HomeMy WebLinkAbout0067 HAZEL PATH - Health 67 Hazel Path
Marstons Mills
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Town of Barnstable P 0
of 1e
Department of Regulatory Services
4 Public Health Division Date Lbl Id
HAM p
200 Main Street,Hyannis MA 02601
Date Scheduled f ,' '1 Time ' Fee Pd. 4ti , C'
/ i
Soil SUii ility Ass sm`ent for Sewa os,,
Performed By:-�' r Is ~2' Witnessed By: ' ,d to ! . b
LOCATIONry&GENERAL INFORMATION , S
Location Address 47 4 �+,i �(�/J" I Owner's Name
n`' Address t°M�Ac-,-w k ��`
Assessor's Map/Parcel: b?� (�Z, Engineer's Name ��I e f rnL Ke
NEW CONSTRUCTION REPAIR Telephone# �Q ——7 3-7—1-7 G i
Land Use __> )i lu 4S�1, A"— Slopes(%)Zr 3 Surface Stones AJ0 tom.
Distances from: Opcn Water Body jna/r ft Possble Wet Area ft Drinking Water Wc'7,L U tt
Drainage Way nf1��
_ft PropertyLineJ�^6— ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc teats,locate wetlands in proximity to holes)
w�
Z •'
Or
Parent material(geologic),t�J�%dS H Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: A.)G)/`A Weeping from Pit Face AS
Estimated Seasonal High Groundwater > l pp,2.",
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs,hole: in. Depot 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_
PERCOLATION TEST Date Time
Observation �1
Hole# Time at 9"
Depth of Perc t 4 _ C ' YJ (/ ( Time at 6"
Start Pre-soak Time @ 2 ` �C�`�CAI
Time(9"•6'�
End Pre-soak C' �t6^
Rate MindInch
Site Suitability Assessment: Site Passed Site Failed Additional Testing Needed(Y"
Original: Public Health Division Observation Hole Data To Be Cotnpleted on Back--•---
***If percolation test is to be conducted within 100'of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
QASEPTICTERCFORM.DOC
Role#oats
DEEP OBSERVATION.I3.OLE LOG son
Soil Texture Mottling (Structure,Stones,Boulders.
Depth from Soil Horizon (USDA) (M�) sivol?----
Surface(in.) _
-----
Hole#_
DEEP OBSERVATION HOLE LOG soil Era
soil-Texture Soil Color Motd ng (Strucnue,Stones,Boulders.
Depth from Soil Horizon (USDA) (I I®sell) v_r
'tencsr) --
surface(in.)
o f A L-s 4 /�d (� -
•
l e
1 — Hole# -
DEEP OBSERVATION BOLE LOG spil 2-
(Mtutsell
Depth from Soil Horizon Soil Texture ) Moog (Structure,Stones,Boulders.
Surface(in.) (USDA)
L l X yl
Z c'
C_ Pn�C 5 "Lc
DEEP OBSERVATION HOLE LOG Hole# other.
soil
(USDA)
Depth from Soil Horizon Soil Texture soil
ll) Mottling (Structure,Stones,Boulders.
s�.�(in.) : a/Oraveh
S"
o- GS 6.
r Z t,5 u
Flood Insurance Rate May:
Above 500 year flood boundary No_ Yes
Within 500yearboundary , No Yes_
W ithi'n 100 year flood boundary No�= Yes
Death of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervigus material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pe ious material?
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Envlro ental Protection and that the above analysis was performed by me consistent with
the required ti ' g,expertise Lexe
�encelecribedin 310 CMR 15.017.
Signature � Date ' Zfd(q
0ASEPTIC RRCFORM.DOC ,
_ TOWN OF BARNSTABLE
LOCATION C,7 9k,,1 SEWAGE# J,(. 1-11 ,25f-
VILLAGE ASSESSOR'S MAP&PARCEL M3 :wo'2 �
INSTALLER'S NAME&PHONE NO. lax A llnn,04
SEPTIC TANK CAPACITY `fig t-%j-tN g
LEACHING FACILITY. (type) 5-®0.gr.J )c6^6r6 (size) tl.L3X !3,A.J-2r?--
NO. OF BEDROOMS
OWNERrxQne���
PERMIT DATE: COMPLIANCE DATE: g"X& -/V
Separation Distance Between the: Noove eNcr v� �rJ
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 0k e8t'/C 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
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No.Q-O 14 — a 5 Fee 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
0(pplitation for Disposal *pstem Cari$truttiari permit
Application for a Permit to Construct( ) Repair( ,)/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. C 7 "Pak h Owner's Name,Address,and Tel.No.
/Vla/%Mrac Arlo
Assessor's Map/Parcel 2
I^nstaller's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
�LJ�! ifs �J(t9wc�! � .B e� f+�+� ✓e� /�G
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 30 gpd Design flow provided q114.B gpd
Plan Date—? Number of sheets Revision Date
Title
Size of Septic Tank�k,�, Type of S.A.S. T00 *A1104r
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) s ac hr< 1 u?'t.J 5. A 5
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed " ------ Date 04 1
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. ac))`7 _ �G(? Date Issued
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E _ _
A4
1 ,I P
� TNo.Qo M aFee �V0
Entered in computer:
t THE COMMONWEALTH OF.
PUBLIC HEALTH.DIVISION - TO�N-,OF BARNSTABLE, MASSACHUSETTS
�i�fitation--for �is�o aY �pstetn �OTC�trULtlon �'ET�lttit �
Application for a Permit to Construct( ) Repai)/Upgradel( ) Abandon( ) ❑Complete(System 55 Individual Components
6 Al
Location Address or Lot No.G 7,fl4 t Y PG f h Owner's Name,Address,and Teel.No ti t'
11A& ���s M,J)% -50,ic V0(C)
Assessor'sMap/Parcel
Installer's Name,Address,and Tel.No. u ( r [ Designer's Name,Address;.and Tel.No.
