HomeMy WebLinkAbout0006 HAMBLIN'S HAYWAY - Health HAMBLIN'S HAYWV) AV' I IL LS
'I
C
IJ
ComrrYmeo th.of Massachusetts John Grad
Exeeu" Ofte of ErWorvnentai Affairs D.E.P. Title V Septic Inspector
Department of P.O. Box 2119
Environmental Protection Te 108 5 MA 02536
� (508) 64-68 13
� 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM A 1�
PART A
CERTIFICATION m ROMEO
/ r
b MAY r
►' 3 0 1997
Property Address: '�Hamblin Hayway Marstons Mills Address of Owner:
Date of Inspection:5126197 (If different) to TOOPICEIARNSTABLE ~'
Name of Inspector:JohnGracl Nancy Wong HEALTHDEPT. N
Company.Name,Address and Telephone Number:
1
r Z
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X Passes This Inspection is based on criteria defined in Title y
code 310 CMR 15.303.My findings are of how the system is
_ Conditionally Passes performing at the time of the Inspection.My inspection does
_ Needs Further valuation.By the Local Approving Authority not Imply any warranty or quarantee of the longevity or the
Fails septic system and any of its components useful life.
Inspector's Signature: t Date: 5/26197
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A,B,C,or D:
A) SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
_One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair,passes inspection.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.)
_ The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is
imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11115195)
One Winter Street a Boston,Massachusetts 02108 • FAX(617)556-1049 9 Telephone(617)292-5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 17 Hamblin Hayway Marstons Mills
Owner: Nancy Wong
Date of Inspection:5120197
D] SYSTEM FAILS(continued)
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water 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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11115195)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 17 Hamblin Hayway Marstons Mills
Owner: Nancy Wong
Date of Inspection:5126197
_ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 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 APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
_ The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
_ The system has a septic tank and soil absorption system and is within 50 feet of a private water /
supply well.
_ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
_ I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
_ Backup of sewage in facility or system component due to an 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
cesspool.
SAS is in hydraulic failure.
(revised 11115195)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 17 HambM Hayway Marstons MIIIs
Owner: Nancy Wong
Date of Inspection:5126197
Check if the following have been done:
_X_Pumping information was requested of the owner,occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
n1aAs built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site.
x The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected
for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge, depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 17 HambM HaywayMarstons Mlls
Owner: Nancy Wong
Date of Inspection:5126197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 440 gallons
Number of bedrooms: 4
Number of current residents: 7
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: Ma
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL:
Type of establishment: n1a
Design flow:9 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings,if available: n1a
Last date of occupancy: n1a
OTHER:(Describe) Na
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the last year.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:9 gallons
Reason for pumping: n1a
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
1995
Sewage odors detected when arriving at the site:(yes or no) No
(revised 11115105)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1T HamblIn Hayway Marstons MOTs
Owner: Nancy Wong
Date of Inspection:5126197
SEPTIC TANK: X
(locate on site plan)
Depth below grade: r
Material of construction:X concreate_metal_FRP_other(explain)
Dimensions: L 10'6• H 5-7'W 5-9-
Sludge depth:3'
Distance from top of sludge to bottom of outlet tee or baffle: 24'
Scum thickness:4'
Distance from top of scum to top of outlet tee or baffle:6'
Distance form bottom of scum to bottom of outlet tee or baffle: 14•
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance.
GREASE TRAP:_
(locate on site plan)
Depth below grade: n1a
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: nfa
Scum thickness:nfa
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle: n1a
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
Iva
(revised 11115195)
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 Namblln Hayway Marstons MOTs
Owner: Nancy Wong
Date of Inspection:5126197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: Na
Material of construction:_concrete_metai_FRP_other(explain)
Dimensions: n1a
Capacity: n1a gallons
Design flow: n1a gallons/day
Alarm level: n1a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nla
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: O u� Id levelwlth bottom of pipe.
