health Division 1639.�EDMA'�A Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Sewage Permit# 2-609-2k Assessor's Map\Parcel y-7/1D Designer: ' r�����- -,1 Installer: ®� � l Address: `� ��1 2'I' 6A Address: 11 45­44�--e G/3 On �y®� / / ,f1� �c. was issued a permit to install a (date) (installer) septic system at y G-� ��'� �-�— eA l� based on a design drawn by (address) dated 6'1 i 7/®t / (designer) V 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. N 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. (H OF 41.48.0, ti DANIELA. cGN o CJALA (Insta is Signature) " CIVIL W o No.46502 &�(S T E��O C--CD- (Designer's Signature) I (Affix Designer's Stamp Here) �l b 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:Health/Septic/Designer Certification Form 3-26-04.doc CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory Report Prepared For: Report Dated: 6/19/2008 Kevin Flynn Flynn Mortgage Realty Order No.: G0846871 P O Box 152 Harwichport, MA 0.2646 Laboratory ID#: 0846871-01 Description: Water-Drinking Water Sample#: Sampling Location 40 Gristmill Path Maritons Mills,MA Collected: 6/17/2008 Collected by: K.Flynn Received: 6/17/2008 Routine +Ammonia ITEM RESULT UNITS RL MCL Method# Tested Ammonia 0.36 mg/L 0.20 EPA 350.1 M 6/18/2008 Nitrate as Nitrogen 7.0 mg/L 0.10 10 EPA 300.0 6/17/2008 Copper 0.16 mg/L 0.10 1.3 SM3111B 6/18/2008 Iron 1.3 mg/L 0.10 0.3 SM3111B 6/18/2008 Sodium 21 mg/L 1.0 20 SM 3111B 6/18/2008 Total Coliform Absent P/A 0 0 SM9223 6/17/2008 Conductance 230 umohs/cm 2.0 EPA 120.1 6/17/2008 pH 6.5 pH-units 0 SM 4500 H-B 6/17/2008 Sodium level is above the maximum contaminant level Those on a low sodium diet may wish to consult a physician. The water may present aesthetic problems(taste,odor,staining)due to Iron. Approved By: Jab D (Lab D ctor) to w r W t" ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory s,1 Report Prepared For: Report Dated: 6/19/2008 Kevin Flynn Flynn Mortgage Realty Order No.: G0846871 P O Box 152 Harwichport, MA 02646 Laboratory fD#. 0846871-01 Description: Water-Drinking Water Sample#: Sampling Location 40 Gristmill Path Marstons Mills,MA Collected: 6/17/2008 Collected by: K.Flynn Received: 6/17/2008 EPA 524.2- Volatile Organics by GUMS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Dichlorodifluoromethane ND ug/L 0.50 EPA 524.2 yn 6/17/2008 Chloromethane ND ug/L 0.50 EPA 524.2 yn 6/17/2008 Vinyl chloride ND ug/L 0.50 2.0 EPA 524.2 yn 6/17/2008 Bromomethane ND ug/L 0.50 EPA 524.2 yn 6/17/2008 1,1,1,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 6/17/2008 1,1,1-Trichloroethane ND ug/L 0.50 200 EPA 524.2 yn 6/17/2008 1,1,2,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 6/17/2008 1,1,2-Trichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 6/17/2008 1,1-Dichloroethane ND ug/L 0.50 EPA 524.2 yn 6/17/2008 1,1-Dichloroethene ND ug/L 0.50 7.0 EPA 524.2 yn 6/17/2008 1,1-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 1,2,3-Trichlorobenzene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 1,2,3-Trichloropropane ND ug/L 0.50 EPA 524.2 yn 6/17/2008 1,2,4-Trichlorobenzene ND ug/L 0.50 70 EPA 524.2 yn 6/17/2008 1,2,4-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 1,2-Dibromo-3-chloropropane ND ug/L 0.50 EPA 524.2 yn 6/17/2008 1,2-Dibromoethane(EDB) ND ug/L 0.50 EPA 524.2 yn 6/17/2008 1,2-Dichlorobenzene ND ug/L 0.50 600 EPA 524.2 yn 6/17/2008 1,2-Dichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 6/17/2008 1,2-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 6/17/2008 1,3,5-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 1,3-Dichlorobenzene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 1,3-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 6/17/2008 1,4-Dichlorobenzene ND ug/L 0.50 5.0 EPA 524.2 yn 6/17/2008 2,2-Dichloropropane ND ug/L, 0.50 EPA 524.2 yn 6/17/2008 2-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 4-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 Benzene ND ug/L 0.50 5.0 EPA 524.2 yn 6/17/2008 Bromobenzene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 Bromochloromethane ND ug/L 0.50 EPA 