HomeMy WebLinkAbout0015 HAZEL PATH - Health 15, HAZEL PATH
i�Marstons;Mills
,.�A ',063-- ,022 0-27
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TOWN OF BARNSTABLE
LOCATION 15 OAZE'L_ Axik SEWAGE# ?oJ!J ►y�1
VILLAGE /h; IS ASSESSOR'S MAP&PARCEL 1,3- 2Z
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Sob• y77• DGS 3
LEACHING FACILITY:(type) Spp ogNJ L_Ic �3> (size) 13 A 33 A 2-
NO.OF BEDROOMS y
OWNER Col Occ n CVnac c
PERMIT DATE: y •Z2-19 COMPLIANCE DATE: '1.2L• 19
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 �yy�u_i C;/toy
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No. CzV — FEE::
COMMONWEALTH Of MASSACHUSETTS
Bo(crd'of Health, SQ ns G a bh ,MA. c6U
APPLICATION POR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct )' Repair( ) UpgradeO Abandon( - ®'Complete System ❑Individual Components:
Location 5 4'p 1 i Owner's Name
Map/Parcel# �/�C� U3 Address /J HaLLI
Lot# a Telephone# y — 239 - ?/8�S
Installer's Name V Designer's Name
l�
Address /"T`� �� Address AQ 8ox 3,3 l S
11 Telephone# Telephone# /7 V f ll&fV
Type.of Building' Lot.Size sq..ft.
Dwelling-No.of Bedrooms _ Garbage grinder( )
Other-Type of Building No.of persons Showers O;Cafeteria
Other Fixtures.
Design Flow(min.required) gpd Cal culated design flow Design:ffow provided gpd
Plan: bate y v� Number of sheets_ Revision Date
Title
DescTiption:of Soil(s):
Soil Evaluator Form No. Name,of Soil Evaluator � G Date of Evaluation A'`3`
DESCRIPTION OF REPAIRS:ORAITERATIONS �00 qCd -5 T �t, N`2O C3 7V2v 5-06
The:undersigned agrees to install the above described Individual Sewage'Disposal System.in;accordance with the provisions.o.,f TITLE 5 and
further agrees oft p e the.syste operatio ntil a Certificate of:Compliance has been.issued by the Board of Health..
Si ned. Date '4 — 1-7-1 �7
Inspections . J
' No� •a , r, '.. ' FEE'.
COMMONFW11-OF MAS ITS
" BoardofHealth, 'w �ctnS�a lc. MA f
APPLICATION FOR DISPOSAL SYSHM, CONSTRUCTION PERMIT
Application fora Permit to Construct Repair( Upgrade( :) Abandon( - U'Complete System O individual:Components;
Location F_'1 PJCgh M / l 111� Owner's Name e��!Il�%7 ���(j�,�!
Map/Parcel# C.r ' Address !5 / 'aZ LP
Lot# o� Telephone# f - 23 9 ' J�i ww
Installer's Name I� XGC,vat (�l Designer's Name l�c� ;e T;/ n ll
Address �� ( ��t- (/( Address kl� 80X 3,3 t �!V ya n n
Telephone# Telephone# VI? I
Type.of Building ��l�lt —� _ ' - Lot Size sq:ft.
Dwelling:-No. of Bedrooms: Garbage grinder( )
,� .. _.
Other-Type of Building __. . . . __ No:of persons Showers(. ),Cafeteria.O 4
r
Other Fixtures
Design Flow(min,required);=7 gpd Calculated design flow Design:flow provided gp:d
_mow
Plan: Date. Number of sheets— Revision Rafe
- _.
Title
Descilpdon,ofSoil(s).
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS.OR AI:TERATIONS !
The:undersikned..agrees to install the above described Individual Sewage,Disposal System.in accordance with the provisions.of TITLE 5:and
further agrees(to n'o�t to�pllaace�the sy�stemirih%operaationn until a Certificate_of(Compliance has been issued-by the Board of Health.
Si necl `�r"��`� � Date
It r
Inspections l t 1
x
ro COMMON I ]'R Of MASSACHUSETTS 1 EE fC1t�-
. Board o f Health; , NIA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual.Corn ponent.(s) El Complete System
The undersigned here,bycertify that the Sewage Disposal System Constructed ( );Repaired ( ),.Upgraded ( ),Abandoned ( ). -
hy. r j 1.., t_ct u .'� 4�
at
has been installed in accordance with the rovifsiOns of 310 CMR:15.00 (Title 5) and(t'he.approved design plans/as-built plans relatilig to.
application Noz, Cf-I'N dated,�i Ali Approved Dekgi Flow 4 l 0 (gpd)
Installer ��.C�1 ��:�4 �./ /� t r
Designer:C.+i�.i�_T I l i f Inspector: (l. ,.L.1.'P Date: Ll t ��! �.