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
D-box is structurally sound
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
n1a
(revised 11115105)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 Hamblin HaywayMarstons Mills
Owner: Nancy Wong
Date of inspection:5120197
SOIL ABSORPTION SYSTEM (SAS):X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
nla
Type:
leaching pits,number: 2-1,000 gallon leach pits
leaching chambers,number:nfa
leaching galleries,number: nIa
leaching trenches,number,length: nla
leaching fields,number,dimensions:nfa
overflow cesspool,number:nfa
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach pits are structurally sound and functioning property.The pits had 2'of water In them at the time of the inspection.
CESSPOOLS:
(locate on site plan)
Number and configuration: nfa
Depth-top of liquid to inlet invert: nfa
Depth of solids layer: nfa
Depth of scum layer: nla
Dimensions of cesspool: nfa
Materials of construction: nfa
Indication of groundwater: nfa
inflow(cesspool must be pumped as part of inspection)
nla
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nla
PRIVY:_
(locate on site plan)
f Materials of construction: nfa Dimensions: nla
Depth of solids: nfa
Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
nla
I
(revised 11115195)
8
y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 Hamblin Hayway Marstons Mills
Owner: NancyWong
Date of Inspection:5126197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
1
AP !a O
ASAC
�9�y
DEPTH TO GROUNDWATER
Depth to groundwater: 12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9
-
MgrZ r �
BORTOLOTTI CONSTRUCTION,INC. � 1996
/ 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648
508-771-9399 508-428-8926 TAX: 508428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION 1F0ItMy ,�
PART A
/ CERTIFICATIONProperty Address: Gt/?� �S
Date of Inspection: Inspector's Name: ,-
Owner's Name and Address:
CERTIEICATIOI+I MIEM NT•
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection. The inspection was per-
formed based on ra�training and experience in the proper function and maintenance of on-site sewage
disposal systems. The System:
t� Passes
Conditionally Passes
Needs.Further Evaluation By the Local Aproving Authority
Fails
Inspector's Signature: Date: -2da4a�
The System Inspector shall submit a copy of this inspection report to the Approving authority within thir-
ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional
office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY,
A)SYSZ' PASSES:
✓✓ I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any fail6rc criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more"system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair, passes inspection.
Indicate yes, nor,or not determined(Y,1N,OR ND). Describe basis of determination in all instances. If
not determined",explain why not. �, j �►
The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or
exfiltration, or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
1 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four tunes a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by The Board of Health in order to determine if
the system is failing to protect the public health, safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS'NOT FUNCTIONING.IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 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 FAIT.UNLESS THE BOARD OF HEALTH (AND.PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has aseptic tank and soil absorption system and is within 100 Feet to a surface
.water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private.
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CUR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than G" below invert or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year due to clogged or obstructed
pipe(s). Number of times pumped
-2-
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safety and the environment because one or more of the following
conditions.exist:
The system is within 400 Feet of a surface drinking water supply
The system is within 200 Feet of a tributary to a surface drinking water 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.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
_Pumping information was requested of the owner, occupant,and Board of Health.
None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
,i As-built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
_L,,--The system does not receive non-sanitary or industrial waste flow.
_L/The site was inspectedfor signs of breakout.
�A11 system components,excluding the Soil Absorption System, have been located on site.
r/The septic tank manholes were uncovered,opened,and the interior of the septic tank was in-
spected for condition of baffles or tees, material of construction,dimensions,depth of liquid,
depth of sludge,depth of scum.
6,"The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3-
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
_ PART 13
CHECKLIST(continued)
`/ The facility owner(and occupants, if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal S_yste►n
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
-PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RESIIDENTUL: l/_
Design Flow: allons Number of Bedrooms: Number of Current.Residenls:
II
Garba a Grinder: Laundry Connected To System: Ye-0 Seasonal Use. C2/
Water Meter Readings, ifs fiilable:
Last Date of Occupancy:(
('OMMER LW INDUSTRIAL:
Type of Establishment:
Design Flow: gallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informa 'on:� �Ions
System Pumped as part of inspection: Lf yes,volume ►roped:
Reason for pumping:_
TYPE OF SYSTEM:
eptic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain):
APPROXMIATE AGE of all component ,date installed(if known)and source of information:
�s & i� 9 -
Sewage odors detected when Wriving at the site:
_4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade: Material of Construction: e concrete metal FRP_Other
(explain) ,
Dimisions: /19 S"\l �,;� �— Sludge Depth: Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation to utlet/invert, stru1.