Type of Building:
Dwelling No;of Bedrooms 3 `Lot Size 4/3, sq.ft. Garbage Grinder'( )
Other " Type of Building No.of Persons Showers( ) Cafeteria(_ )
Other Fixtures
Design Flow(min.required) 3 3 y gpd Design flow provided G//H. y gpd
Plan Date 7 -/7 Number of sheets 2— Revision Date -
Title t M� �. �y
Size of Septic Tank E�r,t i.,.c TYpe.o:f S"A.^.5,�" TE07 4-�,//G N l�o- 1j r/S /1 H AS X 2
Description of Soil f
a Xt —
' Nature of Repairs or Alterations(Answer when a plicable) 1,uS F c,1 t A)?-W 5..,�f S
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in }
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
L
Signed Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. r)Q '- Gr�j Date Issued
--------------------------------------------------------------------------------------------------------- ----------------------'------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(✓ ✓+' Upgraded( )
Abandoned( )by'ay f�c c A mil (ow-
at & 7 fl4 z r l 72,t ti N1ais�o,5 M, 15 has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer,( ,J tu, A _Rowro TNe' Designer
#bedrooms 22 Approved design flow 330 and
The issuance of this permit shall not be construed as a guarantee that`the systemwill function as de ' ned.
Date —2,r,h
----------------------------------------------------------------------------------------------------------------------------------------
No. C 5 Fee !O d c
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal bpstent Construction Permit
Permission is hereby granted to Construct( /) Repair( ✓) Upgrade( ) Abandon
System located at 6 7
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions. ~
Provided:Construction must be completed within three years of the date of this permit. 9f /
Date .- Approved by
Town 0 Barnstable
Regulaf ory Services
Richard V. Sgali, Interim Director
• 7ARNM LE;.'
Public �ealth Division
°'cfl 59. A Thomas 4cKean, Director
200 fain Stre#t,Ilyannis,lW>(A 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer.& Designe-ir C6rtWcatioza Form
Z
Date:� Sewage Permit# 0�®9�- ��P Assessor's 1Map\Parcel
rho�-e✓ N`Re Qwt�e ro(F -P /7 - 1�2i ✓1 {vx(-
Designer: nrnt.�?c � In t Installer:
'Address; t2 W. Cmss'�e Address: P-d- C�Djc tu,s-
'oresr—ell-L,a mW c�2 to y y �,ew�-ervi I lu M a 2 6 3 2-
On VA ��`'`� ''` kex C`-t _was issued a permit to install a
(date) (installer)
.septic system,at 67 �e42e I J),kk fAarskns based on a design drawn by
(address)
�►�d-e� dated -7 17
(designer) !
I certify that the septic system referencerl above was installed substantially according to
the design; which may include minor alroved changes such as lateral relocation of the
distribution boa and/or septic tank. Strip out (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 yvith State & Local Regulations. Plan revision or
certified as-built by designer to follow, trip out (if required)was inspected and the soils
were found satisfactory.
I certify that the system referenced abov was constructed in complia �i�th the terms of
the IAA approval letters (if applicable) � SLi 4L tf
PE.TrR T
+ltc TEE "
aller's Signature)
(Designer's Signature) "x Designer's )
PLEASE RETURN TO BARNSTABU PU13LIC BTKALTH DWISION, CERTIFICATE
�OF COIPLIANCE WILL NOT BE -ISSUED tTPITIL BOTH THIS EOR1YI AMID AS-
RTM.T CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\Septic\Designer Certification Form Rev 8-14-13.doc
TRANS. NO.:
CITY/TOWN:
APPLICANT;
ADDRESS: f'® ? HO Ze 1 'S
DESIGN FLOW: L{ to &-&® gpd I
REVIEWED BY: 1?CJ' :✓�cC-n � DATE: � 2't J ] ',I
N/A OK NO
GENERAL , 7777777,--7�7-
Legal boundaries denoted [310 CMR 15.220(4)(a)]
Street, Lot,tax parcel number and lot number noted on plan [3.10 ✓
CMR 15.220(4)(u)]
Locus Provided 310 CMR 15,2204(t)]
Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for
components) 310 CMR 15.220(4)]
Easements shown [310 CMR 15.220(4)(b)]
System located totally on lot served [310 CMR 15.405(1)(a) for
upgrades]- if not, a variance is re uired [310 CMR 15.412(4)]
Location of impervious surfaces (driveways, parking areas etc.) ✓
[310 CMR 15.220(4)(d)]
Location all buildings existing and proposed 310 CMR e ✓
15.220(4)(c)]
Location and dimensions of system components and reserve ✓
areas. [310 CMR 15.220(4)(e)]
System Calculations [310 CMR 15.220 4
daily flow
septic tank capacity (required and rovided ✓
soil absorption system (re uired andprovided) e/
whether system designed for garbage grindei V/
North arrow [310 CMR 15.220(4)(g)] ✓
Existing and ro osed contours [310 CMR 15.220(4)(g)]
Location and log of deep observation holes (existing grade el. on
each test) [310 CMR 15.220(4)(h)] v
Names of soil evaluator and BOH representative [310 CMR
15.220 4 h and i
Location and date of percolation tests (performed at proper r
elevation?) [310 CMR 15.220(4)(i)]
Percolation test results match loading rate? 310 CMR 15.242] _
Certification statement by Soil Evaluator [310 CMR 15.220(4)U)]
Observed and Adjusted groundwater(method for adjustment e V
given or indicated) [310 CMR 15.103(3) and 310 CMR
15.220(4)(n)]
Address Sheet 1 of 7
N/A OK NO
Location of every water supply,public and private, [310 CMR ✓
15.220(4)(k)]
within 400 feet of the proposed system location in the case v
of surface water supplies and gravel packed public water supply
within 250 feet of the proposed system location in the case t/
within 150 feet of the proposed system location in the case -
of private water supply wells
Location of all surface waters and wetlands located up to 100 ft. -
beyond setbacks listed in 310 CMR 15.211 and any catch basins Cl/
located within 50 ft. 310 CMR 15.220(4)(1)]
Water lines and other subsurface utilities located [310 CMR
15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[1]
Profile of system showing invert elevations of all system
components and the bottom of the SAS 310 CMR15.220(4)(o)]
Stamp of designer [310 CMR 15.220 1 and 310 CMR 15.220(2)]
Stamp of Registered Land Surveyor(required if construction
activities within 5 ft. of lot line) [310 CMR 15.220(3)]
Test Holes adequate (two in each of the primary and reserve
unless trenches as permitted in 310 CMR 15.102(2) or as
approved for an u ade under LUA at 310 CMR 15.405 1 k ]
Test hole adequate to demonstrate four feet of suitable material?