524.2 yn 6/17/2008 Bromodichloromethane ND ug/L 0.50 EPA 524.2 yn 6/17/2008 i Bromoform ND ug/L 0.50 EPA 524.2 yn 6/17/2008 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 ITA CERTIFICATE OF ANALYSIS Page: 2 ` Barnstable County Health Laboratory ssCFt Report Prepared For: Report Dated: 6/19/2008 Kevin Flynn Flynn Mortgage Realty Order No.: G0846871 P O Box 152 Harwichport, MA 02646 Laboratory ID#: 0846871-01 Description: Water-Drinking Water Sample#: Sampling Location 40 Gristmill Path Marstons Mills,MA Collected: 6/17/2008 Collected by: IC.Flynn Received: 6/17/2008 EPA 524.2- Volatile Organics by GUMS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Carbon tetrachloride ND ug/L 0.50 5.0 EPA 524.2 yn 6/17/2008 Chlorobenzene ND ug/L, 0.50 100 EPA 524.2 yn 6/17/2008 Chloroethane ND ug/L 0.50 EPA 524.2 yn 6/17/2008 Chloroform ND ug/L 0.50 80 EPA 524.2 yn 6/17/2008 cis-1,2-Dichloroethene ND ug/L 0.50 70 EPA 524.2 yn 6/17/2008 cis-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 Dibromochloromethane ND ug/L 0.50 EPA 524.2 yn 6/17/2008 Dibromomethane ND ug/L 0.50 EPA 524.2 yn 6/17/2008 Ethylbenzene ND ug/L 0.50 700 EPA 524.2 yn 6/17/2008 Hexachlorobutadiene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 Isopropylbenzene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 Methylene chloride 0.68 ug/L 0.50 5.0 EPA 524.2 yn 6/17/2008 Methyl-tert-butyl ether ND ug/L 0.50 EPA 524.2 yn 6/17/2008 Naphthalene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 n-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 n-Propylbenzene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 p-lsopropyltoluene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 sec-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 Styrene ND ug/L 0.50 100 EPA 524.2 yn 6/17/2008 tert-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 Tetrachloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 6/17/2008 Toluene ND ug/L 0.50 1000 EPA 524.2 yn 6/17/2008 Total xylenes ND ug/L 0.50 10000 EPA 524.2 yn 6/17/2008 trans-1,2-Dichloroethene ND ug/L 0.50 100 EPA 524.2 yn 6/17/2008 trans-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 6/17/2008 Trichloroethene 0.77 ug/L 0.50 5.0 EPA 524.2 yn 6/17/2008 Trichlorofluoromethane ND ug/L 0.50 EPA 524.2 yn 6/17/2008 Sodium level is above the maximum contaminant level. Those on a low sodium diet may wish to consult a physician. The water may present aesthetic problems(taste,odor,staining)due to Iron. Approved By: � (Lab Dg ctor)I 's-- / ? �� ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 0p TNF Taw a Town of Barnstable Barnstable Town �°;��, ty Regulatory Services Department �ca� * 6AtL4 ABLE. • 1 039MASS a Public Health Division 9OOATF0 MA't m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO January 2, 2008 Edwin Kelley 40 Grist Mill Path Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 40 Grist Mill Path, Marstons Mills MA was inspected on October 24, 2007 by Robert J. Bortolotti, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system FAILED under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORD F THE OARD OF HEALTH 7007 0710 0005 5820 7557 Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\40 Grist Mill Path.doc i 7007 0710 0005 5820 7557 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.•'' 40 Grist Mill Path Property Address Ed Kelley P. O. 'Box 0484 - Rockland, MA 02370 Owner Owner's Name information is required for Marstons Mills MA 02648 10/24/07 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. Important: A. General Information When filling out „ S� forms on the lY computer, use 1. Inspector. only the tab key �- to move your Robert.J. Bortolotti cursor-do not Name of Inspector ; use the return p key. Bortolotti Construction, Inc. -- Company Name P. O: Box 704=45 Industry Road _Ir Company Address , Marstons Mills MA �} Cltyrrown - 02648 State Zip Code 508-771-9399 t'.a r- Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site - sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes 96ls ❑ Needs Further Evaluation by the Local Approving Authority Inspector' gnature 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. 