HomeMy WebLinkAbout0036 HALLETTS LANE - Health 36 Halletts Lane
Marstons Mills
A = 064 008
9,� Oq -- j5 r Fee 7 ��
BOARD OF HEALTH
TOWN OF BARNSTABLE
0[ppricatiou jfor Yell Cougtructiou Permit
Application is hereby made for a permit to Construct( ), Alter( ), or Repair(kr an individual well at:
36 Au11< 7rs L . , O&L/Cso$'
Location-Address yam- Assessors Map and Parcel
/
J/CJ� tyke [! -?I: H. M.71' 4 A40-,S/a.,5 ^4
n Owner Address
lot INJ" S A ]e4NNe// IOU 9S. De(.iaS4 /l�l MQg4,ete /V1a nJGy�
Installer-Driller Address
Type of Building
Dwelling
Other-Type of Building No. of Persons
Type of Well SI 4 a C Capacity
Purpose of Well D6 n..e s r.e- w.7.
Agreement:
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the
well in operation until a Certi ate of Compl' nce has been issued by the Board of Health.
Signed
Date
Application Approved By
Dat
Application Disapproved for the following reasons:
t
� ) Date
Permit Nb�/��� ?j t�9� Issued
Date
--------------------------------------------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Compliance
THIS IS TO CERTIFY,that the individual
/well Constructed( ), Altered( ), or Repaired(—r
by DeNrj-s 4
Installer
at
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
Date Inspector
NW a !7 Fee
BOARD OF HEALTH
TOWN OF BARNSTABLE
2pplication for Yell Con5tructiou Permit
Application is hereby made for a permit to Construct( ), Alter( ), or Repair(vf an individual well at:
Location-Address L/ / y� //Assessors Map and Parcel
C�Tc-) cy� j
� /t- ?G /'c.; l/,//S /_ /LAG,;?--- 5 //
Owner Address
Oe/` ";s G Cc4,�nJe �� 1,� JSJ I' ��� - Si /'c ,l MoS���r /✓�U JJGyS
Installer-Driller Address
Type of Building
Dwelling v,'
Other-Type of Building No. of Persons
Type of Well `/ l o c Capacity
Purpose of Well ; 7-1
Agreement:
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the
well in operation until a Certificate of Compfiance has been issued by the Board of Health.
Signed A," -0I
Date
Application Approved By �� / �f �J ,� /---:�>
Da
Application Disapproved for the following reasons:
/ Date
Permit NO�U� � ��� Issued
Date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Compliance
THIS IS TO CERTIFY,that the individual well Constructed( ), Altered( ), or Repaired(�
by
Installer
at
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
Date Inspector
BOARD OF HEALTH
TOWN OF BARNSTABLE
��J Vern Cougtructiou Permit
N¢Up�� Fee
Permission is hereby granted to nt
Installer
to 2 Construct( ), I A er(/), or Repair an individual well at:
No. 3GJ ��f�T� Li'� M/
Street
as shown on the application for a Well Construction Permit No. Dated r
DateLlApproved By Ll���t 7I C
08/01/2013 TEV 10: 47 PAX 508 428 0875 W. RaVdie RE Oatervilla
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'THE T
ti
Town of Barnstable Barnstable
.� Regulatory Services Department medcaCft
• a ARNSTAsL-
Public Health Division
200 Main Street,Hyannis MA 02601 2007
Office: 508 862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7012 1010 0000 2850 7549
May 8, 2013
Steven & Linda White !
36 Halletts Lane
Marstons Mills, MA 02648
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 36 Halletts Lane, Marstons Mills, MA was last
• inspected on4/12/2013, by Ricky Wright, a certified septic inspector for the State
of Massachusetts:
The inspection of the septic system showed that the system "Conditionally
Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the
following:
• Distribution Box is deteriorated.
• Water level at the invert of one of the leaching pits.
You are ordered to repair or replace the septic system components within Two
(2) years from the date you receive this notification by replacing the distribution
box and replacing the failed leaching pit.
It is recommended that the entire leaching system be replaced.
Failure to repair/replace'the septic system within the deadline period will result in !
future enforcement action.
PER ORDER OF THE BOARD OF HEALTH
omas McKean, R.S., CHO
Agent of the Board of Health !
Q:\SEPTIC\conditionally passed\36 Halletts Ln MM May2013.doc
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M
36 Hallett Lane
5 ... ... .... .... .... ..
Property Address:. ..
.
Steven White
Owner
Owner's Name
information i e
required for every Marston Mills Ma 02648 4/12/13
..
page: -City/Town State Zip Code,: Date of Inspection -
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: (� f
.. . 8 .
key to move your
cursor-donot Ricky Wright
use the return:
urn:
key. Name of Inspector
B & B Excavation,Inc.
Company Name
14 Teaberry Lane_ .. ..
Company Address
Forestdale MA 02644
Gay/I own State Zip Code
508-477-0653 S 14595 -
Telephone Number License.Number
r
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and thaRbe
information reported below is true, accurate and complete as of the time of the inspection. TWinspeetion
was performed based.on my training and experience.in the proper function and mai tenance,.of on
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1 r-.3 40
Title 5(310 CMR 15..000). The system:
. . .
M
❑ Passes.