[310 CMR 15.103 4 ]
Test Holes adequate to confirm adequate groundwater separation?
[310 CMR 15.103 3
Benchmark within 50-75' of system [310 CMR 15,220(4)(g)]
Materials specifications noted? [various sections of 310 CMR ✓
15.000
System components not> 36" deep (unless Local Upgrade
A roval or LUA requested)_[310 CMR 15.405 l(b)]
Address Sheet 2 of 7
N/A. OK NO
SJEr]P'TIC, }
z 21
Size OK? [310 CMR 15.223 1
Inlet tee located ten inches below flow line 310 CMR 15.227(6)]
Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR
15.227(6
Outlet tee with gas baffle or approved filter 310 CMR 15,227(4)] ✓
Note regarding installation on stable compacted base [310 CMRj, p
15.228(l)] "/i fi`nJ'
Separation between inlet and outlet tees (no less than liquid
depth) 310 CMR 15.227(2)]
Inlet/Outlet elevations at least 12" above high groundwater
(except as described 310 CMR 15.227(5)) or permitted for
upgrades under LUA [310 CMR 15.405(1)(k
Minimum cover 9" (Tanks buried more than 9" must have risers
on all openings and on the d-box) [310 CMR 15.2228(1) and 310
CMR 15.232(3)(f)]
Three access covers (inlet and outlet must be 20" or greater) -
middle access at least 8" b 7/07 310 CMR 15.228(2)]
Access to within 6 " of grade - one port for systems<1000gpd,
two fors stems >1000 gpd [310 CMR 15.228(2)]
All at-grade covers secured to unauthorized access? [310 CMR f
15.228(2)]
> 10 ft from building foundation [310 CMR 15.211 1)]
Buoyancy calculation Re uired/Done [310 CMR 15.221(8)]
H-20 Where appropriate? 310 CMR 15.226(3)]
Setbacks from resources [310 CMR 15.2111
Mulh��om�artlm�� t `
Required when other than single-family dwelling or flow>1000
d [310 CMR 15.223 1 b
First compartment 200% daily flow; Second compartment 100% `
daily flow [310 CMR 15.224 2 and 3 ]
"U" pipe through or over baffle, outlet of each compartment with
as baffle or approved filter [310 CMR 15.224(4)]
Address Sheet 3 of 7
N/A OK NO
Located at least ten feet from any water line? [310 CMR
15.222(2)]
Disposal piping at least 18" below water line(when water and
sewer cross, see 310 CMR 15.211(l)[1])
Cleanouts required/provided ? [310 CMR 15.222(8)]
Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)]
Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable
[310 CMR 15.222(6)] \ ✓
Proper pitch on all runs? (.005 within gravity-distributed trenches
and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)]
Siphonproblem/ leachfield below pump chamber f
Endca s or vent manifoldspecified?
Size and orientation of discharge holes specified? (not smaller
than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310
CMR 15.252(2)(h)]
Materials specified (310 CMR 15.251(5) specifies various pipe
types allowed
�IS,,,'PRItB'UIOI\1,�BOX �::.
Stable compacted base [310 CMR 15.221(2) and 310 CMR
15.2322 a ]
Splash plate or baffle tee required on inlet/provided? (when /
pressure sewer to d-box or steep pitch of gravity sewer) [310 ✓
CMR 15.323(3)(a)]
Riser if dee er than 9" [310 CMR 15.232(3)(f)]
Inside minimum dimension 12" [310 CMR 15.232(2)(b)]
Minimum sum 6" [310 CMR15.232(3)(e)]
Watertight cover if<2000gpd); waterproof manhole if>2000gpd
[310 CMR 15,232(3)(d)]
PUlVIPC3 , {S
Capacity (emergency storage above working=design flow)? [310
CMR 231 2 ]
Proper setbacks 310 CMR 15.211 (same as septic tanks)]
Watertight 20-in minium access manhole at least 20" MUST BE
TO GRADE [310 CMR 15.231(5)]
Service components accessible (not too deep with piping,
disconnects accessible) r4_j I'S
Alarm floats- alarm on circuit separate from pumps specified?
Exceeds two units must have two pumps operating in lead-lag
mode. [310 CMR 15.231(6) and(8)]
Stable Compacted Base [310 CMR 15.221(2)]
Buoyancy calculations needed ? Provided? [310 CMR 15.221(8)]
Address Sheet 4 of 7
N/A OK NO
S`QIL1 � ' < ¢ IUTYSYST1kIS^� AS,) G �! z Q`�.3 x,. i...xtxs.n
Calculations correct?