_ . The ssuance.of.this;permit shall.not be construed as a guarantee that the system will function.as designed.
i
/676
No.. 'l E � 1 FE.EV�
COMMONW ILTII Of MASSACHUSETTS
Board of Health, i( 11 �%t 1�(. _. AM.
DISPOSAL SYSTEM CONSTRUCTION PERMIT �
Permission is hereby granted to;:Construct( ) Repair( ). Upgrade;( ) Abandon( ) an individual sewage disposal:system
a H C 1 { t
at I .f. as described:in.the application.for
r.
Disposal System Construction Permit No4 v � dated qY ZAt�
Provided: Construction shall be completed within three,vears of the:date of this pe 11 nit AllDndiaons must be met.
Form 1255 Rev.5/96.A.M.Sulkin Co.Chadestown,.MA Date ' Board of Health --
�e_ V
Town of Barnstable
PFTHE Tph� Regulatory.Services
�p
Thomas F. Geiler, Director
MA-C& Public Health Division
r� 1639. 0. Thomas McKean Director
AlFD MA'S
`200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Date: .y -ZG- 19 Sewage Permit# 7o19- ILILA Assessor's Map/Parcel L3-7-7.
Installer &Designer Certification Form
Designer: Installer:
Address: 331 arWi¢L-, Address: Jy -Tba,5c rre.l t.#J
Forc&l J411C_
On (4-ZZ- 1 q B 4, i o was issued a permit to,install a
(date) (installer),
septic system at is i4C,-Ze1 !&A- . bused on a design drawn by
(address)
.Db_Vc_ 7AoA-sr_r-A t dated Lj-ZI- !q
(designer)
Y— I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distri4ution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above.was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Stripout (if required) was inspected and the soils
were found satisfactory.
nn DANVID
D.
staller's Si ) L AHE12TY'JR.
Pilo. 1219
i
(Designer' Signatu ) (Affix Desig p Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE_ PUBLIC HEALTH DIVISION..
THANK YOU.
gAoffice forms\designercertification form.doc
Town of Barnstable PT# If 930
Department of Inspectional Services
t f Public Health Division
i679
200 Main Street,Hyannis MA 02601
Office: 508-862 4644
Date Scheduled Time
Soil Suitability Assessment f I ewage Disposal
Performed By: Witnessed By:
LOCATION& GENERAL INFORMATION
Location Address: l �; tim Owner's Name:
Owner's Address: S'V r1'L
Assessor's Map/Parcel: �" certified Soil Evaluators Name:
Certified Soil Evaluators Email:
New Construction or Repair: � Certified Soil Evaluators Telephone# l
Land Use Slopes(%) Surface Stones JV
Distances from: Open Water Body ft Possible Wet Area��ft Drinking Water Wel ft
Drainage Way�—�ft Property Line _ft Other ft
Parent material(geologic) � Depth to Bedrock /
Depth to Groundwater. Standing Water in Hole: /�/ Weeping from Pit Face
Estimated Seasonal High Groundwater ,V
Method Used: DETERMINATION FOR SEASONAL HIGH WATER TABLE
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Date:. Index Well level Adj.factor Adj.Groundwater Level
Observation PERCOLATION TEST Date ime &►'''1
Hole# Time at 9"
� ar
Depth of Perc ` Time at 6" Al-
Start Pre-soak Time @ ;V ` Time(9"-6")
End Pre-soak
Rate MinAnch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/l)
f
Deep Observation Hole Log Hole#:
Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other
(in) (USDA) (Munsell) (Structure,Stones,Boulders,
Consistent %Gravel
�Ojf32Alll�
to - S S
Deep Observation Hole Log Hole#:
Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other
(in) (USDA) (Munsell) (Structure,Stones,Boulders,
Consistent %Gravel
O L "Or
to -
Deep Observation Hole Log Hole#:
Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other
(in) (USDA) (Munsell) (Structure,Stones,Boulders,
Consiste cy,%Gravel
Deep Observation Hole Log Hole#:
Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other
(in) (USDA) (Munsell) (Structure,Stones,Boulders,
Consistent %Gravel
0
Flood Insurance Rate Map: /
Above 500 year flood boundary No Yes "
Within 500 year boundary No Yes
Within 100 year flood boundary No Yes o�
Depth of Naturally Occurring Pervious Material
Does at least four feet of natura y occurring pervious material exist in all areas observed throughout the area proposed for the
soil absorption system?