_77ctural integrit , evidence of leakage,e
-aox 3
ir
GREASE TRAP:
Depth Below Grade: Material of Constructions:_concrete_mctal_FRP_Other
(explain)
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid
level in relation to outlet invert, structural integrity,evidence of leakage,etc.)
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction:+coacrete_metal_FRP_Otlier(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert:_rnli nvU�
Comments:.(note if level and distribution is e al evi ei�of solids carryov r,evide ce of 1 age into
or out of box, tc� y' � � i`a�) ��/,��� t^ '
PUMP CHAMBERA
Pump is in working order:
Comments: (note condition of pump chamber,condition of punips and appurtenances,etc.)
-5-
}
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFOI MAINON(contiuucd)
SOIL ABSORPTION SYSTEM(SAS):_
(Locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive
methods) If not determined to be present, explain:
Type:
Leaching pits,number: Leaching chambers, number: Leaching galleries,number:
Leaching trenches, number, length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Comme ts: (note condition of soil, signs of hydra lic failure level of ponding, condi of vegetation,
etc.)
C2 61Z., a
7�t ,? .
CESSPOOLS:
Number and configuration: Depth-top of liquid to inlet invert:
Depth of solids layer: Depth of scu►il layer: Dimensions of Cesspool:
Materials of construction: Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk, signs of hydraulic failure:, level of ponding,condition of vegetation,
etc.)
PIIVY:A/—b
Materials.of construction: _ Dirrimsions:
Depth of Solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)
i
-6 -
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet. —
V �
�J
r
00
�n
1
DEPTH TO GROUNDWATER: �
Depth to groundwater: 6}'7 Feet
Method of Determination or.Approximation:
✓CGl/�!/L��
T
- 7-
':. (0 TOWN.OF BARNSTABLE
LOCATIUN '1S > SEWAGE #
VILLAG ASSESS 'S MAP & LOT� �
DNS -' "9'�' '
NAME&PHONE NOS _ /2�/U
SEPTIC TANK CAPACITY I<W
LEACHING FACILl TY: (type) �S o"Z (size)NO.OF BEDR TR __Z
BUII,DER R OWN �12r G
PERMITDA COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
F
.�� 51 ,
TOWN OF BARNSTABLE
LOCATION �iL/�.15 ,CL4ylcjA� SEWAGE # 9y'lr y3
VILLAGE 6YI 1 y S ASSESSOR'S MAP & LOT.
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY /SAD (;N
LEACHING FACILITY:(type) /T`S ��-� (size) -C4 �/A
NO. OF BEDROOMS PRIVATE WELL O UBLI WATER
BUILDER OR
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: 7,- G
VARIANCE GRANTED: Yes
>47
r
. 1
0
3 z
No..-,c..-.c•-........ Fps........... . ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appli ration for Diopmttl Marks Ton.strnrtion Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair (64 an Individual Sewage Disposal
System at:
---..... ----------
/�� Location•Address f / or Lot No.,�}
....... . T..-C......4veE-1!%V�_ ..Y'.( t ✓L�✓�. ...............................er Address
763
W --- --��-�u,�'�-----------------�s..-------------------------------- .���- l�Jll !I ....
------------------- ---------
Installer Address
UType of Building �/ Size Lot............................Sq. feet
Dwelling—No. of Bedrooms--------------/__________________--_.__.__Expansion Attic ( ) Garbage Grinder--(— "JO
aOther—Type of Building ___________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures .-_..__._____________________ _ _
W Design Flow.................. ..................gallons per person per day. Total daily flow..............._�.�'_I_Q.................gallons.