10-24-07-40 Great Mill Path Inspection•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 it � commonwe alth of Mas sachusetts achusefts s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Grist Mill Path Property Address Ed Kelley P. 0. Box 0484 - Rockland, MA 02370 Owner Owner's Name information is Marstons Mills MA 02648 10/24/07 required for State Zip Code Date of Inspection every page. City/Town 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. ASystem 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 breakout 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 10-24-07-40 Great Mill Path Inspection 08106 Page 2 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 40 Grist Mill Path Property Address Ed Kelley- P. O. Box 0484- Rockland MA 02370 Owner Owner's Name information is required for Marstons Mills MA 02648 10/24/07 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 aseptic 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. 10-24-07-40 Great Mill Path Inspection•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Grist Mill Path Property Address Ed Kelley-P. O. Box 0484- Rockland, MA 02370 , Owner Owners Name information is required for Marstons Mills. MA 02648 10/24/07 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 aseptic tank and SAS and the SAS is Iess.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: Y s No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ [ Any portion of the SAS, cesspool or privy is below high ground water elevation. b Any portion of cesspool or privy is within.100 feet of a surface water supply or tributary to_a surface water supply. 10 24-07-40 Great Mill Path Inspection•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 40 Grist Mill Path Property Address Ed Kelley- P. 0. Box 0484 - Rockland MA 02370 Owner Owner's Name information is Marstons Mills required for MA 02648 10/24/07 every page. City/Town 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. ❑ ER Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ [R 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.] ❑ r 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 Sectiion 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. 10-24-07-40 Great Mill Path Inspection•08l06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title. 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wC., 40 Grist Mill Path Property Address . Ed Kelley- P. O Box 0484 - Rockland MA 02370 _ Owner Owner's Name information is. required for Marstons Mills MA 02648 10/24/07 every page. City/Town State Zip Code Date of Inspection C. Checklist „ „ no a s to each of the.followin : Check if the following have been done. You must indicate yes. or g Yes No in information was provided b the owner,.occupant, or Board of Health Pum p Y � ❑ p 9 ❑ ® 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? ® a 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? , Z 0 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)] 10-24-07-40 Great Mill Path Inspection•08/05 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 40 Grist Mill Path Property Address Ed Kelley- P. O. Box 0484- Rockland, MA 02370 OwneF Owners Name information is required for Marstons Mills MA 02648 10/24/07 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: vacant 1 month Does residence have.a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): well Sump pump? ❑ Yes Z No Last date of occupancy: vacant for one month Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 10-24-07-40 Great Mill Path Inspection-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Grist Mill Path Property Address Ed Kelley- P. O. Box0484 - Ro ckland, d, MA 02370 Owner Owner's Name information is Marstons Mills MA 02648 10/24/07 required for Cit /Town State Zip Code Date of Inspection P every page. Y D. System Information (cont.), General Information Pumping Records. Pumping history unknown 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) El maintenance 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): Septic