4 feet of naturally occurring material demonstrated? [310 CMR
15.240(l)] ✓
Required separation togroundwater? [310 CMR 15.212)
Aggregate specified as double washed 310 CMR 15.247(2)]
System Venting required/provided? (system under driveway or
>36" deep) [310 CMR 15.241]
Inspection ports specified and within 3"final grade? [310 CMR ✓
15.240(13)]
Breakout requirements met? (No violation of breakout elevation
within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and V/
Guidance Document]
GALExRI�F�S;PITS;,ChIrAMBERS'31O�C1V15 253
Chambers and Gal. in trench configuration supplied with inlet -
every 20 ft. [310 CMR 15.253 6 ]
Each structure with one inspection manhole (if>2000 gpd must
be tograde) 310 CMR 15.253(2)]
Aggregate 1' minimum- 4'maximum. [310 CMR 15.253(1)(b)] -
2' sidewall credit maximum [310 CMR 15.253 1 a ]
In bed configuration, inlet every 40 sq. ft. [310 CMR 15.253 6)]
>TRNO ' 'S;31 OCjMZ�15 251
Width 2' minimum 3' maximum 310 CMR 15.251 1)(b)]
100 feet-maximum length [310 CMR 15.251(1)(a)]
Minimum separation 2x effective depth or width whichever
eater 3x if reserve between trenches [310 CMR 251 1 d ]
Situated along contours [310 CMR 15.251(2)]
Breakout OK? 310 CMR 15.211(1)[4] and Guidance Document]
B�p�SA,��(ly���muua,��lze�4f�bec�Ao��'elc��5;0�pOxgpd)� S __ r
minimum 2 distribution lines [310 CMR 15,252(2)(a)] _
Maximum separation between lines 6' [310 CM R15,252(2)(d)]
Maximum separation between lines and outside of bed 4' [310
CMR 15.252(2)(e)]
Aggregate depth below discharge pipes 6" minimum, 12" -
maximum. [310 CMR 15.252 2
Separation between beds 10' minimum. 310 CMR 15.252(2)(f)]
Bottom area used in calculations only [310 CMR 15.252(2)(i)]
Address Sheet 5 of 7
T .
N/A OK NO
Pressure Dosed System 7 Provided pump and piping V'
calculations as required 310 CMR 15.220(4)(r)]
Pressure dosing required on all systems>2000gpd or alternative
systems under remedial approval [310 CMR 15.254(2) and I/A
Remedial Use Approvals]
If used in gravelless system -make sure jet is directed as not to
scour soil interface [Guidance Document]
Inspections once per year (systems<2000 gpd) or quarterly
(>2000 dgood to note on plan 310 CMR 15.254(2)(d)]
Construction in fill - Did the plan specify that the fill shall meet
the specification of 310 CMR 15.255(3)?
Impervious barrier and/or retaining wall ? [Guidance Document
Impervious barrier installation must be supervised by
designer [310 CMR 15,255(2)(b)]
Retaining wall must be designed by Registered Professional
Engineer [310 CMR 15.255(2)(a)]
Side slope not exceed 3:1 ? 310 CMR 15.255(2
Breakout requirements met? [310 CMR 15.252(2) and
Guidance Document]
At least 5 ft. from impervious barrier to edge of SAS (10 ft.
recommended [310 CMR 15.255 2 e
Check DEP Approval letters for credits and design conditions }/
If used with pressure dosing do not allow pressure discharge
to scour soil interface
Alt„eYnattve Se ttcSysem ; 1 A'p�puljLttersj
Was DEP Approval Letter provided and/or have you
reviewed the letter for conditions?
Is the technology being properly applied and does it meet all
DEP Approval Conditions?
Is there a note on the plan regarding the requirement for �(
perpetual maintenance agreement?
Any alarms involved on separate circuits
Did the applicant submit an operation and maintenance
manual?
Has a plicant submitt, ,ed a cop of a maintenance
. -
Are the variances listed on the plan ? [310 CMR 15.220
(4
RLS Stamp necessary on plan if a component is within five /
feet of property line [310 CMR 15,412(4)] V
New construction or increased flow proposed- [Refer to 310
CMR 15.414
Address Sheet 6 of 7
4
N/A OK NO
N"'"X;s�Zs xr •-� ,�',+ -�-,�., ..a rrx. t a n m- ate t,: tom` �Y �' ..✓ 7
l�a�� �fit yeA�ea'p�+� ,� r �j�s��� ���IY�y ..,�f�t;'T'3x 't")���k��^�.�.�?t rhd.E•�� r s�i� 7s F fresh 7 r �C�
Is the system in a Designated Nitrogen Sensitive Area(Zone II for
a public supply well)? [310 CMR 15,214, 310 CMR 15.215 and
310 CMR 15.216 - also refer to Policy regarding upgrades of such
existing systems] g5
Is the system proposed on the same lot as served by private well ?
[310 CMR 15.214(2
Are the nitrogen loads proposed in compliance? [310 CMR
15.216 1
Pumping to se tic tank ? 310 CMR 15.229] -
Shared System [310 CMR 15.290]
i
Address Sheet 7 of 7
f" Page: 1
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
t3' I'Y
' Report Dated: 04/08/2002
Report Prepared For:
Order Number: G0213797
McIntyre,William
P O Box 458
Marston Mills, MA 02648
Laboratory ID#: 0213797-01 Description: Water-Drinldng Water
Sample#: 13797 Sampling Location: 67 Hazel Path,Marstons Mills Collected: 03/25/2002
Collected by: Wm.A.McInt 063-025 Received: 03/25/2002
Routine
ITEM RESULT UNITS MCL Method# Tested
LAB: IC Lab
Nitrates 2.3 mg/L 10 EPA 300.0 03/25/2002
LAB: Metals
Copper 0.2 mg/L 1.3 SM 3111B 03/28/2002
Iron <0.1 mg/L 0.3 SM 3111B 03/28/2002
Sodium 14 mg/L 20 SM 3111B 03/28/2002
LAB:Microbiology
Total Coliform Absent P/A Absent P/A 03/25/2002
LAB: Physical Chemistry
Conductance 122 umohs/cm EPA 1N.1 03/27/2002
pH 6.1 pH-units EPA 150.1 03/27/2002
Note: Water sample meets the recommended limits for drinking water of all above tested parameters.