WSeptic Tank—Liquid capacityl<V1@__gallons Length................ Width---------------- Diameter......---------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.___......__..___. Total leaching area....................sq. ft.
Seepage Pit No-------- "._._._ Diameter------1 ....... Depth below inlet------- Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY-------- ----------------------------------------•------------------------ Date........................................
,.a Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water-.____.______-_______--.
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P+ ----•--•-•••--------------••---•--•••-----••-----••---......---------•--------------........._------.........................................................
0 Description of Soil........................................................................................................................................................................
W
V ......................................................•-------------------------.....----------•-........-------------------•-•--•---...----------•......----------•-------......--•-------•------------
W
UNature of Repairs or Alterations—Answer when applicable.__.ft Mii. ------- .....O. Y.!0,(.__.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance s been is ed the rboard of health.
Signed ----------- ------ ..... ...`......'-:.:C✓ 6i%` ........ r4 / 9 .
Dace
Application Approved BY •t___ 'I---- -------------------------------------------
Application Disapproved for the ollowin reasons: ...... ........ ............................................. .................... ......................
- ....... ............................... ........... ............... ........ ....... ............................................................ . ........................................
Dace
Permit No. ---------�-1.v .. ..�"� .............. Issued ............................ . ..............................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Biupwial Workii Tunutrnrtiun rrrntit
Application is hereby made for a Permit to Construct ( ) or Repair ('54) an Individual Sewage Disposal
System at:
Location-Address or Lot No.
/!J.¢i�...0`.-......-- f,? J -.. 'Y ------- ------ l�_!J .........................................................'
O r Address
a G/l� t_U�- 7 C-c ,vs. 7(�� l�lA-�L�a> �2�.. � '�i ics
--•---.
� Installer
Address
d Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms.............. .........._._.._..........Expansion Attic ( ) Garbage Grinder—(—) ^J(3
a`4 Other—Type of Building No. of ersons____________________________ Showers
g ---------------------------- P ( ) — Cafeteria ( )
Otherfixtures ------------------- ------------------------------------------------ -------------------------------------------------------------
W Design Flow.................. ..._....____..__...gallons per person per day. Total daily flow-.--_--__-__--------�..n------.
..........gallons.
1:4 Septic Tank-Liquid capacity�9� .galIons Length________________ Width---------------- Diameter................ Depth................
x (Disposal Trench—No. .................... Width.................... Total Length.............7...... Total leaching area-------_............sq. ft.
Seepage Pit No......�-------- Diameter......ZA. ..... 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------------------------
tX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......_.................
a ..--••---•-•-----------------•--------.................---------•-••-•---------......-•---•-•--..............-••-•-•---•--•-------.......-----•----•---......
0 Description of Soil........................................................................................................................................................................
x
U ................................................. --•-•-----------------------------------------------•-•-----------------------•---•-••--------•------•------------------•-•---.....-------•-•-•--•---.
w
-------------- ---------- ------------------------------- --------------------------------------------------------------------------------------------------------------------••-- -------•-----••--•-
x -
U Nature of Repairs or Alterations—Answer when applicable.-.-tt4 ------ 4
'S _a ► , � ------�g- ------------ ------------- — ..........
.......................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance Vas.been is ed by the board of health.
/. ..
= cl----------------------------------------------
Signed
Dace
Application Approved BY ------- �� � Due
.-.. ........ /...d.._-.3 ..-...R..7
Application Disapproved for the ollowin reasons: .......... ... ... .. .................................... ..... .. . ............ . .
........ .............................. ......... .................. . ...................................... . - -- - ....... . . ............ ........................................
Dace
Permit No. .... ............ ._ -..--------- Issued ----
Date
-------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C�e>r#ifirate of Tomplian e
THIS IS TO CERY That the Individual Sewage Disposal System constructed ( ) or Repaired
by _.......... -.......
