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HomeMy WebLinkAbout0008 HANE ROAD - Health ,,Hare Road Marstons Mills P --- h 51 008002 �I i' TOWN�OY BARNSTABLE LOCATION �cdl.� <-L VILLAGE �• (�llS ASSESSOR'S MAP&PARCEL v 'S NAME&PHONE NO. 1-11 f UC- Gd 0 K9( SEPTIC TANK CAPACITY 1000 LEACHING FACILITY:(type) Pt'e'1' (size) NO.OF BEDROOMS OWNER Leal 1✓1 PERMIT DATE: DATE: P I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland,and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY k♦ t \ \ 4 \ \ 4 4 4 ♦ ♦ \ 4 4 4 ♦ 4 4 4 4 4 4 4 4 4 ♦ \ 4 4 4 - f f . f f \ . . . 4 4 4 4 . h h h h \ ♦ h ♦ ♦ h h h 4 h ♦ h h ��f f i J f / f J J ' f / �//TT f f f f f f f. \ \ 4 \ \ \ \ \ \ ♦ \ h l \ 4 4 4 4 4 4 \ 4 4 4 4 4 1 \ 4 \ h \ \ h \ \ \ h 4 \ \ \ h \ \ \ k \ \ 4 \ . %4 4 ♦ 4 4 4 4 f f f f f f%f f 4 \ \ \ 4 \ \ h 1 1 \ 4 \ \ A J r r r r J J r Y k 4 \ \ 4 4 4 23 38 26 26 53 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Hane Road Property Address Boris Levin Owner Owner's Name information is Marstons Mills MA 02648 May 5, 2011 required for every page. CityrTown 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: A. General Information When filing out �I forms on the �I computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 Barn City/Town . State Zip Code 508.428.1779 SI 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority May 2 2011 Job# 11-67 I ector's SI ature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 fv I 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Hane Road Property Address Boris Levin Owner Owner's Name information is required for Marstons Mills MA 02648 May 5, 2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (coot.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time, leaching pit had 1' of standing water. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'f 8 Hane Road Property Address Boris Levin Owner Owner's Name information is required for Marstons Mills MA 02648 May 5, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Hane Road Property Address Boris Levin Owner Owner's Name information is required for Marstons Mills MA 02648 May 5, 2011 every page. Cityrrown Slate Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. J 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow 15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Hane Road Property Address Boris Levin Owner Owner's Name information is Marstons Mills MA 02648 May 5, 2011 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 8 Hane Road Property Address Boris Levin Owner Owner's Name information is required for Marstons Mills MA 02648 May 5, 2011 every page. City/town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of El ® this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® El information the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 l5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Hane Road Property Address Boris Levin Owner Owner's Name information is Marstons Mills MA 02648 May 5, 2011 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): N/A IrrigationSystem. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Hane Road Property Address Boris Levin Owner Owner's Name information is required for Ma tons Mills MA 02648 May 5, 2011 every page. Cityfrown State Zip Code Date of inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Tank pumped one year ago. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 8 Hane Road Property Address Boris Levin Owner Owner's Name information is required for Marstons Mills MA 02648 May 5, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance date 1/27/89 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 16" Depth below grade: feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5' long x 5.2'wide- 1000 gal. 3" Sludge depth: l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 8 Hane Road. Property Address Boris Levin Owner Owner's Name information is required for Marstons Mills MA 02648 May 5, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27 2° Scum thickness Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is not in need of pumping at this time. Liquid level was found at bottom of outlet invert and tees were intact and clear. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Hane Road Property Address Boris Levin Owner Owner's Name information is required for Marstons Mills MA 02648 May 5, 2011 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 1 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Hane Road Property Address Boris Levin Owner Owner's Name information is Marstons Mills MA 02648 May 5, 2011 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains present, liquid level was found at bottom of single outlet pipe. a Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Hane Road Property Address Boris Levin Owner Owner's Name information is Marstons Mills MA 02648 May 5, 2011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: e: ® leaching pits number: One 46 pit. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching pit had V of standing water with a faint stain line at 50% capacity. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert TM Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No I t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Hane Road Property Address Boris Levin Owner Owner's Name information is Marstons Mills MA 02648 May 5 2011 required for every page. Cityfrown 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.): c t5ins•09108 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 8 Hane Road Property Address Boris Levin Owner Owner's Name information is Marstons Mills MA 02648 _ May 5 2011 required for City(Town State Zip Code Date of Inspection every page.. D. System Information (cont.) Sketch Of Sewage Disposa eandmrovide arks or benchma view of rks.ks Locate e sewage dalpwelal system,ls within 100 feet.including les cateo at least two permanent reference where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately Hane Road Water Service , , IN IN' IN , , , ,,,,,,,,,,,,,,,,,•,`,`,`,`,`,`,`,`,`,`,`,�, N. , , , , , , , , , ♦ , ♦ , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , NNNNN 34 23 38 26 26 53 < w 4 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Hane Road Property Address Boris Levin Owner Owner's Name information is Marstons Mills MA 02648 May 5, 2011 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 20+ Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: USGS to o map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el 40 and topo map shows property at el. 100. a Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 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 8 Hane Road Property Address Boris Levin Owner Owner's Name information is Marstons Mills MA 02648 May 5 2011 required for State Zip Code Date of Inspection every page. Cityrrown E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 •'`� TOWN OF BARNSTABLE' LOCATION 2A SEWAGE # > v` ���•. VI GAGE AU-MRU-S ASSESSOR'S MAP & LOT151 ®® 0 Z. INSTALLER'S NAME&PHONE NO. } 'LC-L L i11 SEPTIC TANK CAPACITY I ` LEACHING FACILITY: (type) ��T (size) COW qJ NO.OF BEDROOMS 3 BUILDER OR 4�WNE PERMIT DATE: DATE: 1! Z 510 Lf Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet "-_Furnished by - U`Ar e 39 1 �3 i ✓� T)OVIN ()F ` rSTABLE LOCA'TIONcan P r�l Vc,rs��� �, 'WAGE #_ ''-LI.AGE i �-�I ® �l j�t ASSESSOR'S MAP & LOT NSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY JOov_ _ C,,5 �4 (size) Zoo LEACHING I=ACILITY:(typ�=) �,� — NO. OF BEDROOMS_ PRIVATE WELL OR PUBLIC WATER- -® BUILDER OR OWNER / — �d�lrJ�✓S _ DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED. . VARIANCE GRANTED: Yes No / Cora�.,� l' c7 a4 S . 1 1 f(A d' i 0 r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION AP1,..-.�,.' iRCEL i O C TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION x Property Address: 8 Hane Road Marstons Mills MA 02648 ` C Owner's Name: Thomas Handy Owner's Address: 100 Acorn Hill Road Cary NC Date of Inspection: November 23,2004 c,` '`'• Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. -- Mailing Address: 189 CAMMETT ROAD c:D MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper_function and maintenance of on site sewage disposal systems. I am a DE � approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: �````,N OFt/1q M X Passes ` •• ' Conditionally Passes p?.'• ';yG Needs Further Evaluation by the Local Approving Authority _ P T i m Fails = LL . c Inspector's Signature: D •• , � .•Q,' ` ate: 11/23/04 '�., •�F RTLP k `� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design now of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Leaching pit empty at time of inspection,has never been more than half full. ****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. Title 5 Inspection Form 6/15/2000 page 1 r� Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - CERTIFICATION(continued) Property Address: 8 Hane Road,Marstons Mills Owner: Thomas Handy Date of Inspection: November 23,2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Ti+IP S inennrtinn Rnren Aii;nnnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 8 Hane Road,Marstons Mills Owner: Thomas Handy Date of Inspection: November 23,2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health safety and environment:P � y _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a.Zone 1 of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Titla incnartinn Rnrm Aii S/7nnn 3 Page 4 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 8 Hane Road Marstons Mills Owner: Thomas Handy Date of Inspection: November 23,2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool — _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow —X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X— 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — _ the system is within 400 feet of a surface drinking water supply _ — the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, "yes"in Section D above the large system has failed.The owner or operator of any large system cons de ed aered significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Tifla G Tnonnn*inn Fnrm 4/1 si,)nnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 8 Hane Road,Marstons Mills Owner: Thomas Handy Date of Inspection: November 23,2004 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health — _X_ Were any of the system components pumped out in the previous two weeks — _X_ Has the system received normal flows in the previous two week period ? X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? X_ — 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? X_ _ 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: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ 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(3)(b)] T41a G Jfi-'rtinn Rnr..,!/l ci1nnn 5 Page 6 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART C SYSTEM INFORMATION Property Address: 8 Hane Road,Marstons Mills Owner: Thomas Handy Date of Inspection: November 23,2004 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): Yes Water meter readings, if available(last 2 years usage(gpd)): 2002—62,000 gal.2003—64,000 gal.=172 gpd. Sump pump(yes or no): No Last date of occupancy: 6 months prior to inspection. COMMERCIALAND USTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): Pumping Records: None GENERAL INFORMATION Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool —Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 1/27/89 Were sewage odors detected when arriving at the site(yes or no): No Titles C incncrtinn Rnrm 611 C17nnn 6 i Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 8 Hane Road,Marstons Mills Owner: Thomas Handy Date of Inspection: November 23,2004 BUILDING SEWER: XX (locate on site plan) Depth below grade: I' Materials of construction: cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: 30' Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: I' Material of construction:_X_concrete metal fiberglass_polyethylene _other(explain) — — If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:8.5' long x 5.2'wide—1000 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 27" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): L_iguid level at bottom of outlet pipe Baffles intact and clear. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:—concrete metal fiberglass_polyethylene other (explain): — — — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Titles G lnonnnlinn P^rm 4/1;1,)n n 7 Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 8 Hane Road,Marstons Mills Owner: Thomas Handy Date of Inspection: November 23,2004 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Liquid level a at bottom of single outlet pipe no solids or hkh stains present PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): T41. G TncnnrNnn Fnrm 4/1 v,7nnn 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 8 Hane Road,Marstons Mills Owner: Thomas Handy Date of Inspection: November 23,2004 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X—leaching pits,number: One 4x6(600 gal.)pit leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Leaching pit empty at time of inspection and has never been more than half full CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Titlo C inenortinn Perm A/1;mn on 9 r Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 8 Hane Road,Marstons Mills Owner: Thomas Handy Date of Inspection: November 23,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. Hane Road Water service ' #8 34 23 26 38 26 53 1000 gal tank 600 gal pit Title inennrtinn Fnrm�i�ci�nnn 10 Page I I of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 8 Hane Road,Marstons Mills Owner: Thomas Handy Date of Inspection: November 23,2004 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 20 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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) _X_Accessed USGS database-explain: Town GIS and USGS topo map You must describe how you established the high ground water elevation: Topo map shows property above el. 100 and town groundwater contour map shows water below el.40. Titlo i T"cnA,,t1An 17nrm 4/1 rl,)Aln ]l COMMONWEALTH OF MASSACHliSETTS !; EhECL�TNE OFFICE OF E:�'VIRONDIE\TAI. AFFAIRS,, F DEPARTMENT OF F2iMONMENTAL PROTECTION NZONE ttT\TER STREET. BOSTO?