If not,what is the depth of nArally occurring pervious material?
Certification
I certify that on r' Z 0 Z (date)I have passed the soil evaluator examination approved by the Department of
Environmental Prot tion d that the above analysis was performed by me consistent with the required training,expertise
and experience described in 310 CMR 15.017.
Signature Date
SKETCH: (Or you can attach a separate sheet)
(Street name,dimensions of lot,exact,locations of test holes ands in proximity to holes)
s
_
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a�
15 Hazel Path
Property Address
Barnett
y
Owner's Name .�
Marstons Mills MA 02648 2/24/17
City/Town State Zip Code Date of Inspection �.
CA
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
A. General Information
1. Inspector:
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508.272.6433
Telephone 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
2/24/17
Inspecto s Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describ
es conditions at the time of i e o inspection and under the conditions
p Y o s of use
p
at that time.This inspection does not address how the system will perform in the future under
the sar a or different conditions of use.
15 Hazel Path•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15
I rz(�S
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
15 Hazel Path
Property Address
Barnett
Owner's Name
Marstons Mills MA 02648 2/24/17
CityrFown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Cesspool to overflow cesspool
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:
n/a
❑ 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
15 Hazel Path•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 Hazel Path
Property Address
Barnett
Owner's Name
Marstons Mills MA 02648 2/24/17
City/Town State Zip Code Date of Inspection
B. Certification Cont.
B) System Conditionally Passes(cont.):
❑ distribution box is leveled or replaced
ND Explain:
n/a
❑ 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:
n/a
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has 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.
15 Hazel Path•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
15 Hazel Path
Property Address
Barnett
Owner's Name
Marstons Mills MA 02648 2/24/17
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has 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.
3. Other:
n/a
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 Y day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
15 Hazel Path-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 15 Hazel Path
Property Address
Barnett
Owner's Name
Marstons Mills MA 02648 2/24/17
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® 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.
15 Hazel Path•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ,•�y 15 Hazel Path
Property Address
Barnett
Owner's Name
Marstons Mills MA 02648 2/24/17
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
this inspection?
❑ 0 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?
El ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
15 Hazel Path-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 Hazel Path
Property Address
Barnett
Owner's Name
Marstons Mills MA 02648 2/24/17
Cityrrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): n/a Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): n/a
Number of current residents: 0
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)):
Sump pump? ❑ Yes ® No
Last date of occupancy: seasonal
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: n/a
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe): n/a
15 Hazel Path-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M y 15 Hazel Path
Property Address
Barnett
Owner's Name
Marstons Mills MA 02648 2/24/17
Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: No recent pumping per owner
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):
Approximate age of all components, date installed (if known)and source of information:
1972 per age of the home
Were sewage odors detected when arriving at the site? ❑ Yes ® No
15 Hazel Path-03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
15 Hazel Path
Property Address
Barnett
Owner's Name
Marstons Mills MA 02648 2/24/17
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 2'
feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10'feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: n/a
feet
Material of construction:
❑ concrete ❑ metal El 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:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
15 Hazel Path-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
15 Hazel Path
Property Address
Barnett
Owner's Name
Marstons Mills MA 02648 2/24/17
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.):
Grease Trap(locate on site plan):
Depth below-grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
n/a
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
n/a
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):