Z Conditionally Passes ❑ Fails
El Needs Further Evaluation by the Local Approving:Authority
d. 4/12/13
- 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 systern 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•11/10 Title 5 Offcial Inspection •rm ibsurface Sewage:Disposal System;-,Page 1 of 17
Commonwealth :of Massachusetts
_ Title 5 Official Ins ion Form
4 - -
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
36 Hallets Lane
M
Property Address
Steven White
Owner Owner's Name
information i e
required for every-
Marston Mills Ma 02648 4/12/13
page. City/Town - State Zip Code Date of Inspection - -
B. Certification (cont.)
Inspection':Sum mary .Check..A;B,C,D or:E/always complete all of Section D
A) System Passes:
1 have not'found any information which.indicates that any of the failure.criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally.Passes:
....... .......
® One or more system components as described in.the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check:the box for"yes", "no"or not determined'' (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic.tank as approved by the Board of
- Health. -
A mete f 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.
i
❑ Y ❑ N ❑ ND (Explain below):
D-box is deterated and Ieakin Needs to be replaced.,
t5ins•11/10:;; Title 5 Official Inspection Form:Subsurface Sewage:Disposal System Page 2 of 17
Commonwealth of Massachusetts
_ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M 36 Hallets Lane
Property Address:.
Steven White
Owner Owner's Name ..
information is Marston Mills Ma 02648 4/12/13
required for every
page. CltylTown - State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
El 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):
pipe(s) P ❑ (Explain )
❑ :broken I e s. are replaced ❑ Y ❑: N : ND Ex lain below
.... . ....
obstruction Is removed Y N ND (Explain below):
® distribution box is leveled or replaced Z Y N ND (Explain below):
D=box is deterated and:needs replacement.
El 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):
❑ P )obstruction is removed El El El (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 orthe 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System:-Page 3 of 17
.... . .... _ _.
_.. _ .......
Commonwealth of Massachusetts
W Title 5 Official Inspec ion Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M
Sy0
36 Hallets Lane
Property Address:
Steven White
Owner: Owner's Name
information i e
required for every Marston Mills Ma 02648 4/1.2/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless:the Board.of Health and Public Water Su lier, if an
y � pp Y)
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.
El :The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
El:....:.. The system has a septic tank:and SAS:a.nd 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
coliforrn 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: ps
....
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
❑ ® clo
clogged:SAS or cesspool
waters:
... ... El
Discharge or ponding of effluent to the surface of the ground or surface
due to an overloaded or clogged SAS or cesspool
tatic liquid level in the distribution box above outlet invert due toi 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•11/10:.: Title 5 Official Inspection Form:Subsurface Sewage Disposal System:-Page 4 of 17
Commonwealth of Massachusetts
_ AO
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
1.0
36 Hallets Lane
Property Address: .. _ .. ..
Steven White
Owner .. Owner's Name - ..
information is required for every Marston Mills Ma 02648 4/1.2/13
page. Cltyfrown State Zip Code Date of inspection
B. Certification (cont.)
es.. No
Required pumping more than 4 times in the last year NOT due to clogged or
® obstructed pi_pe(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
El ® 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 custodymust be attached to this form.]
. .... . .... _. _.
The system is'a cesspool serving a facility with a design flow of 2000gpd-
El M
10,000gpd•...
El
® 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 largesystem 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: ._
El 0 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
wellArea= IVPA oramaPPed Zone II of:aPublic water suPPI
I
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 orfailed 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•11/10::: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 17
Commonwealth of Massachusetts .
Tit e 5 Official Inspection Form
Subsurface Sewage Disposal System Form = Not for Voluntary Assessments
36 Hallets Lane
Property Address..
Steven White
Owner Owner's Name
information is Marston Mills Ma 02648
required for eve 4/12713
ry.
page. City/Town State Zip Code Date oflnspection
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 thesystem: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-
0 ❑ 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): 4: : Number of bedrooms (actual).. 4
DESIGN flow based on 310 CM 15.203.(for example: 110 gpd x#of bedrooms):
440
t5ins•11110: Title 5 Official Inspection Form:Subsurface Sewage:Disposal System Page 6 of 17
Commonwealth of Massachusetts ..
` Title 5 Official Inspec ion Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 36 Hallets Lane
Property Address:
Steven White
Owner Owner's Name
information is required for every Marston Mills Ma 02648 4/12/13
pager 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? [if yes separate inspection required] ❑ Yes No
Laundry system inspected? ,. ❑ Yes ® No
Seasonal use? El Yes 0 No
Water meter,readings, if available.(last 2 years usage(.gpd)):
n/a
. .... ...
Detail: _:....
Sump pump? ❑ Yes ®.. No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of.Establishment:
Design flow(based on:310 CMR 15.203): _ Galions per day(gPd)
Basis of design flow(seats/persons/sq.ft., etc.):
...Grease trap present? _ ❑ Yes: El No _.
Industrial waste holding tank present? ❑ Yes ❑ No
...
Non-sanitary waste dischar ed to the Title 5 system?