�ItiL�.0210E i61: 292-55Uu TRUDY COX: SecretanP.: ARGEO PAUL CELLUCCI DAVID B ST 'uS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PropertyAddress:8 Hane Rd., Marstons Nameofovner Andrea Sutton Mills Address of Owner: Same Date of Inspection:3` ��"�4`�+L-o Name of Inspector:(Please Prirrt)Wm. E . Robinson Sr. 1 am a DEP approved systerq inspector rsuarrt to Section 15.340 of Title 5(310 CMR 15.000) m Copany Name: Wm. E . Robinson Septic Service Marling Address: PO Box 10 9. Centerville , RA Telephone Number: 7 7�'—R 7 7 0 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 se disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Z inspector's Signature: , Date: 3 620 — &.0 Z The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 ttte system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS ?000 f_ p4 cyS; f �a revised 9/2/98 Page Iof11 %j �rr!ed on Recycled Pane. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART A CERTIFICATION(continued) 'rop"Address: 8 Hane Rd. , Marstons Mills *)wrier: Andrea Sutton Date of Inspection: INSPECTION SUMMARY: Check 4�Q C, or D: A. SYSTEM PASSES: have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. S TEM CONDITIONALLY PASSES: 0 e or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon co pletion of the replacement or repair, as approved by the Board of Health, will pass. 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is 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 complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipets) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipets) are replaced obstruction is removed i revised 9/2/98 page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (corrtinued) Property Address: 8 Hane Rd . , Marstons Mills owner: Andrea Sutton ' Date of Inspection: 0--tr-o C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEAL TH: 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) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)'DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and.the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER .a revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 8 Hane Rd.. , Marstons Mills Owner: Andrea Sutton Date of Inspection: D. STEM FAILS: You m t indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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. Yes o Backup of sewage into 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 SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the 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. LAR E SYSTEM FAILS: You mus indicate either "Yes" or "No" to each of the following: , The following criteria apply to large systems in addition to the criteria above: 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: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA) or a mapped Zone If of a public water supply well) The ow er or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office o the Department for further information. revised 9/2/98 iPage 4of11 F r - J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 8. Hane Rd.. , Marstons Mills owner: Andrea Sutton Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least 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. _ 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. _ The system does not receive non-sanitary or industrial'waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ 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. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)1 The facility owner (and occupants,if different from owner) were provided with information on the proper maintenaacj�-0f SubSurface Disposal Systems. re—1 sed 9/2/98 Page 5ofII s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION troperty Address Hane Rd.. , Marstons Mills Owner: Andrea Sutton Date of Inspection: ro�b•��-v`� FLOW CONDITIONS RESIDENTIAL: Design flow:36 b g.p.d.lbedroom. Number of bedrooms (design): 3 Number of bedrooms (actual):3 Total DESIGN flow 3 6 p Number of current residents: Garbage grinder(yes or no): 6 Laundry(separate system) (yes or no)A-0• If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):A.0 Water meter readings, if available (last two year's usage(gpd): 1999 76, 000 gal. Sump Pump (yes or no): o Last date of occupancy 3 aa_}G— 1998 58, 000 gal. COM ERCIAL/INDUSTRIAL: Type o establishment: Design f ow: gpd ( Based on 15.203) Basis of esign flow Grease t ap present: (yes or no)_ Industri I Waste Holding Tank present: (yes or no)_ Non-so itary waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last d to of occupancy: O R: (Describe) Last a e of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)X, If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEM 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: Sewage odors detected when arriving at the site: (yes or no),.,4— Tevised Page 6(if II r = SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ,ropenyAddress: 8 Hane Rd.. , Marstons Mills Owner: Andrea Sutton Dste of Inspection: 3_ ®_may BUILDING SEWER: (Local on site plan) Depth elow grade:_ Materi I of construction:_cast iron_40 PVC_other (explain) Dista ce from private water supply well or suction line Diam ter Com ants: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: (locate on site p an) 1 Depth below grade: Material of construction: "concrete _ _metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ (sage confirmed by Certificate of Compliance_ (Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffler i� 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 baffler How dimensions were determined: 0 ?CJv, H ;omments: (recommendation for pumping, condition of inlet and outlet tees or,baffles, depth of liquid level in relation to outlet invert, structural integrity, eviden�Sp of leakage, etc.) / b CJ—c�' Q ,a f �L 1- i� 7 }�S >�I-- AA G tb ;& A ' ti. ►, ®i IV 6 S i Ll'/ttLZ- ° GR E TRAP: (locate n site plan) Depth be ow grade:_ Material f construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensi s: Scum t ckness: Distan from top of scum to top of outlet tee or baffle: Dista a from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Com ry ants: (recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, eviden a of leakage, etc.) reV1SAd 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) AropertyAddress: 8 Hane Rd.. , Marstons Mills Owner: Andrea Sutton Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of constructi n: _concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow-_gallons/day Alarm pre nt Alarm le el: Alarm in working order: Yes_ No_ Date of previous pumping: Com ents. (conc)nion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on.site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,vi nee of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHA BER:_ (locate on si a plan) Pumps in w rking order: (Yes or Not Alarms in orking order(Yes or No) Comments (note con ition of pump chamber, condition of pumps and appurtenances, etc.) } Y revised 9/2/98 + page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) toperty Address:8 Hane Rd.. , Marstons Mills Owner: Andrea Sutton Date of Inspection:?—,x O 9�&-c 4' SOIL ABSORPTION SYSTEM(SAS): flocate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:L leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) CESSP LS:_ (locate on site plan) I n configuration: t liquid to inlet invert: sods layer:sc m layer: s f cesspool: of construction: o groundwater: i flow (cesspool must be pumped as part of inspection) Comment Inote con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY.- (locate o site plan) .Materi s of construction: Dimensions: Depth o solids: Comme ts: (note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) '"eViseci G/L/iC PaFc9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'ropertyAddress8 Hane Rd.. , Marstons Mills 'wner: Andrea Sutton Jate of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water'supply comes into house) w r i revised 9/2/98 Page 10 of 11 C a 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) rop"Address: 8 Hane Rd.. , Marstons Mills Owner: Andrea Sutton Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope - Surface water Check Cellar Shallow wells 1-4 Estimated Depth to Groundwater L Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions ' / v Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators. installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11of11 41k� r t i /� - y No. b — 06 _Q) Fss....k.. !.. ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... - .t.......OF... �I"/2 -��` ---•-....--•--- �, ppliration f r DiipnsFai Works Tonotrnrtinn ramit SApplication is hereby made for a Permit to Constructor Repair ( ) an Individual Sewage Disposal System at: __.....- Location•Address �� f I , �r . 1... - -------------- W ............... - =-- - r,!�g,�r_vj-.Me----------------..........................Iq s Type of Building Size Lot_1 0,,_.9 9__..Sq. feet U Dwelling—No. of Bedrooms.........._�.............. .Expansion ttic.(�� Garbage Grinder U Other—T e of Building �-_-- Showers — Cafeteria p., YP g ---�----�-R'�'-'•=!.`__ No. of persons------- ------ (�J—" Cafeteria —l' a Other fixtur s .__ W Design Flow-----_----_---- gallons per person er day. Total daily flow-__------..��-�-.__._____....dons. WSeptic Tank—Liquid'capacity[OP®gallons Length. �..���. Width..`_!.J®w Diameter______ ________ Depth__._..�:_g_.`� x Disposal Trench—No. -___-_---------__. Width_ . .......... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...._..._..i-------- Diameter' ....I............. Depth below inlet.-cAuo.s..... Total leaching area....b .sq. ft. Z Other Distribution box ( ✓f Dosing t nk / c 6,� Percolation Test Result Performed b •••.......ems...• M C"-"S� Date..._..Z- ®) .