Tank and SAS ( Leach Pit) Approximate age of all components, date installed (if known)and source of information: _ Dwelling 37 -system unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No 10-24 07-40 Great Mill Path Inspection 08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 40 Grist Mill Path Property Address Ed Kelley- P. O. Box 0484- Rockland MA 02370 Owner Owner's Name information is required for Marstons Mills MA 02648 10/24/07 every page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 101,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 6' x 5' Sludge depth: Al I/ Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 2" Y I/ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 1l How were dimensions determined? physical observation 10-24-07-40 Great Mill Path Inspection-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Grist Mill Path Property Address Ed Kelley- P. O. Box 0484 - Rockland, MA 02370 Owner Owner's Name information is Marstons Mills . MA 02648 10/24/07 required for State Zip Code bate of Inspection every page. City/Town . 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.): It's a 1000 gallon precast septic tank with covers 10"to grade, it has cement inlet and outlet tees with 2 scum and 4 .stud a at time of inspection. Grease Trap (locate on site plan): Depth below grade: feet' Material of con struction:ction: ❑ concrete ❑ metal. Elfiberglass ❑ 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 0 metal D fiberglass ❑ polyethylene ❑ other(explain): Title 5 Official Inspe ction Form:Subsurface Sewage Disposal System Page 10 of 15 10-24-07-40 Great Mill Path Inspection 08/06 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Grist Mill Path Property Address Ed Kelley- P. O. Box 0484 - Rockland, MA 02370 Owner Owner's Name information is required for Marstons Mills MA 02648 10/24/07 every page. Cityrrown 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 -- 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:): There is not distribution box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 10-24-07-40 Great Mill Path Inspection-08/06 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 40 Grist Mill Path Property Address Ed Kelley- P. O. Box 0484 Rockland, MA 02370 Owner Owner's Name information is Marstons Mills MA 02648 10/24/07 required for State Zip Code Date of Inspection every page. Cityrfown 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: 1 leaching pits number: ❑ leaching chambers number: leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: overflow cesspool' number: ❑ innovative/alternative system Type/name of technology: Comments (note.condition of soil,.signs of hydraulic failure, Level of ponding, damp soil, condition of vegetation, etc.): It's a 1000 gallon precast leach pit with water level 54" below cover,staining indicates water level being 12" below cover at one point.in time. 10-24 07-40 Great Mill Path Inspection.•08/06 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page,12 of 15 i\ Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Grist Mill Path Property Address Ed Kelley- P. 0. Box 0484- Rockland, MA 02370 Owner Owner's Name information is required for Marstons Mills MA 02648 10/24/07 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.): 10-24-07-40 Great Mill Path Inspection•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for.Voluntary Assessments 40 Grist Mill Path Property Address Ed Kelley- P. O Box 0484 - Rockland. MA 02370 Owner Owner's Name information is Marstons Mills MA 02648 . .10/24/07 required for every page. City/Town 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 f et. Locate where public water supply enters the building. ._,,, ell ! s ' �O � I� i 1IG n 10 24P-07-40 Great Mill Path Inspection-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.