❑::Yes El : No
Water meter readings, if available:
t5ins•11110..: Official Form. a Se al y 7 of Title 5 I Inspection �Subsurface Sewage Disposal S stem�.Page 17
Commonwealth of Massachusetts
`w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
36 Hallets Lane
M
Property Address
Steven White
Owner Owner's Name
information is .required for every Marston Mills Ma 02648 4/12/13
page. City/Town State Zip Code - Date of lhspection
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:.
gallon I s
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 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•11/10:: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
..
Commonwealth :of Massachusetts
_ f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form :-Not for Voluntary Assessments
36 Hallets Lane
G'M
.... 5..
Property Address: ...
Steven White
Owner: - Owner's Name ..
information is Marston Mills Ma 02648 4/1.2/13
required for every
page. City/Town: =State Zip Code Date of Inspection
D. System Information (cont.) ..
Approximate age of all components, date installed (if known):and source of information:
1985
Were sewage odors detected when arriving at the site? . Yes Z No
Building Sewer(locate on site plan):
_. _.
2.5
Depth below grade:
feet
... ... ... ... _.
Material of construction:
. . .. . ....
cast iron 40 PVC: other(explain):
>20
Distance from private water supply well or suction line: feet .
Comments(on condition of:joints, venting, evidence of leakage, etc.)
At time of inspection building sewer appeared to be in working order no sign of leakage or:blockage.:
Septic Tank(locate on site:plan):
Depth below grade: 1.6
feet
Material of construction:
concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
_.
...If tank is metal, listage:
years:.::::
Is age confirmed by.a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No
Dimensions: : : 1250 gal
_.
6"
Sludge depth:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 17
i
Commonwealth of Massachusetts
F - Title 5 Official Inspec ion Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
H 36 Hallets Lane
S..
Property Address:.
Steven White
Owner: Owner's Name
information is Marston Mills Ma 02648 4/1.2/13
required for every
page. City/Town State Zip Code Date ofinspectiom
D. System Information (cont.) - -
Septic Tank(cont.)
Distance from top of sludge to bottom:of outlet tee or baffle 31 ...
2„
Scum thickness
. .
6.
Distance from top of scum to top:of outlet tee or baffle
16,E :::: ....
Distance from bottom of scum to bottom of outlet tee or baffle
scour stick
How were dimensions determined?
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 septic tank appears to be structurally sound.No sign of back-up.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-:Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspec ion Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c^ 36 HaAets Lane
M
Property Address:.
Steven White
Owner - Owner'E Name
information is
required for every Marston Mills Ma 02648 4/12/13
..
page City/Town: State Zip Code Date ofinspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee.or baffle.condition,-structural-integrity,
liquid levels as related to outlet invert,:evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene :El other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: El El 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? El Yes::: El 'No.:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•_Page 11 of 17
I,
Commonwealth of Massachusetts
`F Title 5 Official Inspection Form
Subsuirface Sewage Disposal System Form - Not for Voluntary Assessments
M 36 Hallets Lane
Property Address
Stever White
Owner Owner's Name ..
information is Marston Mills Ma 02648 4/1.2/13
required for every:.
page. City/Town State Zip Code. Date ofinspectlon
D. System Information (cont.)
Distribution Box-(:if:present.must be opened)(locate on site.plan):
Depth:of liquid level above outlet invert
0
Comments(note if box is:I.evel and distribution:to outlets equal, any:evidence:of solids carryover,any
evidence of leakage into or out of box, etc.):
At-time of inspection d-box is deterated and needs to be replaced. .
Pump Chamber(locate on site plan):
_. P g
Pumps in working order: ❑ Yes ❑ No
Alarms.in working order: ❑ Yes - ❑ No -
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: ...
t5ins•11/10; Title 5 Official Inspection Form:Subsurface Sewage Disposal System-:Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official In Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M 36 Hallett Lane
s
. .... Property Address
Steven White
..Owner, .. .
Owner's Name
information is Marston Mills Ma 02648 4/1.2/13
required for every
page. City/Town State Zip Code Date oflnspection
D. System Information (cont.)
Type: .... ...
® leaching pits number:
2
El
leaching chambers: : number:
❑. leaching galleries. number: .
leaching trenches number, length:
❑ leaching fields number, dimensions:
P
overflow cess ool 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:
At time of inspection leaching appears to be in working condition Water level is-at the invert of one pit
and two feet lower than the invert in other pit,at time of inspection.
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:
i
Dimensions of cesspool
Materials of construction::
Indication of groundwater inflow - - ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•:Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspec ion Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M 36 Hallets Lane
Property Address _. ..
Steven White
Owner
Owner's Name
information is required for every_ Marston, Mills Ma 02648 4/1.2/13
page. - Clty/Towr- State Zip Code Date of Inspection
D. System Information (cont.)
-.Comments (note condition of.soil, signs.of hydraulic failure,.level of ponding, condition of vegetation,.
etc. : .......
Privy(locate on site plan):
Materials of construction
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 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 s 36 Hallets Lane
Property Address -
Steven White
Owner: Owner's Name
information is required for every Marston Mills Ma 02648 4/12/13
page. Cityrrown - 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:
Z . hand-sketch in the area below....
El drawing attached separately:
1
T
s
3
V.
O
t5ins•1 1/10 . TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System•:Page 15 of 17
Commonwealth of Massachusetts
.Title 5 Official InSpection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
H 36 Hallets Lane
Property Address ... _.