(" P �7 Y. } 1.4 Test Pit No. 1................minutes per inch Depth of Test Pit...j.1,------ Depth to ground water....... Test Pit No. 2....L_z..minutes per inch. Depth of Test Pit--- ......... Depth to ground water........ :_-.. ------------ ---- __ ------------------- O Description of Soil.........� ...... -51"Z VJ: ----- �------------" ----..-----"----4. � _ - U ••-•-•-•--------------------------•---------•-•-----•--...---------•-••--••••----...-----------••-------•----•--•--•--------------•-----•---••-••-----------•----------"--- U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ,.i -----••---------••-------------•--•----------.... ------------------------.---"--••---- -----•---"-------------------------------------------------------•-------------------•---"-------.._. Agreement: The undersigned a�Ho install the aforedescribed Individual Sew ge Disposal System in accordance with the provisions of iITL L 5 of the State Sanitary Code e undersigne urt grees not to place the system in operation until a Certificate of Compliance has been is ed y b h Signed'........... .. .. ........ f .....-----Y/....Application Approved BY----... ._. ... .. .............--------.....--•---........._._.._......._ Date Application Disapproved for the following reasons:..............................................................................................................-- "------------------------------•--....------------------•----•------.............---------.........•.........•.....•------------......•-----•--•. ............-- Date PermitNo.........................-------------------------------- Issued....................................................... Date � r ' i 60- NO.S.L._-••_2.___.1- FEs....(...:..i..r-........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... .......OF.... �R`I/_S .. c L__ .. ....................................... Appliratiun for Uiujiuual Workii Tunutrn.r#ion ramit Application is hereby made for a Permit to Construct ( l,)or Repair ( ) an Individual Sewage Disposal System at: � !� _ e;) - Z- <2-'a cam vV. 3 ... 2 -. - ................. ., ..``. ..- :.... -•••...... ................................ Location-Address j s............:.......!..=.: .?::.-= .:............................._---.;_............. .......................... ....,... W .......................... owE`= �•_• _s •-- 1!-?y l ....-----------------------•.. --- �� . �-t - --- Installer Address UType of Building Size Lot._�.�:. �.. ...Sq. feet Dwelling—No. of Bedrooms...............�'�..._-__------------------- Expansion ttic (''"') Garbage Grinder Other—T e of Building ( t'+^"' No. of persons...... ... ( )� Cafeteria ..� dOther fixtures—,,, ....._....---••-•--..._------ Wgn ..........................................gallons per person per day. Total daily flow............................................gallons.,, De`si Flow. ` • 3 � V WSeptic Tank—Liquid'capacity.100 gallons Length.__�.�._.� _ Width...'._....... Diameter................ Depth_. ._..4.. x Disposal Trench—No..................... Width..................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._.•----_-_.I-------- Diameter...... �._-.... Depth below inlet..��-:��.. Total leaching area.....'�_....: sq. ft. z Other Distribution box ( l Dosing tank (-�" 7 /`©/ )N /I°�) r��r >< 1 �)r:? chi 2 7 Percolation Test Result Performed by ...---•--•..... ..... ..................• •--•--- _ ------ Date------------...............-----o...) a Test Pit No. 1................mmutes per inch Depth of Test Pit____ __ _________ Depth to ground water............j.... . . �X4 Test Pit No. 2._._.`.Z.minutes per inch Depth of Test Pit---- .......... Depth to ground water-___------------------- •-••••••--•-••••-•-•-•-----•------------•--•-•-•••--•-----------•-••----•---•-•••••----•-----•....:.........•--•--------...._......----••••--..._._......---- O Description of Soil U Soil......._... — ... ______ .. C_ -t, / IL- 1 %= _ _ .. _... - '< �� �r L .f_^_.. W UNature of Repairs or Alterations—Answer when applicable................................................................................................ ---------•-•--------------------------------------------------------------------------•----.......---------------------------------------------------------------------•--.._...-••--------•••••---•---- Agreement: The undersigned agr . install 'the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ITA IZ 5 of the State Sanitary Code e n ersi ne rt rees not to place the sy em in operation until a Certificate of Compliance has been isst.1 d o d ea ��•'�'f� Signed.'_........ ...... . .............. .............................. -•------------/ - .� at Application Approved By..... -......... I 6 Date Application Disapproved for the following reasons:......................................... -------•------------•••........................• - .._..