Installer
at ---------------------------------------------............--�. .�.�.6 —s. _� ....>------- f ,'1 /L-tS................
has been installed in accordance with the provisions of TITLE 5 f The State Environmental Code as described in
--��-�"/.__1 dated .: ---- ...
the application for Disposal Works Construction Permit No. __..._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE... --/~. - v.... - _._ Inspector
�� ---- ---------...-----
----------- -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
q TOWN OF BARNSTABLE
No..... � FEE. =.....`..•.
Disposal orku�Tunutr Lion rantit
Permission is hereby granted-------------------------� u, ,U1...__?J..._._____.___�!�:5''e-�-161J
---------------------------------------•.............
to Construct ( ) or Repair O an Individual Sewage Disposal System
atNo--------------------------------.....................-=`-'.............. y?'1l L e,/ y------- ......... ..- ............................................
as shown on the application for Disposal Works Construction Permit Street
_7 A/3 Dated-------
...................................U U-- --------•---------•-•---•-•-•--•----------•-•-•---
/r0 _
DATE-------------------¢-- ---
Board of Health
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
TOWN OF BARNSTABLE
LOCATION .��Z&1S '/�19/ SEWAGE # 99"-4/, r/3
VILLAGE /11 IN+
ASSESSOR'S MAP & LOT,
INSTALLER'S NAME fa PHONE NO. ' i -�
SEPTIC TANK CAPACITY /dip j
LEACHING FACILITY:(type) ,?"TES
NO, OF BEDROOMS li PRIVATE WELL O UBLI W TA ER
BUILDER OR WNE
DATE PERMIT ISSUED:
DATE` COMPLIANCE ISSUED:
VARIANCE, GRANTED: Yes z'
� R• Si Gt e lt/
i.
0
I �
�xi`srIN �3IN'27 N j
I I
I tH
fitrLt= ' s. 1
E><t.S-r L N(� C: R R C S L
I
1 I -
1
1 DUST G--ovCQ, i
1 I i
- s l;
Ll
GREIVIER PE DC;':_"
O V I '1 LJ A T . l O N P L AN
SCALE: 1/q �r y . APPROVED BY: DRAWN BY
DATE: 10' c1c` REVISED
DRAWING NUMBER _�
f
1_X1_,TIN6 DoolZ
f'
00 ! NOT F
r► N / + GO
f
E,-r- 1'ti L E t=L. x
�. i Ex
NI T .Hl3ovE t S
30.1
I
i i nl,�aKL KAmF-
f
ST �-L Oo R PLAN
i�eADL2 iN%3vvF--
JI
z
ri 2 $ q O
::TR 2
i
2 /VD r LO P PLAN
" RIB€ ��e��-���•-.`
1 1
1 �
w.< LES
1 1
�I.AS[T.
V A Po 1Z
� G DX �i i ►�c 1 �''
i�- rtsvL TvP I 1
1 _ l 4�- . 11 _ I�. fix
t3R�^���v'NC. R- iq zn�� ,tr�kr10P4 RLoG� rc�R.sr4�RS-`_ i
-`?a� G GX =..-L. ..G.c.._P J Z.. �_ �' •i.,;._. try._
i
EC l RCN
{
i � \
� C
rT, 1
' � 1
I - -
i
i
TT
I ,
� i {
1 i I
I
I
r
l
r�
[LUE
..Y
r� .:,.
i
1,
lg
f
i
� I
1
1 � I
0. c
� N
Zl
� 1
vo
rl
�1
. D
}ap n
� D 0
z � r
n z
f x p rn
v e
l
J C � P
,h
i
k�
I
i
i
' I
a
i
i
i
T
zr
I
i
• PAPP ,
MZP 6715 CENSUS TRACT �E 131
Dunnin Forman, Kirrane, & Terry DEED BOOK 2537
PAGE 78
Marc J. & Ke11y J GGrenier PLAN BOOK 222 PAGE 7 ' LOTASSESSORS PLAN PLOT.
ORTGAGE INSPECTION PLAK of LqN D
LOCATED AJ ' i�we� ��
17 HAMBLINS HAYWAY D j: (� Oq
SCALE : 1 50' MARSTONS MILLS, MASSACHUSETTS
JUNE 4, 1997
LoT I G,
LOT 17 �►
W ZY,150 S.F.