•Page 14 of 15 Commonwealth of Massachusetts w �3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 40 Grist Mill Path Property Address Ed Kelley- P. O. Box 0484- Rockland, MA 02370 Owner Owners Name information is required for Marstons Mills MA 02648 10/24/07 every page. CitylTown 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: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: 10-24-07-40 Great Mill Path Inspection•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: Lot No. Owner: Address: Contractor: /7 Address: T r. Notes: G STEP 1 Measure:depth-to water table _. to nearest 1/10 ft. ....... Date month/day/year STEP 2 Using Water-Level Range Zone and Index.Well.Map locate site and determine: OA Appropriate index.well..:..... �Je I Water-level range zone STEP 3 Using monthly report "Current Water Resources Conditions" determine.current depth to water level for index well ........................... A 7 1. month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3J, and water level zone (STEP 213) determine water-level adjustment ..... ........ .:..............................:....... STEP 5 Estimate depth to high water by subtracting the water level adjustment (STEP 4) from measured depth to water level at site (STEP.1 ..........................................::............... . >�/y ................_............................... Figure Q.-Reproducible computation form. 15 / 00 Ff Ilfy f� z Town of Barnstable P# Department of Regulatory Services (� � Public Health Division Date el e m INUMEMASIA Mom. rb»F 1e 200 Main Street,Hyannis MA 02601 t rh �AIFD fAh't t' ! fo Date Scheduled Time Fee Pd. t/ P Soil Suitability Assessment for Sewage Disposal Performed By: Witnessed B ~=` Y� LOCATION& GENERAL INFORMATI ,/� / Location Address 0 Owner's Name 91.Q/` a`s L 1 ! W , Address- i Assessor's Map/Parcel: 7/ 90 Engineer's Name Jav-)_ e— =- c NEW CONSTRUCTION REPAIR Telephone# / �J b DL J 7 �I 1T Land Use Slopes(%) r Surface Stones Distances from: Open Water Body,> V v ft Possible Wet Area ft Drinking Water Well/ "" - ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands t?n proximity to holes) Parent material(geologic) �✓ t/v! ry Y N Depth to Bedrock ,✓ - Depth to Groundwater: Standing Water in Hole: / Weeping from Pit Foce N Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: ` Depth Observed standing in obs.hole: r_r in. Depth to soil mottles., Depth to weeping from side of obs.hole: ln, Groundwater Adjustment fr. Index Well# Reading Date: Index Well levell.e. �.�n Adl,fActor— Adj.Oroundwater Level PERCOLATION TEST Date Thne Observation Hole# ^ Time at 9" V� u Time at 6" ," Depth of Perc �4r-P-- Start Pre-soak Time @ O Time:(9"-6") ----- End Pre-soak �V , . t Rate Min./Inch Site Suitability Assessment: Site Passed Site.Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. Q:\SEPTIC\PERCFORM.DOC r� DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture :Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Con istenc we ravel s DEEP OBSERVATION HOLE LOG Hole#—2,— Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) , (USDA) '.(Munsell) Mottling (Structure,Stones,Boulders. / Consis enc %Gravel 2- DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in.) (USDA) f Other (Munsell) Mottling (Structure;_her Stones,Boulders. Consi to c' go 0,-ave1 i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. onsi ten o Flood Insurance Rate Map: Above 500 year flood boundary No— Yes , Within 500 year boundary No Yes Within 100 year flood boundary No-& Yes . Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring per i us material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring p vious material? Certification I certify that on ` C&(dattie)I have passed the soil evaluator examination approved by the Department of En iron enttecon and that the above analysis was performed by me consistent with . the required train ,expertise d e eri ce d ribbed in 310 CMR 15.017. Signature Date QASBPTIC\PERCFORM.DOC Q / r I�-a 57 ppp z1S 99 J 0 00 A N E Qro to J.12..� Iris 'a t 1 ¢r•ya�uo�P �4® 0 1Zs ,70 41 O00 M �ia^•P ^�• ® � •5<� v 137 13® -`Lees -K.c 139 ® m ® 14Z I SaK I OGM .51k 23 \r I51 m •55 ISz •SI.c ® Q h 150 I e2 50C Id y ® 3 e 90 SI.c b1 -\ (6iP G011 y 158 9 /L.C.'77i2� Sa ^ 148.465 Ja s O Jv � d�,�C .� �F( 574C 119 ° / � tiN a ® o ® q • 15s C° 1 14 ` o • 9q.