__-._-__ .................................................... ............................................._..................................................................................... PermitNo...................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .!......D vvl......OF..... .`-.. 2/V,.:3...... 7 /_ .....................I.........°... Trdifiratr of Toutpliatta THIS I TO CE T FY, hat d vk .ewage Disposal System constructed ( y) or Repaired ( ) by............... :._....� - f ., �--------------- -----•--------•--...........---------•----•-•------------......-•-----...------------ �- -J Installer / at-----------------------------------------------•-----------•--__------------------------------ S'-............................................................................................. has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......................................... dated----------...................................... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... / 1 THE COMMONWEALTH OF MASSACHUSETTS / ( BOAR_D OF HEALTH .............................. .......�.........................OF.. No.� .............. FEE.-•----1..?r_.x......-....... f, .l�'-�.---:.��.L.� . • f �t'u�rou 1 � PnniuT"Urrutit Permission Is hereby granted..____ '_....______._ _ to Construct 1��r Repair-( ) an Indi idua�l Se age Disposal System I - at No `° —`a ----• - ----------------------------------------••--- .............................................. Street as shown on the application for Disposal Works Construction ermit No..................... Dated.......................................... Board of Hea th DATE--------. / 4` ...... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i BENCH MARK �- TE-ST H4l. E RESULTS i P G L.4 V ) 3 w s 7 4, /V,ITS.V.�..! _1 DATE � 348 I WITNESSED BY T-N0M r1 /� `IC��AN L3. 0 H. IY) 'n,► T O r 8 a .S c x; L.,5 )z Y N 7 U3 TL L z { o . rr cq va 1 1 l 2 'f. R------•-•-- t .. c0 f m 1 rt �, 7- , 7'7\- 24 N o P ; �. 11 7 \ , s c ] c..o ``� 13 2 r 3 1 JV Q v'✓ /2c�0 � GA2 I \ I I IDlz A V l+l. L["f .7 � ; T "] r y A 0 ER TO BE BUf LT T ,. ., , -• :,. � - r _ S MANHOL.E;S N D C V y 8 . 1 r p�ry h : •, ELEY T P � D RADE '.. . , 12 4F flN1SNE G :. YdiTHI:N _ I t FOUNDATION _ .. . m 2 . ._ , •.,, _ IN1SHEb -GRA - . PE J 4 A. F Irfil _ :+r Di PIP 4RS ;" �.. M F:, � LA 0 C� MI N. 2 L R M N. _ PIPE 2 ♦ , ...._._.�_ ,N. M l N.PITCH 1 L V � �+ 1 ` r y ._ PEAST;ONE � N. PITCH , _ r . r . r l 12 / a .T --- ., F T. / / i N`V Rw»tP T Pkaros _ ! 6. fNVER •,E� -_ � � N V T GALL N 9 i E R �,, G L O . - , cn tII r . . -. _. G9 .. --..� 1 2 I 0 A. L cry . fare l� 12�.17 . . 4 2 A N K GJ . .---.�. E P T f G T O . . _ . s —_ aA �s - _ . 84X 'L _ 9� _..- \ INVERT w l: 1 _ VERT t r ALL F� ACE 01, m '^ 1 - � 80TT0M - _ s 71-0 MI ) 4 A1 GARBAGE. . ,d ND ,. GRI R E �.._ N .� 407 7, ELEV. If w �`R•..�: -GROUNO WATER TAt3LE t3�'" O , _ PR0F.1_LE O.F. : ,a J E -_ , .. — ISPQS AL Y T M t._• _ TAR Y D SA N I , , T SCA L E NOT 0 � is DES ! G N ;DATA BEDROOMS Y DISPOSA ,L - .,��' _- --;C - • : CONSTRUCTION OF A S NITAR - E' M ASS. / SHALL CONFORM TO TN t� ' _SYSTEM S L _- GAL. .DAY � - DESIGN FLOW ., . G DE I "I., LE ENVIRONMENTAL, 0 T i - - : LEACH RATE ..- MIN IN _ W F : _ 7 D HE TOWN - 0 REVISED_ 7 } 7 I AN T 33 t7 a w t �-- ,�' cca vn�rr-��.'� REQUIRED LEACHING GAPACtTY � .. CL� y .r' RE4 1R D - S t-1EALTH R`EGUL' AT1O N r-�'.�" �` �! cam' �r- s . . - -- � SEPTIC ..TANK DISTR118UTi0N- BOX AND LEAC, H -PROPOSED _: G A DAY — tz ,�-.� v ry- ING UNIT TO BE OF REINFORCED; CONCRETE . 4,000PS.I. G'aMIN. CONCRETE REQUIRED SEPTIC T - - I L a ANK c r�r� c t �-.-�-�/ MIN. STEEL STRENGTH IR E N G T H 20,000 P S. 1. r N /Ca MI N. OESIGN LEAD I N.G ,. _ PROPOSED SEPTIC TANK: DRIVEWAYS NOT TO BE LOCATED OVER SYSTE M UNLESS H2O DESIGN LOADINGJS - - USED - .G BE . WATERTIGH T; s ALL PIPES AND ;FIT,TI N S , TO'. - AND TO BE OF CAST IRON . OR APPROVED P.V.C: , HEALTH AGENT APPROVAL. D ATE r /�HNS ` ,S `I 1 ,T.E- P 1� N SHOWING _ PROPOSED CO TRUCT 10 N ,. LOCATION : 7, LEG EN D w 7- '�^,f Z :DATA ZONING , :. '. , t ,,FOR : DATE .,� C.� .51 . TEST HOLE LOCATION , J ? `v�' f@� z oN E _. _ ._.._ ._ .— � --RE F E REN:C E .rz .� '� R EV I S i 0 N S .�._ 4 5 �4 EXISTING NG SPOT E Ht•.r ,� ". :. ..� .��l tit .�`J,�3 h}Vr J` „�• 1 C.��! ,�,� ,�'i�'� r R E t� U I�R E�D A R E A ..� , . �� "REQUIRED FRONTAGE ..... ._..� cu EXISTING CONTOUR , l� 6 � - _ CIVIL . FRON T • SETBACK PROPOSED CONTOUR SCALE * W 5 r:� P R OP 0 S E 0 WAT:E R S R i ENo.27483 - r SETBACK ,:C K �.. sue. U E D SIDE E S T A , , _ R EQ 1 R S s PROPOSED . AS '.SERVICE s NAfi• BA GK ._ E RED R E R E - .. .. :. , - PROPOSED E - TE O R A-,,,I -,G S_ H C. R .- R, P. E E_ p 1 N EER , _ r FILE N ,. _ . 3 4LD R:t3UT t N . . , APPROv D _ _: TO R Y 8 U i LD N G _ 1 N S P E C T_ ._ S HE ET: ZZ: � - -, ,