Approved By:
(Lab Director)
Yh7 Loot
d} :f r 3': vr.:'.:I -u3".`.-.t�:r .. . {,!,.. ..tr �?....•.f;�i.: p
1 _ r
t
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
r
tT.33 IF
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTI N :RECEIVEjDTO
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 67 Hazel Path
Marston Mills. M4 02648
Owner's Name: Bill Heusted
Owner's Address: Same
Date of Inspection: February 23, 2002
Name of Inspector:(Please Print)Gordon E. Bumpus
Company Name: Gordon E. Bumpus
Mailing Address: 215 Ost.-W. Barnstable Road Map:063
Osterville,MA 02655 Parcel. 025
Telephone Number: (508)428-5640
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 DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Z 5J t�u� Date: March 20, 2002
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.
Notes and Comments
****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
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 67 Hazel Path
Marston Mills, MA
Owner: Bill Heusted
Date of Inspection: February 23, 2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. 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:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 67 Hazel Path
Marston Mills, MA
Owner: Bill Heusted
Date of Inspection: February 23, 2002
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.
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:
3
f
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 67 Hazel Path
Marston Mills,MA
Owner: Bill Heusted
Date of Inspection: February 23, 2002
D. System Failure Criteria applicable to all systems:
You must indicate either"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 '/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ 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 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 System:
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,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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 67 Hazel Path
Marston Mills, MA
Owner: Bill Heusted
Date of Inspection: February 23, 2002
Check if the following have been done: You must indicate`yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS,located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ 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(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 67 Hazel Path
Marston Mills. MA
Owner: Bill Heusted
Date of Inspection: February 23, 2002
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
Number of current residents: 1
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): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Private well
Sump Pump(yes or no): No
Last date of occupancy:. Currently occupied
COMMERCIAL/INDUSTRIAL
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 occupancyluse:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Owner
Was system pumped as part of the inspection(yes or no): Yes
If yes,volume pumped: 1,000 gallons--How was quantity pumped determined? Septic tank
Reason for pumping: Maintenance
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)
hmovative/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:
Sep. 13184-See sewage permit#84-811
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 67 Hazel Path
Marston Mills, MA
Owner: Bill Heusted
Date of Inspection: February 23, 2002
BUHMING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron ✓ 40 PVC _other(explain):
Distance from private water supply well or suction line: 175'+/-
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 18"
Material of construction: ✓ 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: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tee and baffle were present. The liquid level was even with the outlet invert. There were no signs of leakage.
GREASE TRAP: None (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.):
7
f
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 67 Hazel Path
Marston Mills, AM
Owner: Bill Heusted
Date of Inspection: February 23, 2002
TIGHT or HOLDING TANK: None (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: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was working properly. The water level was even with the outlet.
PUMP CHAMBER: None (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.):
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: 67 Hazel Path
Marstons Mills, MA
Owner: Bill Heusted
Date of Inspection: February 23, 2002
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -6'x 6'with 3'stone-hand probed
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.):
The pit had 2'ofwater on the bottom. There were no signs offailure. The bottom to grade was approximately 9'. The cover
was approximately I'below grade.
CESSPOOLS: None (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: None (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 67 Hazel Path
Marston Mills. AM
Owner: Bill Heusted
Date of Inspection: February 23, 2002
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.
b
0
0 10 r
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 67 Hazel Path
Marstons Mills, MA
Owner: Bill Heusted
Date of Inspection: February 23, 2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 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: topographic and water contours map
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe ho,%v you established the high ground water elevation:
The bottom ofthe leach pit to grade was approximately 9. Using the Barnstable topographic map and the Cape Cod Commission
water contours map, the maps were showing approximately 47'to groundwater at this site. Using the Cape Cod Commission
Technical Bulletin, the high ground water adjustment for this site(SDW 253, Zone B, 1102)was 7.2.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report.
11
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GrOvndWATer /eA
ro un C�WAre r eve
TOWN OF BARNSTABLE f'
LOCA i0N �,� h4. FE Z SEWAGE # Y'
VILLAGE �s(�Q ��5 ASSESSOR'S MAP & LOT 063 od S
INSTALLER'S NAME& PHONE NO. �/�,S
SEPTIC TANK CAPACITY /000 aA I
LEACHING FACILITY: (type) X�� w/�/1 � rC (size)
L,
NO. OF BEDROOMS //
BUILDER OR OWNER �`S��/_ / uxlr-cJ
PERMITDATE: COMPLIANCE DATE: -13
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ��,�- Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) l/J� Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leachin f cihty) Feet
Furnished by �'a o o U C1
fir,
J
/�AcK
o
l-0 C,� T ION S 7 SEWAGE PERMIT NO.
VILLAGE
INSTA LLER'S NAME A ADDRESS
rtc i 5
B U I L D E R OR OWNER
0o R
DATE PERMIT ISSUED
pDATE COMPLIANCE ISSUED G� 13- 3Y
0
LP
FEB SA................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... 4 4..-.......OF............ ...$F ..............................
lwr Alipfiration for Uhiposal Works Tonotrurtion Frrmit
Application is hereby made for a Permit to Construct ( or Repair an Individual Sewage Disposal
System at:
................................wpt .....P ............. ................................... /......................
Location
-Address or
No.
...........R.X.tkol ..................................... .........EQ........ ......!:Tom----------- ...........
t Address
YK 4L 5
...........C-Ab s.......... Owner......... .... .............la-ce".0.................................................................
Installer Address
, Sq. feet
Type of Building Size Lot....
U
Dwelling—No. of Bedrooms.............3..........-------------Expansion Attic Garbage Grinder (
4
PL, Other—Type of Building ............................ No. of persons---------------------------- Showers Cafeteria (
Other fixtures
Design Flow.................. .._._.._._.__gallons per person per day. Total daily flow.....................5S..O......gallons. -P4 Septic Tank—Liquid capacity/6VOgallons Length................ Width..__......_..... Diameter.........._..... Depth................
Disposal Trench—No..................... Width............._._.... Total Length__.................. Total leaching area....................sq. ft.
Seepage Pit No........ D* eter...../Z ..... Depth below inlet___1?e..5.*... Total leaching area..A4.r..sq. ft.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by..3AX72 .24 I.Y.Z5........................... Date..........ve...Test Pit No. I.....79rr!n---minutesperinch Depth of Test Pit.........12-v Depth to ground water........r.............