(►+ I G9 �4 0 .G l.e is sane v dr ss SLAC .41 AC 'O p IS& ® V Idb yCP`so t� IH Os,C o szec bO.c ° G YS3 Q d� .41AC 7/ 69 ® 2 .42AC ® a1 1S8 b� \ 141 9,r © i a J 46 Ae 4s As ss ® 1 S9 00 ,JlAO s0 •414 jog Ac of ® •47 11 ® A ® AC ° ® 160 cr ICI so x .44P0 'S -At ez ® O 's 0 s7 ,10 4) M-L4-@6 AC ,4t AG '�) 8l 'go 1 I •9e I l ' \ 47 S0 .JOAS 00 As 7+ b{q A� .46 Ai ■ .70 AC ® �1� `i t a4 �o •�AC of is .31AC ddd pl fOAs 64 .40'a ® gYsrl y a ® i O � � I .65 a d3 Is i! .N As low, ® s i65 o A4 As < q°r Nµ 4 !• J \V`� INS 63- 53 As � 9/ if � ~ isl " REV. BY AVIS 1970 70 AL As �4i__eb` __� ORIGINAL ISSUE: /968 ��99,, ! L T �1 DE6GTf0 13 mw 9 6 2 i9 A K�1 �fl 48 65 Qoo 1�r41r� narar 1�6 32 47 47 64 31 46 63 . T 3 3' . � w � to � Y -� ay � 7 "' F. � v S � � , h Q m W � � O _ .0 C _ O _ - J Qt �► u b � � � � � .fy � � k e c a v a 1 � h a a r �. t v V .e � [w[�� � •a[ O W y u .e W _ C f FR ........�.................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0,411090 ..... ._.. ..............OF. Appliration for Diopos al Works Tonstrurtion Vrrufil Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: zed - f ; &- ------------------------------------------------------------- or Location-Addy ss ........................................................ ................................ Lot No. • n -•--•-•---..----Address a � ..._. .... --------- ----- - ---------------------------------- ------------------------- ------------------------------------------. Installer Address � UType of Building Size Lot (�a..�®C.___Sq. feet Dwelling—No. of Bedrooms..-___--_dg............................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type of Building No. of persons____________________________ Showers — Cafeteria Q' gn Other fixtur �----------- --•-------- •--- ---------- ..----- ------------------- -------------��Q---------------------- -•-------- d W Desi Flow...................... gallons per person per day. Total dailyflow....... gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width.-_-_--_--_-__ Diameter---------------- Depth------____--__. x Disposal Trench—No..................... Width.................... Total Length...................- Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water__.-_-----_-----___--.-. Gz, Nest Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 --•--•--------------•---------•--•••-------------•-----••--•-------•--•--------••------•-.........•.......----•---••••-••-•••••------•---•-•--•------------- 0 Description of Soil........................................................................................................................................................................ x U ----------------•••------•--------•--•---•••-----•----•-------------•-------------•----•-••-•••---------•--------•----•-•-------•-•----------•-•----•-•-•---------------------------•-----------•--.---- W -------------------•-----............................................................................................................................................................................... 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 Article XI 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... -------------- Dafe Application Approved By---------------------------------------------------------------------------- -------------------- ........................................ Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------•----- ••--••------------------••----•-------•----•-------------••---•...------------•--------••=••.............•-•--------••-•--•-•---•---•----•------•--••---•------•-----------•-••----•-•--------•--------- Date PermitNo......................................................... Issued..... .............................. Date N ... ......... F ........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................ . .......... .......O F...................................... Appliratiun for Disposal 10orks Tunfrurtiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: "a.' �.� '..: ---t'�.' - ------ ------------------------------------------- ----------.....