Steven White
Owner
Owner's Name
information is required for every Marston Mills Ma 02648 4/12/13
:
Clty/Town State Zip Code. Date of Inspection
:-
page.
D. System Information (cont.) -
Site Exam: ... .. ...
® Check Slope...
Surface water -
Check cellar
Shallow wells- -
Estimated depth to high ground water:
>12
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)
El Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
... .. .. .. ..
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10: Title 5 Official Inspection Form:subsurface Sewage Disposal System-:Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
°�M a 36 Hallets Lane
Property Address
Steven White
Owner ... Owner's Name .. - ..
information is Marston Mills Ma 02648 4/1.2/13
required for every
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
Z; Sketch of Sewage Disposal System either drawn on page 15 or:attached in separate:file
_... ...... ......
j
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•_Page 17 of 17
TOWN OF BARNSTABLE
LOCATION 36 ga/l c-15 I_J SEWAGE# Z O 13 - 30Q.
.:,VILLAGE Jn.(n i)I S ASSESSOR'S MAP.&PARCEL
INSTALLER'S NAME&PHONE NO. (3 B EXeaVa�i on �'�7- OLS3
SEPTIC TANK CAPACITY /000
LEACHING FACILITY:(type) Trcncht.$ . (size) Z K 3 x y3
NO.OF BEDROOMS
OWNER C,
PERMIT DATE: $- 9- J3 COMPLIANCE DATE: $- 12 - 13
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 ori`
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
34
A '�
BZ 37
A3.37.G F QoNT
Ay'�7 � A
3
k
pp
i
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OP BARNSTABLE, MASSACHUSETTS Yes
Zipplitation for jBisposal 6pstrm ConstrUrtion 3pPrm t
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 3 �Q Ij=f 5 L&j- f Owner's Name,
tL
Address,and Tel.No.
Assessor's Map/Parcel CA `� �� r w A ncO 1N 111fe—, 5 b8-41 9'
I ller's N e,Address,and Tel.No. Designer's Name,Address,and Tel.No.
t3 Mb\1af1,/)n 609— 17 b653 `D4wn _fin �61V) 362-1f5l�/
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building r e 5 lCj1 (1n Q_ No.of Persons Showers( ) Cafeteria( )
Other Fixtures ��yy
Design Flow(min.required) L`b gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs orAlterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board qRValth. R
Si a Date v f
Application Approved by Date
Application Disapproved by Date
for the following reasons
oe
Permit No.��� ��d Date Issued �.
No. F r :-' .,.- Fee Q V
THE COMMONWEAL TH2 OF MASSACHUSETTS Entered in computer:
Yajr r Yes
PUBLIC HEALTH DIVISION - TOWN s F BARNSTABLE, MASSACHUSETTS
sue`
.�_ . pYitatior� for is osaY peffit Construction permit
R Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 3( H Q(It+5 L&n-L Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel Uy /I? M M Wdn W t 1 i¢e 509-41 q -5 6L 7
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
"61 •C3 EY Lc+va{ I an 5D8- J�i 17-665
5v 3 `�Jo�n Cam. �n ( ) 3l,Oz �54�1 ,.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder9
( )
1 ..
Other Type of Building r e s'I d�n W No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets ( Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) N I L) hl)Y
Date last inspected: ,
Agreement: ,.
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board okiealth. I
Si e Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. �� d Date Issued /
---------------- - '----------------- --- - -- - - - =
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO-CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by !" l F) y Q i t&
at 7j +n�,�'_ n t' has been constructed in accordance
with the pro isions of Title 5 and the for Disposal System Construction Permit Nam' "r. , ted h h 3
Installer - ( Designer (�II n I n I
�� � _� � tl ��t 1�
#bedrooms 4 Approved design flow H q ) 1 / gpd
The issuance of this perm' hal of be co trued as a guarantee that the system wil n de igi ed.
Date40-1 Inspector /� /;
Y44
-• ---------------- ------------------ ---------------- - _- - - - ------- - -
_. No:�� G�- Fee / Qo
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( )
R
System located at 3 �
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be complet•'d within three years of the date of this permit.
Date �! �� Approved by
FROM :down cape engineering inc FAX NO. :1508362gee0 Aug. 13 2013 01:39PM P1
13 -160
a D-lTfl U o f 13 2.7 U.s ta h 1.a
-Public --eleoffll
T hu-m,,Ds mexezn,Mreetor
�00 Y,.pjirn.,qle-Pel-, Hyz aaim,MA 07,601.1
Fax: 508-79D.-6304
Date- QW13 -302,
Desigipill, too f I fl-rl 4 Yn0allen Zlela p"
AArlircsq: mict.l.r, Adth-em: /oV
tin
was,lss�aed a pplilm,-,to instep.9.
based on.a dt;siga drawn by
(address)
Cz f\ 12 -lot dated
thatrefer anued abovo-was iLiqtalled c-abstmtiqD.y accoTding to
t.11f. desiv,14 -which may mirllud,r, mLaox approved changes sijc,'tt Pm TaLualxlor,�fion of tht;
Lux and/ocse]-tc,tank.
that I(; Sep-p.,.r, system ji.1)ovc- -qiaq inAmdhd withzajoT rliallg(-'S (i3O.
grc,,.jtcIr fl.an,10' latrual relocation.afthe SASS ci:ally vnitacal.T-elcoation of aTay componont
d t 1(-septic qygcf;arl) ljl3t in.&cf.oTdance'IM'Lh &Local. 1.11 e LIT L a[I OILS. au 1-:�V sj.cm (3 1!
cer6E(:d,qs--lJ'uil.t by di_sipt-,r to fb-l.ovr.