Test Pit No. 2................minutes per inch Depth of Test Pit................._.. Depth to ground water._._..__.._.........___.
............................................................................................................................................................
- --------------------------------------------------------_---------------------------------------------------------
r
0 Description of Soil ...
................--------------------------- ----Y .............................................................................................................................................................................--------------
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
.......................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual,Sewage Disposal System in accordance with
the provisions of TITLE;TJ LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Co pliance has been issued by the board of health.
�aAA/,XM-�- Signed......... .. ............ .... .................... .. .................. ..........................
IF Date
ApplicationApprove By___!_-4 ---- ------ - - --------------------------------------- ----------------------------------------
D ate
Application Disapproved for the following reaso :................................................................................................................
........................................................................................................................................................................................................
Dat
PermitNo......................................................... Issued-.......................................................
Date
No..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... ...........OF..............
.........................................................
A',phrathin for isposal Works Tonotrurtion Frrutit
Application is hereby-made for a Permit to Construct (k-<or Repair ( t--4)�-an.Individual- Sewage Disposal
System at:
F-/V
.............. ....
........... .............................. . ..... .
............ ..........
......................... ................ /I
Location-Address or Lot No.
........... ----------�4 1.lv i�
"I------------------------------------------ ....... ........... ..
Owner Address .............
.......... V.!........ ............ 1,14
..................................................................
Installer Address
Type of Building Size Lot...V5, 9P.0 --
Sq. feet
P,
U ---- ----
Dwelling—No. of Bedrooms............. ........................Expansion Attic Garbage Grinder
134 Other—Type of Building ..........!�................ No. of persons............................ Showers Cafeteria
04 Other fixtures ..................................................................................................................................................
Design Flow....................j.._............_..gallons per person per day. Total daily flow...................:5-�.D......gallons.
N04 Septic ,Tank—Liquid capacity&VO.gallons Le\ngth................ Width....._.......... Diameter................. Depth....___.........
tk�, Di
sposal Trench—No..................... Width......_............. Total Length.............;.. Total leaching area---------_--------sq. ft.
Pit No--------/---------- Diameter.....IZ ...... Depth below inlet__;_?4_.5..... Total leaching area.9:!?-.r...sq. f t.
Z OtHL-,r Distribution box Dosing tank
t-4 Test Results Performed by..:5A . . ......................... 7
0-1 Percolation-Test
/N , _t.... .............. ......
Test Pit"Nb�,l..... ....minutes Depth of Test Pit........ Depth to ground water.......—................
Test Pit No. .....minutes per inch Depth of Test Pit.................... Depth to ground water._.___.............____.
............................. .....................I.........................................................................................................
0 Description of Soil------ .... . ............... ... .....................................................................................................................
... ......................
----------------------------M .... ....................................................................................
................ ............................ ...........y .......................................................................................................................................
�0
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
. ........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T IZj 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Co, pliance has been issued by the board of health.
Date
ApplicationApproved By.. ....... ........ .... ............................... ........................................
�% 7*----------------- ...*----------------------
Signed.......
Date
Application Disapproved for the following real ................................................................................;............................
.........................................................................................................................................................................................................
Date
PermitNo....................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........IeX.�...........OF...... .........�V5J
(Infifiratr of Iff-Vampliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by-........................1g.. -1...........................................................................................................................................
.........IV,—
at................ I�ns.t .I.-
.,--Z ............. . . ..........
I-------- -------- ?Kt,�- ---- .......1.1 ......\..............................................................
has been installed in accordance with the provision's of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...... ................. dated.__..____......_..__....._______......._........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................................................I..' I� '.. I
00q
....... ......... nspector..........t��............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............la ......0 F.........e �....................
..................... FEE........................
Disposal Works 0annotnution Vanfit
Permission is hereby-granted............... ..........................................................................................................
to Construct �or Rej3air an Individual Se rage Disposal System
atNo...............;z .:-- .............._&Zf-a .............. ....................................................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated.__........_.__................_......._..
.......... ..... .....................................................................
./,3 / �7 S V A Board of Health
........ ..........
7........................................
FORM 1255 A. M. SULKIN, INC., BOSTON
jGLG- FAMILY - '.'S 6COROOM
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DAVID
CHARD
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`� No. 29976
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Log Number_ 3891 Bottle # D001 Date: 8/3/84
o f BqR�
BARNSTABLE COUNTY HEALTH DEPARTMENT
a: g SUPERIOR COURT HOUSE
v �' BARNSTABLE, MASSACHUSETTS 02630 i
g1Aso,
DRINKING WATER LABORATORY ANALYSIS PHONE: 362-2311
} EXT. 331
� �Client:', Richard Hewry Collector: Kenneth C. Pike
Mailin Address: 50 Shell Ln. Affiliation:- Atlantic Well
9
Cotuit, MA 02635 Time & Date of
Collection: •8/.1/84, 1.:15 p.m.
Telephone: 428-7479 Type of Supply: well water
Sample Location Lot 344 Well Depth: 63'
Hazel Path Date of Analysis: 8/l/84
Marstons Mills
PARAMETER SAMPLE RESULT RECOMMENDED LIMITS
Total Col iform Bacteria/100 -m1 --- 0 - - - - - -0.
e
H 5.6
. 4
Conductivity (micromhos/cm 500.0 106. '
Iron ( m) <0.05 0.3
Nitrate-Nitrogen ( m). 2.6 10.0
Sodium m) 12.0 20.0
h
I, xx -Water sample meets the recommended limits for drinking of all above-tested parameters.
II . Based only on results of the parameters tested for this sample; the water is
suitable for drinking but may present the problems checked below:
A. Water sample has higher than average levels of Nitrate. Future monitoring is
recommended (2-3 times per year) to establish ,any upward trends.
B. The low pH of the water may shorten the useful life of the house's plumbing. .
C. Water may present aesthetic problems (taste, odor, staining) due to
D. Water sample has high levels of sodium: Persons on low sodium diets should
consult* their doctor.