------------------------. -- -- ------------ /�"�"} cation-Ass or Lot No.— Address Installer Address ��rr Type of Building Size Loth- ........ ....Sq. feet �-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ...................................................... W Design Flow..................... 0............gallons per person per day. Total daily flow.....'�.................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter_--..---_____-__ Depth................ Disposal Trench—No..................... Width.......:............ Total Length.................... Total leaching area--------------------sq. ft. . Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_____________-______._.. �T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ w .................-------------•---••-••••--•----•--•-------•--------•--......--•---............---•••-••--•-----•----•-•-••----•---........................ 0 Description of Soil........................................................................................................................................................................ x , . V ......--•-------•-•-•-----------•-...•-------•-•-••-••--•--•••------------------------------••---•-•-•-•-•--•---•------...•--•-•------••----•-•-••••----•----•......------•-•--------•------------------ W 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 Article XI 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.. !_ '.ei +4 4.7/ ---Z'' Yae ApplicationApproved By.................................................................................................. ----•-••-•-•------•-------••-----•-•---- Date Application Disapproved for the following reasons:-•-----------------------------------------------•------------------------•-----•------------------------------- ••-•-•---.......-•----------•••-•-•-•----•--•-----••---•--•••---------------------------•-------------•--•----•--•-•----•--------•-------••-----•--...-------•----•-----------•-----•----------•--•---•. # Date. PermitNo......................................................... Issued----Q. !3/•- '.'------..........----------••-- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD�O.Fx.HEALTH (Inrtif irate of Tomplittnre THS IS 0 CERT ,Y, That the Individual Sewage Disposal System constructed ( �orepaired ( ) by... ` ....-- ' "�► .,..has been installed in accordance with the provisions of Artic" QL.The State Sanitary C$de s desc 'bed in the application for Disposal Works Construction Permit No....... ! �................ dated.------- ----•-.... THE ISSUANCE OF, THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL 'FUNCTIONI SATISFACTORY. x DATE /... ' - � �?w. .................. Inspector " /y`-?-'� THE COMMONWEALTH OF MASSACHUSETTS C BOARD OF HEALTH No. FIEE........................ Uiiipr iial Workii Tonfitrnrtion rprmit Permission is hereby granted.....01'4----•�W1p0.4 to Construct ( or Repair ( ) an Individual Sewage Disposal System atNo...... f Q_ F� 1Arl.!�:� 6, - ----------------------------------------------------------------.................... Street as shown on the application for Disposal Works Construction Permit No.—S...---. Dated_ i !_% dQ 9i -------------- .. ' ....: ►,Q.$..---------- -------- ---- - DATE................................................................................. Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS _ d ' a SYSTEM DESIGN: SYSTEM w LEGEND S i STE�VI PROFILE ALL SYSTEM COMPONENTS SHALL BE NOTES MARKED WITH MAGNETIC TAPE OR . APPROXIMATE NGVD (Nor To SCALE) COMPARABLE MEANS FOR FUTURE LOCATION 1._DATUM IS JONES 99 - EXISTING CONTOUR GARBAGE DISPOSER IS NOT ALLOWED ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCRETE COVERS TO WITHIN 3" GRADE RD, 2" PEASTONE OR GEOTEXTILE 2. MUNICIPAL WATER IS NOT AVAILABLE X 99• EXIST. SPOT ELEV. DESIGN FLOW: 2 BEDROOMS ® 110 GPD = 220 GPD TOP FOUND. EL 102.7' FILTER FABRIC OVER STONE 0 3. MINIMUM PIPE PITCH TO BE 1/8„ PER FOOT. I LOCUS 99 PROPOSED CONTOUR USE A 22O GPD DESIGN FLOW \ 1.O' MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 1 CC Q' C (n A41SCH40 PVC PRECAST H-10 BLOCKS OR 4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS 7p 198.41 PROPOSED SPOT EL RISERS � PRECAST RISERS TO BE AASHO H-LQ r TH1 SEPTIC TANK: 220 GPD (2) = 440 1 .7,� 4"OSCH40 PVC H-10 TOP SYSTEM EL. 98.3' fn r ` ' MORTAR ALL 1 5. PIPE JOINTS TO BE MADE WATERTIGHT. ,•: PIPES LEVEL; 1ST 2 4' COMPONENTS INVI EL. 97.5' 4' TEST HOLE **RE-USE EXISTING 1000 GAL. SEPTIC TANK "EXISTING t5oo CAL H-10 ENDS (TYP.) SIDES Ex 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH *EXISTING SEPTIC TANK �owo aovO r' '.