NISLA.-
OJALA
(kp,^tq*Ps7ST-g—,oa—fuTe) U CIVIL
No.46502
01ST
/()NAL E
CG
(Aff. cc
MVILSION. r.F.RTMEATE ff
U l' <-A-!) Al!TIJTM U()T j�ORW.t 4ND ASs-L?Q W.)
T.tEr-Ef Vjr!,D BY TIff Dl..Vl..S.lQN.
n. ("eithcafanD.rm'-26-04.6ic
1
Town of Barnstable Health Inspector
optHE 1p� Office Hours
do Regulatory Services 8:30—9:30
: Thomas F.Geiler,Director 1:00—2:00
■AINSTaaLE,
MASS.
i639• Public Health Division
♦�
AIFo 'rA Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT— SEPTIC QUESTIONNAIRE
1. General Information: Size of Property: a�3 acrP�
�j� 9 o600
Address: Ly5 )_alLe ,►'I'/fin Q'Y154 Map Parcel
Name:"'�.Ule_� Phone#:SR L(2s6 aq79
2a. How many bedrooms exist at your property now? `T
2b. Are you planning to add any bedrooms? If yes, how many?
2c. How many bedrooms total are proposed at this property (including the amnesty unit)?
—4-
2d. Please include a copy of the floor plans for the entire property - showing the existing
rooms in the home plus the proposed amnesty apartment and/or addition. Please label
each room clearly on the plans.
3. Is the dwelling connected to public sewer? YES or NO
If the dwelling is connected to public sewer,skip questions#4 through 49 below.
4. Location of dwelling is INSIDE or UTSID a Zone of Contribution to public supply wells?
L . Is th&dwell' connected to an =0ZITE WELL- or to PUBLIC WATER?
r _
m
;%. Is a disposal vorks construction permit on file? YES or CNO)
Lo
x � z
a. I -'Byes,how -y bedrooms were approved according to this permit? Bedrooms.
47. WeENxe any bu'#wmn permits obtained for construction of additional bedrooms? YES or NO
. Is re an ex gineered septic system plan on file at the Health Division? YES or NO
e"v
9. Has the septi system been inspected by a DEP certified inspector within the last two years? 69 or NO
--------------------------------------------------------------------------------------------------------------------
FOR OFFICE USE ONLY
The Public Health Division has no objection to bedrooms at this property.
Special Conditions:
Signed: Date:
Q;/heal th/wpfiles/amnestyapp
L-v, 446kr
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Town of Barnstable P# D
7� Departiment of Regulatory Services
r Public Health Division Date /� l�
200 Main Street,Hyannis MA 02601 I�I
Date Scheduled Time Fee Pd. 6 0U
Soil Suitability .Assessment for ISe � .Dis o l
Performed"By:
Witnessed By:
LOCATION OENERAI. C+RIVIA`Ti'ION
Location Address ?/ �C/a /(e L Owner's Name /
Address
Assessor's Map/Parcel: �/� Engineer's Name &I/J ki,
NEW CONSTRUCTION x
REPAIR Telephone# ..f-06- 36 a
Land Use: L a UVk-? 0--��
Slopes(96) Surface Stones ,f/Oh e '
Distances from: Open Water Body Possible Wet Area L-LoG ft Drinking Water Well ft
Drainage Way >la!/ ft Property Line ft Other ft
SIMTCH:(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands fn proximity-z Aolcs)
> _ 1
v .
S z. .
ti� •
6
Parent material(geologic) o tl+wa S,` Depth toBedrock `,
Depth to Groundwater. Standing Water in Hole: F N��" Weeping from Plt Face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HlG�I WATER TABLE
Method Used:
Depth Observed standing in obs.hole: In, Depth to soil mottles:
Dcpth to weeping from side of obs,hole: In, Groundwater AdjuAtment f.
Index Well# Reading Date: Index Well loyal Adj.factor,,,,,y,-.,._. Adj,Groundwater Level ,
Observation
PERCOLATION TEST' Dates8/-///�? Thna//,CO
� —•---
Hole# Time at 9"
Depth of Pero ' 7 64
Tlme at 6'
Start Pre-soak Time @ ) -OU _ Time(9"-6")
End Pre-soak
Rate Min.fluch L Z-
Site Suitability Assessment. Site Passed' Site Failed: Additional Testing Needed(YIN)
Original: Public Health Division Observation Holt;Data To Be Completed on Back----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable ConseVvation Division at Ieast one(1) week prior to beginning.
Q:\S EPTIC\PER C PORM.D 0 C
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Sdil Color Soil• Otbcr
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders,
• o i ten=y,96'Gravel)
A L S
LS �GyRsr1-
DE',EP OBSERVATION HOLE LOG Hole it
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
o sis en, %Gravel)
27-t2U C
DEEP OBSERVATION HOLE LOG Hole#.
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in") (USDA) (Munsell) Mottling
(Structure,Stance,Boulders.