III. Due to one or more of the reasons checked below, this water sample is unfit for
human consumption: A. High Bacteria B. High Nitrates
REMARKS:
CC: Atlantic .Well .Drilling
CC: Barnstable Board of Health �l p
Labo tory- Director
7/17/84 `'%
N ;r
Explanation of Test Results 6
Total Coliform Bacteria r r
Coliform-bacteria are an indicator of the sanitary quality of a water supply. Water supplies may become
contaminated from malfunctioning septic systems,cesspools and surface runoff. A total coliform count of zero ;
indicates that your water supply is safe and approved for human consumption. A total coliform count of greater
„ than zero is,most often,the result of accidental contamination of the sample bottle through improper sampling
methods.-For this reason, it would bedadvisable to retest any well water that is not'approved.
pH
th•measure f acidity or alkalinity of the water. On •H scale the number 7 is neutral, less than 7
pH is e a o y p
is acidic and more than.7 is alkaline..The.pfi of water on Cape Cod tends to be acidic in•th_e`range of 5.0 to 6.5 '
Conductivity
Conductivity is a measure of the dissolved salts in solution. Amounts in excess of 500 micronthos'cm are
generally considered unacceptable and may h"ave a laxative effect upon users. _
Iron •k __ . . . _ _ . . .. .�,:� V
The presence of iron in water in concentration of .3 ppm or greater may: give the water a bittersweet
astringent taste, cause an unpleasant odor, often gives the water a brownish color and cause staining of laundry
and porcelain. The average concentration of iron in Cape Cod's water is ,2 - .6 ppm. Although the presence of
iron-in water may cause the problems fisted-above, it is not considered.deleterious to health. Iron may be.
removed by use of an iron removal system
Nitrate-nitro en
The Massachusetts Drinking Water Regulations,have seta maximum contaminant level.for nitrates at 10
ppm.;Excessive concentrations may cause methemoglohinemia (an infant disease)and have been suggested to
form potentially carcinogenic nitrosamines. Contamination sources include fertilizers,`ce' pooli and industrial
wastes.
Copper
Due to the acidic nature of the water on'C'ape'Cod, copper tends to leach from pipes. This normally,does
not present a health hazard; however, concentrations in excess of 1.0 ppm may cause a metallic taste and/or a '
bluish green stain on porcelain fixtures.
Sodium . . ' .. 'r _ '';• . ,. t
µ ' A'concentration of sodium over 20 ppm is only of concern to people who are on a low sodium diet.' If the
F water supply has more than 20 ppm sodium, it is up to the people who are on such a diet to find another source
of drinking water or contact their doctor to,determine if consuming the water is advisable. Concentrations
exceeding 50 ppm indicate that there may be ocean water or road salt runoff water vetting into the well.
r' ,
t
- 95--EXISTING CONTOUR °�a° N
x 100.98 EXISTING SPOT GRADE
• EXISTING WELL
G EXISTING GAS SERVICE
U UNDERGROUND WIRES 0 Gcy
TEST PIT
BENCHMARK o LOCUS /
LEGEND
f I v
4
IfE
a
TING LEACH PIT RECORD AS-BUILT) ° Drive
E PUMPED, FILLED
W/SAND & ABANDONED o \
LOCUS MAP
NOT TO SCALE
S 58'48'35" W
174.87'
LOT�`344
MBL 0637-025
�`� 43,900 ±SF
EXISTING SEPTIC TANK \� �\ �� i rn `\ ,p
TOP OF TANK, EL.=94.69
IN V.(OUT)=93.36t \ �� �\
TP-1 \ 1
BENCHMARK SET 6 .... . .3 .5'-� �� 98. 7
OUTSIDE CDR./TOP STEP -� 9360 - 1 - -95.32 i•. �,
EL.=96.96 ` I O' O O 1 {�_94 / r P8.84
_ ROP_S.A. -J /T \�'•• //� GARDEN
95.63 V / 96,94 97.52 \ �•.
95.93 �/ �� 3 ,S, t 99.27
95.80 SP �bs 'O x 96928� fs� qR 5 z 1
1.
L4 \ / : / DECK 6.83
N i
L4
96 CONCRETE v C I
¢,/ _ x BASKETBALL Yy- Q` •6 _ - _ _ .._
p 9 .53/ : ( 95.80 ' / shr COURT ) �_ " y 0`
/ / + S EXISTING �6• r
HOUSE(#67) ��
frl i \\ `� 96. \� T.O.F.=97.Of72
GARAhk
GE ,
.03
x 97.12
` \ 97.11
.82
CONCRETE \
\\92.04 \\ 93.62�J SLAB \\
\r \
gyp. \ `r.`:',; •'S:c �.w'-` : : 95.09 9r \
61
6
�.
94.04
\
91.25
,8 .29:,
\ N
89.25 1`45.00 ;.`;:::• ��o
N 58* 0' E �. \
----� WELL '.Bt365 Y`<' 90A x
...,' , 89 47 \ \
87.5. 88.35 CATCH BASIN 89.16 EDGE OF PAVE ENT 91.60
88.43 Cb
may'
PK S 89.76 PAT H
HAZEL AJ
����� of MAssgcti
PROPOSED SEPTIC SYSTEM UPGRADE PLAN
o PETER
McENTEE 67 HAZEL PATH, MARSTONS MILLS, MA
CD
CIVIL "' Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632
No. 35109 OWNR OF RECORD
EO BOUCHARD, NORMAN E JR Engineering by: SCALE DRAWN JOB. NO.
° REGIST�� & KRISTEN P 1"=30' P.T.M. 178-14
67 FFs E Engineering Works, Inc.
HAZEL PATH
MARSTONS MILLS, MA 02648 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
g ZO (508) 477-5313 7/17/14 P.T.M. 1 Of 2
ti
NOTE: TO PREVENT BREAKOUT, THE PROPOSED
FINISH GRADE SHALL NOT BE < EL:92.5
FOR A DISTANCE OF 15' AROUND THE
SEPTIC TANK PROPOSED D-BOX PERIMETER OF THE S.A.S.
INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER PROPOSED SA.S.
OUTLET AND SET TO 6' OF FINISH GRADE
SET TO 6" OF GRADE INSTALL RISER & COVER OVER EACH CHAMBER AND
T.O.F.=97.0t SET TO 3' OF F.G. TO SERVE AS INSPECTION PORTS
F.G. EL.=96.5t F.G. EL.=96.2t F.G. EL.=95.5t F.G. EL.=95.0t
4Amozom
3'(max.) L = 25' _
® S=1% (MIN. L - 23'(MAX.)
_ ) 0 S=1% (MIN.) 2- LAYER OF 1/8" TO 1/2"
4"SCH40 PVC 4"SCH40 PVC
6"' DOUBLE WASHED STONE
" *m2em7m7. ." ."
Baaaaaa (OR APPROVED FILTER FABRIC)
74" 9aaaaaa
EXISTING 48" LIQUID aaaaaaa -3/4" TO 1-1/2" DOUBLE
LEVEL WASHED STONE
�c/asADBaFFLE J ' INV.=92.403.5' 4.8' 3.5'
D BOX . 2.23
INV.=93.36t EFFECTIVE WIDTH = 11.8'
EXISTING 3 OUTLETS INV=92 00
FLt EXISTING SEPTIC TANK 3-500 GALLON LEACHING CHAMBERS
SURROUNDED WITH STONE AS SHOWN
H-10 RATED
TOP CONC. ELEV.=92.8t
NOTES: BREAKOUT ELEV.=92.50
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INV. ELEV.=92.00 aaaa
aaaa
INVERTS, PRIOR TO INSTALLATION. eases -aaaa
2) D-BOX SHALL BE SET LEVEL AND TRUE TO BOTTOM ELEV.=90.00
GRADE ON A MECHANICALLY COMPACTED SIX 3.5' 3 x 8.5'=25.5' 3.5'
INCH CRUSHED STONE BASE, AS SPECIFIED 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH = 32.5'
IN 310 CMR 15.221(2). PERVIOUS MATERIAL
5' (MIN.) ABOVE G.W.
3) INSTALL INLET & OUTLET TEES AS REQUIRED. LEACHING SYSTEM SECTION
4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE BOTTOM OF TP, EL.=84.3
AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. (NO GROUNDWATER)
SEPTIC SYSTEM PROFILE
SOIL LOG
DATE: july 16, 2014 (REF#14,423)
SOIL EVALUATOR: PETER McENTEE SE#1542
WITNESS: DONNA MIORANDI R.S.
HEALTH AGENT
GENERAL NOTES: ELEv. TP-1 DEPTH ELEv. TP-2 DEPTH
1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL 95.4 A 0 95.3 A 0Y SAND LOAMY SAND
BOARD OF HEALTH AND THE DESIGN ENGINEER, LOAMY
SA 10YR 4/2
2, ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 95.1 B IOY4" 95.0 B 4"
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE - LOAMY SAND LOAMY-SAND
' LOCAL' RULES AND REGULATIONS" _-
3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 10YR 5/6 10YR 5/6
93.2 26" 93.5 22"
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE C C
DESIGN ENGINEER. PERC
4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 24"/36'
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
ENGINEER BEFORE CONSTRUCTION CONTINUES.
5. ALL ELEVATIONS BASED ON ASSUMED DATUM.
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF M-C SAND M-C SAND
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 2.5Y 6/6 2.5Y 6/6
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
7. WATER SUPPLY PROVIDED BY PRIVATE WELL.
8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S.
9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS
AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE 84.4 132" 84.3 132"
DIRECTED BY THE APPROVING AUTHORITIES.
10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY PERC RATE <2 MIN/IN. ("C" HORIZON)
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
CONSTRUCTION. ELEV. TP-3 DEPTH ELEV. TP-4 DEPTH
11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS 97_6 A 0" 97.5 A 0"
IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND LOAMY SAND LOAMY SAND
REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). 10YR 4/2 10YR 4/2
12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE 97.3 B 4 97.2 B 4
INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL. LOAMY SAND LOAMY SAND
13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND 10YR 5/6 10YR 5/6
IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. 95.6 24' 95.6 23"
C C j
PERC
DESIGN CRITE CIA 24"/36'
NUMBER OF BEDROOMS: 3
SOIL TEXTURAL CLASS: CLASS I M-C SAND M-C SAND
DESIGN PERCOLATION RATE: <2 MIN/IN 2.5Y 6/6 2.5Y 6/6
(0.74 GPD/SF LOADING RATE)
DAILY FLOW: 330 GPD
DESIGN FLOW: 330 GPD
GARBAGE GRINDER: NO-NOT ALLOWED WITH DESIGN
86.6 132" 86.5 132"
LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF
PERC
RATE <2
IN
.74 GPD/SF NO GROUNDWATER ENCOUNTERED
HORIZON)
EXISTING SEPTIC TANK: 1000 GALLON CAPACITY '
PROPOSED DISTRIBUTION BOX: 1 INLET, 3 OUTLETS PROPOSED SEPTIC SYSTEM. UPGRADE PLAN
USE 3-500 GALLON LEACHING CHAMBERS IN SERIES
SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES 67 HAZEL PATH, MARSTONS MILLS, MA
SIDEWALL AREA: 2(11.8' + 325) X 2 = 177.2 S.F. Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632
BOTTOM AREA: 11.8' x 32.5' = 383.5 S.F. Engineering by: SCALE DRAWN JOB. NO.
TOTAL AREA:..............................................................560.7 S.F. . Engineering Works, Inc. N.T.S. P.T.M. 178-14
DESIGN FLOW PROVIDED: 0.74 GPD/SF(560.7 SF) = 414.9 GPD 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO.
(508) 477-5313 7/17/14 P.T.M. 2 Of 2