_-� LOT 18
III �5, #I_7
?
J �R
Q �. a„
� 3(,. BtT.DRIVE t
I
co
87.44n' gp.88`
HAMBLINS HAYWAY
" I CERTIFY TO DUNNING, FORMAN, KIRRANE, & TERRY, MORTGAGE CORP , EAST, AND ITS
ITLE INSURANCE COMPANY, THAT THERE ARE NO VISIBLE ENCROACHMENTS OR EASEMENTS
XCEPT AS. SHOWN AND THAT .THIS PLAN WAS PREPARED UNDER MY IMMEDIATE SUPER-
THE LOCATION OF DWELLING AS SHOWN HEREON IS
IN. COMPLIANCE WITH THE LOCAL APPLICABLE
ON I NG . BY-LAWS WITH RESPECT TO .HORIZONTAL
IMEN.SIONAL REQUIREMENTS , `
p; K . N�T-H' NA
HE DWELLING SHOWN HERE DOES NOT FALL WITHIN FE REI v; r
SPECIAL FLOOD 'HAZARD ZONE AS DELINEATED ON
MAP OF COMMUNITY #250001-0015C DATED gss F�IsTEP���
/19/85 BY THE F. I .A. rLAW`'�
Kenneth'R. Ferreira
" Engi'n g, Z11C.
eer 111
Po. Box 190.1
'New Bedford,.MA 02741-1903
508 992-0020 ♦Pax:508 992-3374
[. GENERAL NOTES: (1) The declarations made above are on the basis of my knowledge, information, and .belief as the
result of a mortgage plot plan tape survey inspection made to the normal standard of, care of registered land
surveyors pracL•iciog in Massachusetts. (2) Declarations are made to.. the above name& client only as of this
date. D) This plan was not made for recording purposes; for use in preparing deed descriptions or for. con—
s'truetions. (4) Verifications of property line dimensions, building offsets, Fences, or lot configuration may
'be accomplished omly by an accurate instrument survey.
m
� 1
d1 N 10
exel
s
2
LOT 17
2(�2A•.3 S.F.
R=194.od
A=9o.88'
I
{ GERT I f I EP PLOT PLAN
LOCATION: 6 HAM$LINS HAYWAY MARSTONS MILLS, MA
c sf
e w.9`y PREPARED FoR: MARL & KELLY eREN IER
: .fig m SCALE: DRAWN 6Y:
4d TMW
FSS10�P� JM NU45M DATE: St$FT:
SUR\j 04-O51 09-OZ-2004 GPP-1
A- VVELLER & AEEOG I ATE
1645 FALMOUrtl RIP - SUITE 46 GENTERVILLE, MA 07/on
TEL.: (508) 775-0735 - FAX: (508) TI5-0754
PROFESSIONAL ENGINEERS & LAND SURVEYORS
--
I
r
-12
CC
CA
El
I 10
i !
a
i0
. o
cr
j
cc
+ f
6 f
�f
I
c; t
I11
f�
I I
€I i
;{ 5
1
43Qr
�;v
dpedd
t4 . J rj -T
40 g
01,
® e -
V j
I Q F1
1
f t 11C i \
w
!
!�
49
34 Ell
vl-
Q pr
�7
`�
yf i W
I
ILE # MIP 6715 - CENSUS TRACT # 131
CL I ENT: unnina. Forman Kirrane, x Terry - ' DEED BOOK 2537
OWNER: PAGE 7a
APPL ICA : Marc J. & Ke11y J. Greasier PLAN BOOK 222 PAGE ' LOT
ASSESSORS. PLAN PLOT.
MORTGAGE I NSPECTI ON PLA >y of LAND
LOCATED A* T
HAMBLINS HAYWAY
SCALE: 1 50' MARSTONS MILLS, MASSACHUSETTS
. JUNE 4, 1997
LoT
186, 18`
LOT 17
LOT .1,8
11 a71
1.8;5 #I7
,.