-c—onliatency.CIP p c
r �
DEEP OBSERVATION HO'LIE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soll Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders,
Co si ton
y
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 pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? -e 5
If not,what is the depth of naturally occurring pervious materlall
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me,consistent with .
the required training,expertise and experience described in 110 CMR 15.017.
Signature /� " Date ZAPAI?
Q:IS.EPTICIPERCPORM.DOC
J
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MAP
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K_s*JX5 M. ;1 is
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L0CATION SEWAGE' PERMIT N.Q.
VILLAGE ,
1 �ST &41�ER'S NAME ADDRESS
ILDE R OR OWNER
4 r
DATE PERMIT ISSUE,p, -7 /1 §f
DATE COMPLIANCE'. IS SUED
Y 41 f
Poo
d
i
t
No...�.y: 3 F�S...l'J ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ ..............................O F............................._.........------------.....------------............._........
ApplirFa#ion for UiipooFal Works Tonotrnrtion Trani#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
...Ln:A......N rsAm ...Ki ls-------- ------------------------------------------------------
�V ^ Loc lion-Address or Lot No.
.... ! r._... `.._�.. •-•------•-•------•-----•.......... .................................•--•-_...-• . -•---•••--•-----...._._......................--
O_r ^� Address
:..,.. ... .................................
_.. -^--- ---------------••-----------------------------•-•-•---
-
Installer Address
UType of Building � Size Lot____________________________Sq. feet
a Dwelling—No. of Bed
Other—Te of Burooms...........................................Expansion Attic ( ) Garbage Grinder
a Other fix y ding ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
es
W Design Flow......... a�...v..__gallons per person per day. Total daily flow__.F��__......................gallons.
WSeptic Tank—Liquid ca acity _ gallons Length................ Width................ Diameter________________ Depth____.___.._..._.
x Disposal Trench Width ... ........... Total Length.................... Total leaching area.... ...__ ft.
Seepage Pit o.............: Diameter-___•:__�]f_j-__- --_ Depth below inlet.................... Total leaching area..
T
Z Other Distri uti ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a .....................................................=......................................................................................................
Descriptionof Soil %------------------------------------•--•--------....--------....--••-•---------------•-
----------------------------- ------ i2s� ...............wi ... _..
------------------------------ ------------------------------------------- - - -
---- ---- -
U OL
Nature of Repairs or Alterations—Answer when applicable°_' ____..... _.... ______ _ .?`...: CP--t? -.- -----•_l___.__._ __..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL 11 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
Z-on un ' ertificate of CompliaSi nh s een issued by the bo�aof health.g [�fJ tion A rov = = 7 f f
/ Date
Application Disapp oved r the following reasons:........................................................................................... ................._
.............................................. •--•---•------------------............._...----------••••-'----------------•-•-----••------.........._........................•----... ......•••-•••.
Date
PermitNo................................................... Issued.......................................................
Date
No... ........ Fps...... .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ ............ ................OF..........................._...........----------------•---......................_.....-_.
ApplirFa#ion for Bitipm al Workii Tonstrnrtinn rrmff
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:....y ly.rars••�_n...---..i 1 Y ?�5...1.�:5
n
-IL5......... ............................................... ..__.... •-- .....
Location-Address or Lot No.
C`._....�:- 10�.......................................... ..................................................................................................
Owner — Address
W �.� :r �' !.................. .
...... 1 7.�.�:........... ..................................................................................................
I-1 Installer - Address
Type of Building Size Lot.;..........................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Bmldin No. of persons............................ Showers — Cafeteria
Other fixtures �................•---"•......•-- .
W Design Flow............1...: �_,.;�............gallons per person per day. Total daily flow....................... ..........................gallons.
WSeptic Tank—Liquid capacity _'_..gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench-mo o.-•____ ........ Width................... Total Length.................... Total leaching area....................sq. ft.
'
Seepage Pit . o.__._.� ._____r Diameter........r....... Depth below inlet.................... Total leaching area...� .��....�sq..fL_.
Z Other Distribution--boxC( ) Dosing tank ( )
Percolation Test Results Performed by.........................................................................:' Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ra' ----•-•--------------------------•----------------•-------••--•-•-•-----•------•----------------•----•------••---.............._•----••-•---.......••-....--
0 Description of Soil........................................................................................................................................................................
x
w •-----------•... . _ -------•• •-•-••-•-----------•-•-••-•----•----•.... . ---
-
Nature of Repairs or Alterations—Answer when a hcable. .....(/1- Y.......�l
-----------------------------------------------"----------"--------•--"----••-••-••-.....--•___......__..._...••--•--•---•---•••---•••-----•--•-•-•-•--•...............................................
Agreement:
i 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
on.un ertificate of Compliance has teen issued by the board of health.
Date
ication 'A rove.. = ........................................... -j---•----••----
Date
Application Disapp owed r the following reasons---------------••-- -----•-----•----•--•---------------•--------•--------------•------------------------_-_..._
Date
PermitNo.................................................. Issued----•----•-------------------••-•--••------•-•--•------
1 Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........................................OF........1.1.1.......................................:................................