=o..o,00a,o ?� SLOPE OF GROUND 10' t4" ° ° ° ° °°°°°°°° 310 CMR 15.000 {TITLE V.) LEACHING: , : EXISTING TEE TEE * ®rn= ®®®® ®®®® �l®®® ° ° ° o SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD 4' uQ. LEVEL 99.3 f Wf9 7, 0006° ° ° ° ° ° ° °�Q UTILITY POLE cAs °°°°°°°° ®®®®®®®®®®® ®®®®®®®®�®� °°°°°°°° 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO ° ° ° ° ®®®®®�®®®®® ®®®®®®Fn®®®® ° ° ° ° ,00000000 000000o0 BOTTOM 25 x 12.83 (.74) = 237 GPD °°°°°0°° ®®®®®®®®®®® ®®En®®®�®®�® °°°°°°°° BE USED FOR LOT LINE STAKING OR ANY OTHER °°°°°°°° °°°°°°°° PURPOSE. 97.7457 >°°°°°°°° ' ° ° ° ° � FIRE HYDRANT ��.••a�••.: NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING TOTAL: 472 S.F. 349 GPD " ''.. "' ' '"�'' ' "�" '" "` EL. 95.5 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. 0 0 0 0 0 0 0 0 0 0 o H-10 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL. USE 2 500 GAL. LEACHING CHAMBERS ACME OR EQUAL - 4 0 0 0 0 0 0 0 0 0 0 o ALL AROUND .PRECAST STRUCTURES ONE 4' MIN.. REQUIRED 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED o000000000000000000000 _ _ ( ) ( ) DEPTH OF FLOW - " » (X) UNITS RE LOCUS MAP TEE SIZES: 6 CRUSHED STONE OR MECHANICAL WITHOUT INSPECTION BY BOARD OF HEALTH AND P OVERALL TO OUTSIDE OF STONE: 2!5.00 X 12.83 PERMISSION OBTAINED FROM BOARD OF HEALTH. WITH 4 STONE ALL AROUND COMPACTION. (15.221 [2]) *THE INSTALLER SHALL VERIFY THE INLET DEPTH = 1QLO- DEPTH _ 14 LOCATIONS OF ALL UTILITIES AND ALL99 10. CONTRACTOR 'SHALL BE RESPONSIBLE FOR CALLING NOT TO SCALE OUTLET BUILDING SEWER OUTLETS AND LOCATION (1 F ALL UNDERGROUND AND VERIFYING THE LOCATION -0F ALL UNDERGROUND & OVERHEAD UTILITIES ASSESSORS MAP 47 PARCEL 90 ELEVATIONS PRIOR TO INSTALLING ANY PRIOR TO COMMENCEMENT OF WORK. 90.5' BOTTOM TH-1 PORTION OF SEPTIC SYSTEM (_4a% SLOPE) ( 1 % SLOPE) NO GROUNDWATER FOUND 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE LOCUS IS WITHIN GP OVERLAY DISTRICT MA REMOVED 5' BENEATH AND AROUND THE PROPOSED APPROVED DATE BOARD OF-HEALTH FOUINDATION EXISTING SEPTIC TANK 32' D' BOX g' LEACHING LEACHING FACILITY, FAC'I LITY **THE INSTALLER SHALL CONFIRM MIN. 12.'EXISTING LEACHING FACILITY SHALL BE PUMPED AND SEPTIC TANK SIZE AT 1000 GALLONS AND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. ITS SUITABILITY FOR RE-USE 13. NO KNOWN POTABLE WELLS (OTHER THAN SHOWN) WITHIN 150' OF PROPOSED LOCUS SAS. I tK' TEST HOLE LOGS ENGINEER: DAVID FLAHERTY, R.S., SE2755 WITNESS: DON DESMARAIS, R.S. DATE: MAY 29, 2008 PERC. RATE _ < 2 MIN/INCH CLASS I SOILS P# 12219 I Ott ELEV. ELEV. CD A A LS LS 10YR 3/2 10YR 3/2 B B N LS LS 37" 10YR 6/6 97.9' 36" ,10YR 6/6 98.0' rn I rn _• y PERC •o' ;: ":,:� ':�.'• o'oo MCS BENCHMARK MCS EDG CLEARING CORNER CONC. o BULKHEAD <o ELEV. = 102.1 2.5Y 6/3 2.5Y 6/3 100 LPIT1 cG ST�� G TH-1 �\ G \\�\ 126" 90.5' 120" 91 .0, \ NO GROUNDWATER ENCOUNTERED DECK GAS P \j METER G� TH-2 I EXISTING ELEC. DWELLING METER TOP FNDN = 102.7' %.JFITE PLAN TITLE b OF o 40 GRISTMILL PATH 0T 400 (MRSTONSAd MILLS) BARNSTABLE, MA \ h L APP. EXISTING \ 21,701 SFt �, VELL (NOT FOUND) TEL o RISER PREPARED FOR BORTOLOTTI CONSTJ \ PAVED \ 4o���� EDWIN KELLY \ DRIVE e" cn Q \\ \ DATE: J U N E 17, 2008 Scale: 1"= 20' _ QP ; 0 10 20 30 40 50 FEET off 508-362-4541 i fax 508-362-9880 TEL / RISER �tHOFMyss downcape.com o��� ARNE q�yG � Tti OFSS9 down cope engineering, /1c. EXISTWELLING o� H. N� ��� ARN H. �yN civil engineers oJALA °JIon d sur veyors No.2�6348 !V y G 939 Main Street ( Rte 6A) D sua\ H. OJAL;A, 01 �``� YARMOUTHPORT MA 02575 Q .. I D CE # 0 U 103 � -_... ��CN.4 L E•NG 08-103 B0RT0L0TTI_KELLY(2).DWG (DDF) I t � p