n/a
15 Hazel Path-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 5 15 Hazel Path
Property Address
Barnett
Owner's Name
Marstons Mills MA 02648 2/24/17
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
n/a
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert n/a
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
15 Hazel Path-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
15 Hazel Path
Property Address
Barnett
Owner's Name
Marstons Mills MA 02648 2/24/17
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
n/a
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number: 1
❑ 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.):
Overflow cesspool is 2' below grade, 30"cover, 6x6 block construction, it is dry at this time, sidewalls
are clean, no indication of past fail
15 Hazel Path-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 Hazel Path
Property Address
Barnett
Owner's Name
Marstons Mills MA 02648 2/24/17
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) '
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration cesspool to overflow
Depth—top of liquid to inlet invert
2'
Depth of solids layer
10"
Depth of scum layer trace-1/2"
Dimensions of cesspool 6'x4'
Materials of construction block
Indication of groundwater inflow ❑ Yes ® No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Cesspool was about 1/2 full at the time of inspection, it is 18" below grade with a 30"cover, outlet T is
in place, no indication of past backup
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.):
n/a
15 Hazel Path-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Comm86ealth of Massachusetts
Title 5, Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 15 Hazel Path
Property Address
Barnett
Owner's Name
Marstons Mills MA 02648 2/24/17
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
C
coo c)
I �
<3d
�- f
15 Hazel Path•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 Hazel Path
Property Address
Barnett
Owner's Name
Marstons Mills MA 02648 2/24/17
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: >12'feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Per elevation of home
15 Hazel Path•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
I
TOP OF FOUNDATION COVERS TO BE WATERTIGHT AND SEPTIC SYSTEM PROFILE
EL. 62.0' EL. 60.0' BROUGHT TO WITHIN 6"OF FINAL GRADE Snot to scaled Flaherty Environmental Services
INSP. PORT W I 3" OF GRADE CLEAN SAND P.O. Box 331
2" of e" to " DOUBLE WASHED EL. 60.0' Harwich, MA 02645
PILTER FABRIC
GEOTEXTILE 774,994.1166
4"CAST IRON or EQUIVALENT FILTER FABRIC � —��
MIN. PITCH 1/4" PER FOOT t
4"SCHEDULE 40 PVC PIPE 4" SCHEDULE 40 PVC PIPE
FLOW LINE ' VENT IF REQUIRED
(flrat 210 be level) �•
_ 0'(2% 5,(1%) ;•
:.'•: L.59.0' 14" '` °°Oo°o°°°
EL.57.7' L.57.4' *Goo0000000 0 0 0 .'®� en Ell
°o°o°o°oc
0 0 0 0 0 0 0 0 0 o e
0 0 0 0 0 0 0 0 0 0
y ' EL.56.03' o 00000 000e
EL 56. ' ° o°o°o°o°o°o° o-0.*°o°o°e 2.0'
+ H-20D-BOX EL.56.0' o°o°o°o°o°o°o°o° ® ® ® o°o°o°o°e-
0'MIN.(2.5%)—� GAS BAFFLE ( ) 000°oo°o°o o°o°o° a .' o°o°o°o°c
i:• °o°o°o°o° o°o°o° ' �• a °o°o°°o°oc EL.54.0'
4 .
• .`ti!, 6"CRUSHED STONE OR SOIL ABSORPTION SYSTEM
�' �' ` •''• MECHANICALLY COMPACTED (3) 500 GALLON H-20 CHAMBERS
5.0'
(DATUM: ASSUMED) "---� WITH 4'STONE AROUND IN A
�" to 1 " DOUBLE WASHED STONE
1500 GALLON SEPTIC TANK 12.83'W X 33.51 X 2'D CONFIGURATION
(PROPOSED) BOTTOM OF TEST HOLE EL. 49.0' EL. 49.0'
USGS ADJUSTMENT: N/A LOCAT/ONMAP
GROUNDWATER ELEV: N/A
� yd N TH
Race Lane
SNED o
TH-
TH-1 0
60
LOCUS
0
29.2' o 'r 19.6' A
PML 0 .;�% NiAj BENCHMARK: AF,po,
TOP OF FNON
- N7S
EL.62.0'
LOT 343
1.0 ACRE t LECTICyey�OF
MAP 63 CAUTION HI PRATE RaUND1
LOT 22 � iN[S AREA 4 aim
46.8'
F J .
60 DES 21
O GARAGE
PROP.
1500 GST
E I TIING
DWELLING
\ DRIVEWAY `� DATE 4/14/2019 /SED: 2Iq
711
LEGEND
SITE AND SEWAGE PLAN FOR
6 6 6 6 GAS LINE 1 \\V w V V- WATER LINE B & B EXCAVATION, INC./
E E E E E EXIST. ELECTRIC \ COLLEEN CHACE
99 EXIST. CONTOURS \ —� 1S HAZEL PATH
—--——— 99 PROP. CONTOURS \ MARSTON'S MILLS, MA
SCALE : 1" = 40'
0 o a EXIST. FENCE _
tie
q �(
REF.LCP 30751-F SH 1 PAGE 1 OF2
/ � V
......... ............................ ................ ......... ...... ............................. .................. .......................................................................................................................... ....... ... ....... ................................... ............................... .......... ............ ............ ............................ ............... ................................................................................................. ............................ ................
GENERAL NOTES Flaherty Environmental Services
DESIGN CAL COLA TIONS
S YS TEM DETAIL
P. 0. Box 331
1. ALL PRECAST COMPONENTS TO BE H-1 0 Harwich, MA 02645
RATED UNLESS OTHERWISE SPECIFIED. NUMBER OFACTUAL BEDROOMS 4 774.994.1166
DISTRIBUTION BOX(ES)AND ANY
COMPONENTS WITH ANY ANTICIPATED GARBAGE DISPOSAL UNIT NO
VEHICULAR TRAFFIC TO BE H-20 RATED.