C9rdifirate of Tout pliFaurr
THIS�S CERTI Y, That the Individual Sewage Disposal System constructed ( ) or Repaired
-------------
by-...' ..: :.... _ f2 t�tr s
--_•----- �,-<
� \ Installer
y '
at ----------------------------------------------------------------•-•----
has been installed in accordance with the prow+;sions of TILE 5 of�Tl�e State Sanitary Xas ied in the
application for Disposal Works Construction Permit No-_K... ..Y..�.�................. dated_!? ------------------------------
THE ISSUANCE OF THIS CERTIFICATE\SHALL NOT BE CO STRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUj4CTIPN SATISFACTORY.
DATE................... ......................................... . Inspector........,.
THE COMMONWEALTH,;OF MASSACHUSETTS
BOARD OF HEALTH
OF.........................-...
7
No. ..........: FEE.......................
i to 1,,Forks �,ani#rnr#uan Trani#
Permission is hereby granted._ _.. : _.__......�_`. ..?j"�"� .
-...-------•--------•--•---"----------------------------•--••..........-------•-----
to Construct )norf Repair';fin IndWidual Sewage Disposal System
�
at No �• - ��. rf 1 - ,
•. - = --------------------•=--- .....
3 Street
as shown on the appli tion f r Disposal Works Construction Permit No.__ mac /..... Dated..........................................
'--:Board of Health
DATE......._j ....----••-------•------------------ -�.:'._?.. .... �,
FORM '1'2,55 A. M. SULKIN, INC.. BOSTON
H'
SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE
SYSTEM DESIGN. MARKED WITH MAGNETIC TAPE OR
TOP FNDN. AT EL. 81 .1' PROVIDE WATERTIGHT MIN. 20� DIAM. COMPARABLE MEANS FOR FUTURE LOCATION. NOTES
ACCESS COVERS TO WITHIN 6 OF FIN. GRADE (NOT TO SCALE)
LEGEND ACCESS COVER (WATERTIGHT) TO PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE 1. DATUM IS APPROX. NGVD I
GARBAGE DISPOSER IS NOT ALLOWED
I
100.0 PROPOSED SPOT ELEVATION
DESIGN FLOW: 4 BEDROOMS ® 110 GPD = 440 GPD MINIMUM .75' OF COWER OVER PRECAST � WITHIN 6" OF FIN. GRADE
2. MUNICIPAL WATER IS NOT EXISTING Rac Lone
100x0 EXISTING SPOT ELEVATION 2� SLOPE REQUIRED OVER SYSTEM o�
USE A 440 GPD DESIGN FLOW ' 1/8"
78.48 RUN PIPE LEVEL 2" DOUBLE-WASHED PEASTON 3. MINIMUM PIPE PITCH TO BE PER FOOT.
1 OO PROPOSED CONTOUR - EXISTING FOR FIRST 2' OR GEOTEXTILE FABRIC 77
' ��s Locu
SEPTIC TANK: 440 GPD (2) = 880 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO
EXISTING CONTOUR RE-USE EXISTING SEPTIC TANK** ** 77.08'*f H- 10 O
SEPTIC TANK ° ° ° ° ° ° ° ° ° ° 9�� Locu
o0o0o0o000o0o°00o0000°000000000000000000op060oo00 0000000°0000o c+
100 GAS 76.5 gggggggggggggggggg00000000g000gogog000g°g°ggggggg gogogogog00000
BAFFLE o0 76.55 000000000 ° ° 0000 0000 000 0000000 ,
76.72' �� °°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°° ° °°°°°° °°°°°°°°°°°°°°° 74.28 5. PIPE JOINTS TO BE MADE WATERTIGHT.
LEACHING: ° ° ° ° 0000000000o000000000 ° ° ° ° ° ° °
i
6" MIN. SUMP 4" PVC SET AT .005'/' SLOPE
SIDES: 2[2 (43 + 3) 2 (.74)] = 272 GPD " Mystic Loke
6 CRUSHED STONE OR MECHANICAL 12" MIN. INT. DIM. ON 6" DOUBLE WASHED 3/4" - 1 1/2" STONE 6. CONSTRUCTION DETAILS' TO BE IN ACCORDANCE WITH I
COMPACTION. (15.221 [2]) 2 TRENCHES: 43' L x 3' W x 2' INVERT MASS. ENVIRONMENTAL CODE TITLE V.
BOTTOM 2[43 x 3 (.74)1 = 190 GPD DEPTH OF FLOW = 4' SLOPE) SLOPE) 3.58'***
( 1 % ( 1 %
*THE INSTALLER SHALL VERIFY THE TEE SIZES: 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO j
LOCATIONS OF ALL UTILITIES AND ALL
TOTAL: 625 S.F. 462 GPD 29':f BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE.