_-J PoR
0 , 3y k
rr nn I ,1(, SST.DRY VE
vJ
5875'
I '
H AMB LINS HA` WA`(
j'FXCEPT
Y. TO DUNNING, FORMAN, ,.KIRRANE, & TERRY, MORTGAGE CORP , EAST, AND ITS
SURANCE
, COMPANY, THAT THERE ARE NO VISIBLE ENCROACHMENTS OR EASEMENTS
S SHOWNiAND THAT THIS PLAN WAS PREPARED UNDER MY IMMEDIATE SUPER-
I HE LOCATION OF DWELLING AS SHOWN HEREON IS
IN COMPLIANCE WITH THE LOCAL APPLICABLE
ONING , BY-LAWS ! WITH RESPECT TO .HORIZONTAL
IMENSIONAL REQUIREMENTS,
HE DWELLING SHOWN HERE DOES NOT FALL WITHIN PE AEI v,
SPECIAL FLOOD 'HAZARD ZONE AS DELINEATED ON 0.
MAP OF COMMUNITY #250001-0015C DATED
/19/85 BY THE F. I .A 0isTEa�°
Kenne. th'R. Ferreira
Engin' eerin Inc.
r�HvdYhaN�. 903
New Bedford,.MA 02741-1903
508 992-0020 A Fax:508 992-3374
GENERAL. NOTES: (1) The declarations made above are on the basis of my knowledge, information, and belief as the
result of a mortgages plot plan tape survey inspection made to the normal standard of .care of registered land
surveyors practieing �in Massachusetts. (2) Declarations are made to•. tl�e above named client only as of this
date. (1) This plan ;was not made for recording purposes, for use in preparing deed descriptions or for.con—
struetions. (4) Verifications of property line dimensions, buil(ling oFfset•s, fences, or lot configuration nay
be accomplished orrly !by an accurate ins•trument.survey.
--
}
i T-I HI
_ r
-!
t=RAJ4N T E E E VA T I DN
�•eC>C..NI � -
TT .I
211
LA-
00 Ty
�L. �_.. I
T
` T 7.
SIDE. E L.E VA T i c�1v/
j�itpGE vp,�(t— ,
f �.t►NC,F W_ — Tce
i etc-
'
�Ln$�Y_ (�1t'T= 'Q.. 1 `L C.-jmNv('�.(Z �I` 7 O •(
VAP�o2
13at2a,.1EfL
cox
yz
{
----- KIV
GX ... .
Qtz,p�,tJf�. R- Iq �N ,L��ir<tlorl roc t=c�.R.sr'4,R5 �'•. *,1�•'�',-• .
I 1
c�e
I S-r'./A) CROSS SEC I i 0 nl _
t '
���� r
_ r t 1 t r I' 9t E 1 �_,� ► i T � -
4 - -
i .
1
• �I TAT' t t_J_ L__. _ _ _ E
r E ( 1 1Y r L.
t
61
I I,
l�Ec..Ly Cz' I'V► �"�0 NT E L r V A;/ 0 A) ,
vq
-TI �
I.
71
I.
l
11
,
-
i I I 1 I
f
t s
i � 4
;
J
I
�I
I _
f•' y
F;
_ s f
i
I
_ Irr)
IIi � ,
' 1 0
rr
iLi
q
j --��
Jj
c
10 .
A
11CIO
l cs, c
j C-T-1 '
j dV e� it
i3/4
l
4
!
i
I
i
�t
3-0
i
r
'PITH ,
I
CE`fZ
Cv
c
P V
10
r,4 �
�i
t/ l
� f
s
,-��
o� �
9
17-
A -9 1 ,\
boo
YJ
� I
�.
0
l
rr K of
a cox•
LlAll IA NA A A
I!t
ruo
dy
CQ rJ���..-�"a � • � r G.
S •
OOE tl�ikkN�)6- NrlCAE�j
t5Tt tpON
aX� fT'v -- S
y-
Lai
-T(fo A)
•• GG�G l
J \