2. THE DESIGN OF THIS SYSTEM DOES NOT TOTAL ESTIMATED FLOW
(110G4L/BR1VAYX4BR) 440 GAL./DAYALLOW FOR THE USE OFA GARBAGE
GRINDER.
REQUIRED SEPTIC TANK CAPACITY 880 GAL.
3. MUNICIPAL WATER IS AVAILABLE.
BLE.
4. ALL CONSTRUCTION TO CONFORM WITH 33-51
SIZE OF SEPTIC TANK 1500 GAL. (PROPOSED)
310 CMR 15.000 AND ALL OTHER
APPLICABLE LOCAL, STATE AND FEDERAL SOIL CLASSIFICATION
CODES AND REGULATIONS.
5. INSTALLER/CONTRACTOR TO REVIEW& DESIGN PERCOLATION RATE <2 MIN./INCH
VERIFY ALL ELEVATIONS AND DETAILS
EFFLUENT LOADING RATE a74 GALADAYIFT2
AND REPORT ANY DISCREPANCIES TO
'
0
DESIGNER PRIOR TO CONSTRUCTION OR 12.83
ASSUME ALL RESPONSIBILITY. LEACHING AREA
-7
12.837(2) = 185SF
6. INSTALLER/CONTRACTOR IS 33.5'x3 12.83' 429 SF
RESPONSIBLE FOR MAINTAINING SAFE 614 SFx 0.74 =454 GPD
WORK AREA, VERIFYING ALL UTILITIES
AND NOTIFYING "DIG SAFE" USE(3)500 GALLON H-20 CHAMBERS WITH 4'STONE
(1-888-344-7233) 72 HOURS PRIOR TO AS DIAGRAMMED INA 33.5'X 12.83'X 2'CONFIGURATION
(
CONSTRUCTION. LINEAR FEET)
7. ANY CHANGES TO OR DEVIATIONS FROM
THIS PLAN MUST BE APPROVED IN RESERVE LEACHING CAPACITY 454 GPD
WRITING BY FLAHERTY ENVIRONMENTAL
SERVICES AND LOCAL BOARD OF
HEALTH.
8. FINISH COVER OVER COMPONENTS IS
NOT TO EXCEED 3'PER 310 CMR 15.000 (NTS)
UNLESS SHOWN PER PLAN
9. ALL ABANDONED SEPTIC SYSTEM
COMPONENTS TO BE PUMPED DRY AND SOIL EVALUATION OF
FILLED WITH CLEAN SAND OR REMOVED
TEST HOLE#1 TEST HOLE#2
AND REPLACED WITH CLEAN SAND. Evaluator. David D.Flaherty Jr.,RS,REHS Evaluator. David D.Flaherty Jr.,RS,REHS
10.ALL COMPONENTS TO BE PROVIDED SE#2755 SE#2755
BOHW1h7ess. David Stanton,RS BOH Wknesc David Stanton,RS
WITH WATERTIGHT ACCESS PORTS
Date., AP/y/3,2019 Data- Apd13,2019
WITHIN 6"OF FINISH GRADE.
11.ALL SEPTIC TANKS, DISTRIBUTION als-r
TH-I ELEV.60.0' TH-2 ELEV.60.0'
BOXES AND PIPING TO BE INSTALLED I T
WATERTIGHT 0"-10' A LS 10YR W 0"-to, A LS IOYR312
12.NO KNOWN WETLANDS OR WELLS
9
WITHIN 150 FEET OF PROPOSED to'-34' B LS 10YR W 10'-34" B LS 10YR 516
LEACHING.
13,THIS IS NOT A CERTIFIED PLOT PLAN F77 PERC
AND UNDER NO CIRCUMSTANCES IS THIS
'i rfiTy on November 12,2002, have passed
PLAN TO BE USED FOR ZONING OR
thece th at examination approved by the Department of
BUILDING PURPOSES. Environmental Protection and that the above analysis
has been performed by me consistent with the
14.LOT IS SHOWN AS ASSESSOR'S MAP 63 SITE AND SEWAGE PLAN FOR
requiredfraInIng expertise,and mgmitence described
8 & 8 EXCAVATION
LOT 22. in 310 CMR 15.018(2). TZON, ZNC.1
COLLEEN CHACE
15.LOCUS PROPERTY IS LOCATED WITHIN
39'-132' C MS 2.5Y614 39'-120' C MS 2.5Y614
AN AQUIFER PROTECTION DISTRICT 15 HAZEL PATH
MARSTON'S MZLLS, MA
(ZONE 11). G.W ELEV.NIA G.W.ELEV NIA
BOTTOM TH-1 ELEV. 49.0'1 BOTTOM TH-2ELEV 50.01
PAGE 20F2
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