BUILDING SEWER OUTLETS AND ELEVATIONS INLET DEPTH = 10"
PRIOR TO INSTALLING ANY PORTION OF , '�
SEPTIC SYSTEM lo�P
USE (2) 43 LONG x 3 WIDE x 2 DEEP OUTLET DEPTH = 14
LEACH TRENCHES OF PERF. SCH. 40 PVC PIPE AND STONE BOTTOM TEST HOLES 1 & 2 EL 70.7' 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
fiddle Pon
GROUNDWATER EXPECTED AT EL. 45't PEfR TOWN MAP 9• COMPONENTS NOT TO BE ,BACKFILLED OR CONCEALED
FOUNDATION- EXIST SEPTIC TANK 36' D' BOX - 7' LEACHING WITHOUT INSPECTION 'BY,BOARD OF HEALTH AND PERMISSION
FACILITY INSTALLER TO CONFIRM SUITABLE SOILS FO)R 4' MIN. OBTAINED FROM BOARD OF HEALTH. LOCUS MAP
BELOW BASE OF SAS PRIOR TO INSTALLING) ANY
MA PORTION OF SEPTIC SYSTEM 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING NOT TO SCALE
APPROVED DATE BOARD OF HEALTH DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION
**INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO ASSESSORS MAP 64 PARCEL 008
1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE COMMENCEMENT OF WORK.
--- ..----..-WITH- 1500 GALLON SEPTIC TANK APPROPRIATE __TO SITE
_ 11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND
CONDITIONS IF NOT SUITABLE REMOVED OR PUMPED-AND FILLED WITH-CLEAN-SAND:- -- - - -
12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE TEST HOLE LOGS
REMOVED 5' BENEATH AND AROUND THE PROPOSED
LEACHING FACILITY. ENGINEER: DANIEL E. GONSALVES, SE #13587
WITNESS: DONNA MIORANDI, IRS
DATE: 8/5/13
I
PERC. RATE _ < 2 MIN/INCH
VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE
IMMEDIATELY GRANTED BY THE BOARD OF HEALTH AGENT OR CLASS SOILS P# 14094
I
BY HEALTH INSPECTOR
PAPERWORK AND HEARING REDUCTION PROPOSALS APPROVED
ELEV. ELF/,
BY THE BOARD OF HEALTH REVISED DURING A PUBLIC
HELD ON AUG. 4, 2009
HEARING Z Opt80.7' p" 80.7'
A A
1 FAILED SYSTEMS ONLY : SAS TO PRIVATE ONSITE WELL V I
SE LS LS
SEPARATION DISTANCE VARIANCES, IF LOCATED IN THE SAME
GENERAL LOCATION AS THE OLD SAS AND MORE THAN 100
FEET SEPARATION IS PROPOSED BOTH FROM ON-SITE WELL AND 8" 10YR 3/3 10YR 3/3
8»
ANY AND ALL WELLS ON ADJACENT AND NEIGHBORING PARCELS.
`Y B B
LS LS
3) FAILED SYSTEMS ONLY : SOIL ABSORPTION SYSTEM V
INSTALLATIONS PROPOSED MORE THAN THREE FEET BELOW 10YR 5/6 10YR 5/6 78.5'
GRADE WITH PROPER VENTING (PIPED TO THE ATMOSPHERE) 27" 78.5' 27
AND WITH H-20 LOADING, BUT IN NO CASE SHALL THE SAS
74
BE LOCATED MORE THAN SIX, FEET ,BELOW GRADE. 1
• PERC C C
I r-
x 75 4 73.45 /CS I
_ M CS
i
4 2 - --
M
Q: I SHED 2.5Y 6/6 2.5Y 6/6
74.27
74.47-�`
i
I I WELL HOUSE
74.80 I .�Ri x ,. 120" 70.7, 120„ 70
2 .7'
I 74.66 `.F NO GROUNDWATER ENCOUNTERED.
74. 7 \��\ \��\ 73.98
LOT AREA 75
28,758f S.F. // 55\ s
708
7 .14 j
39 TOWN WATER
x 7 1 �g 56
5.04 //
T I T L SITE PLAN
x 80.45
0�/ OF
0
i
x 80.29
80.97 36 HALLETS LANE
/�/ �80.67 80.9�` 2
/ �75. x 80.71 i MARSTONS MILLS
x .0 TH 1 0.20 EXIST. DWELL.
\/ 0.04 P� .'� Z� TOP FNDN. EL. 81.1' PREPARED FOR
Xj I
`-�76.67 \ i�' GFLP �� i'''' T i'�' x
\� x 80.75 B&B EXCAVATION/WHITE
x\77.50 9.97 �.'' 80 O ao AUGUST 8, 2013
/ \ i TWIN 10"
79.44 D \ APLE x 5
� � 1 9. 8 � 8 O
c \ �• . 5 c� o �0 5� Scale: 1"= 20'
\R�4� \ x BENCH MARK - TOP OF BOTTOM
�OR�� � � STEP AT LANDING. ELEV. = 80.8
10" APLE O �a 0 10 20 30 40 50 FEET
\� ■ 0 /r76.69
8 x i
12"
PROP. VENT WITH CHARCOAL FILTER 6 79 E
AND BUGSCREEN (FINAL PLACEMENT BY 79•67'� \
CONTRACTOR WITH HOMEOWNER 7g \ Off 508-362-4541
CONSULTATION) \ 1 77 TI /76.73 fax 508 362-9880
/ 7.01
8.06 OF,a`,� +
� �, down cop e erg giro e erIn g, Inc.
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0j,q_A
i9�0 t a�
Cl 1/ILENGINE
L A ND SUR VE YORS
T DATE DANIEL A. OJALA, P.E., P.LLS. 939 Main Street YARMOU THPOR T, MASS.
>3- 160
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