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0025 HEATH ROW - Health
25 Heath,Row A = 063-076 ,lids Marstons -- Town of Barnstable Elgrnstable THE Tpy_ Regulatory Services Department A94mWia j su KA-Q& I 9 Al Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2851 4242 July 29, 2014 Robert F &Kathleen A Haag 25 Heath Row Marston Mills, Ma 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 25 Heath Row, Marstons Mills,MA was inspected on 6/23/2014 by Brett Hickey, certified Title V Septic Inspector for the State of Massachusetts. • The inspection of the septic system showed that the system"Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: a Distribution box full over outlet invert and leaching full into riser. • Pump alarm is not working. Alarm must be replaced or repaired. • Remove garbage grinder You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH jv Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\25 Heath Row MM 2014.doc 7 , '�Application Center suggested SitesUaeb vl' .Gallery Application Center(2) 91 http--www.town.barnstable... .. k Favorites �,I�Parcel Detail o MA i y ,$p gig rx3 r •. . = ,t Parcel Info 4 Parcel Developer _ ID1063-076 Lot ILOT 23 Location i25 HEATH ROW Frontage 149 Sec _ Sec Roadl Frontage Fire Village�MARSTONS MILLS District�C 0 MM Town sewer exists at this _-..-_... ........ ____-..._... -_—_-W........ __... -_ _ Road Index 0684 address;No Asbuilt Septic Scan: Interactive r � •°, 063076_1 Ma TUN Owner Info �� OwneriH GAA ROBERT F&KATHLEEN A I Co Owner; Streetl 125 HEATH ROAN Street2ti; CityIMARSTONSMILLS I State!MA Zip.026A8 Country. i s 'Land Info F ---- - � i ...,,:4�) i Local Intranet 11 41 AM T �. � � uesda� e f /TOWN OF BARNSTABLE LOCATION SEWAGE# .®/�� � VILLAGE ASSESSOR'S MAP&PARCEL 63 7� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 15 //Da0 LEACHING FACILITY: (type) 62) -,,6-ene4 cr (size) -2 X 3;� X.3 NO. OF BEDROOMS OWNER p ,? PERMIT DATE: &/7& COMPLIANCE DATE: D 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 {{ i A2 - B2= 2z ' .A3: Z3 ' B3 - Ig ALf- 2-vc, T3L4 - 17 - �5° '70'� ° 13641U3'6 Commonwealth of Massachusetts Title 5 Official 'inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Heath Row Property Address Robert& Kathleen Haag Owner Owner's Name information is required for every Marstons Mills MA 02648 6-23-14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms Ji� on the computer, use only the tab 1. Inspector: 1 key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation, Inc. �y Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 Cityrrown State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ N her Evaluation by the Local Approving Authority 6-30-14 Z r's' ign re Date stem I pector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Offcial Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 25 Heath Row Property Address Robert& Kathleen Haag Owner Owner's Name information is required for every Marstons Mills MA 02648 6-23-14 page. Citylrown 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y< 25 Heath Row Property Address Robert& Kathleen Haag Owner Owner's Name information is required for every Marstons Mills MA 02648 6-23-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '( 25 Heath Row Property Address Robert& Kathleen Haag Owner Owner's Name information is required for every Marstons Mills MA 02648 6-23-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank andsoil 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 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 must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Z. ❑ 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 El ® 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 'h day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Heath Row Property Address Robert& Kathleen Haag Owner Owner's Name information is required for every Marstons Mills MA 02648 6-23-14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For you,stems large s must indicate either"yes" or"no"to each of the following, g y y y g, 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 El El Area 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. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Heath Row Property Address Robert& Kathleen Haag Owner Owner's Name information is Marstons Mills MA 02648 6-23-14 required for every page. Citylrown 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? ® ❑ 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: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information .Residential Flow Conditions: Number of bedrooms (design): No Plans Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Heath Row Property Address Robert& Kathleen Haag Owner Owner's Name information is required for every Marstons Mills MA 02648 6-23-14 page. City/Town State Zip Code Date of Inspection D. System Information Description: D-box full over outlet invert and leaching full into riser. Pump working in pump chamber but alarm is not working. Alarm and leaching must be replaced. Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 IN Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Heath Row Property Address Robert& Kathleen Haag Owner Owner's Name information is required for every Marstons Mills MA 02648 6-23-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Tank pumped year prior, per owner Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Heath Row Property Address Robert& Kathleen Haag Owner Owner's Name information is required for every Marstons Mills MA 02648 6-23-14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: leaching replaced 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 212" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >100' feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appears to be in good working order with no signs of leakage. Septic Tank(locate on site plan): 1'8" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions` 1000 gallon 2" Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 25 Heath Row Property Address Robert& Kathleen Haag Owner Owner's Name information is required for every Marstons Mills MA 02648 6-23-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 35" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection tank appeared to be in good working order with no evidence of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date l5ins 3h3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '< 25 Heath Row Property Address Robert& Kathleen Haag Owner Owner's Name information is required for every Marstons Mills MA 02648 6-23-14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 25 Heath Row Property Address Robert& Kathleen Haag Owner Owner's Name information is required for every Marstons Mills MA 02648 6-23-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert over 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.): At time of inspection D-Box was full over outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ❑ Yes ® No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Alarm will not alert when float switch is lifted. Pump is working at time of inspection. * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-.3h2l Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Heath Row Property Address Robert& Kathleen Haag Owner Owner's Name information is required for every Marstons Mills MA 02648 6-23-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 3 (4'X4') ❑ 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.): At time of inspection leaching was in hydraulic failure. Must be replaced Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Heath Row Property Address Robert& Kathleen Haag Owner. Owner's Name information is required for every Marstons Mills MA 02648 6-23-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): II Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•.3)13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth.&Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form:-Not for Voluntary Assessments ` 25 Heath Row Property Address Robert& Kathleen.Haag Owner Owner's Name information is required for every Marstons Mills MA 0264:8 6-23-14 page. CitylTown State Zip Code Date of Inspection j D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately i a From : i .. \/ P omP Ch(Am bm- I ! �- x i A 3 - 25'fit, 3ie25�5 > 132 - 2 i 13 'I 13 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "t 25 Heath Row Property Address Robert& Kathleen Haag Owner Owner's Name information is required for every Marstons Mills MA 02648 6-23-14 page. 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: >5' below systemfeet 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: Pond located behind house showing bottom of leaching is great than 5' above ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Heath Row Property Address Robert& Kathleen Haag Owner Owner's Name information is required for every Marstons Mills MA 02648 6-23-14 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. ,L 412-8 Fee 10 o' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS. tlYication for his OSaY bpstem Construction permit AAicahon for a Permi to onstruct( ) Repair(" Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. '3 5 H tat1 l 1--7 e„`L � Owner's Name,Address,and Tel.No. Assessor's Map/Parcel , I ,�n n t )D` �� 6 D g--11(-i 41 c l �b In ller' ame,Address,and el.No. slignerr'ss NJ `,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building s D,G,G[ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 0 gpd Design flow provided gpd Plan Date 1-2-Cl I 14 Number of sheets Revision Date Title Size of Septic Tank �>C15f1[ZU ISLn Type of S.A.S. Description of Soil �� 1r� W 1-1—t1 GI-e�� SCuI� Nature of Repairs or Alterations(Answer when applicable) b0)4 3` \1 3' X 22 l ) i_)PC-r- n(po -r-str2lu-. 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 Boa o ealth. Signed Date 11171114 Application Approved by -- - Date Application Disapproved by Date for the following reasons Permit No. '�(a I Zj�, Date Issued I 1 y , _ i + , J No.�01L1 1/243 ¢ F Fee _) THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:_ Yes f PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplicatlon for Mi8 -oBal *pstrm Construction 3permit � r A 1 cation for Permit`tro Co Repair Construct r p ( ) p ( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components . _ Location Address or Lot No. Owner's Name,Address,and Tel.No. a� Heath 06o q Assessor's Map/Parcel In'ataller'f ame,Address,and Tel.No. esigner's Na e,Address and Tel.No. Y L-' 5v� ti7-r-Q wnQ . n R Type of Building: t Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building__J;�>6 1( No.of Persons Showers( ) Cafeteria( ) Other Fixtures ' =' Desgn,Flow(min.required) 3 gpd Design flow provided gpd Plan Date (D 4 2.� 4 ./Number of sheets Revision Date Title Size of Septic Tank (1Q �SQr�Q(�.I Type of S.A.S. Description of Soil 51 ��cnrN i rc Nature of Repair".or Alterations(Answer when applicable) 0 d. 1 t'_a c h t c)G ` -f P nr h 1 -2-� '3' Y 3' X 2_ID -�-- r r 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 Boar o Health. Signed Date � ` l Application Approved by C — - •- Date Application Disapproved by Date for the following reasons Permit No. 7 �(- N Z� Date Issued y t y --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS E Certificate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal system Constructed( ) Repaired(0 Upgraded( ) Abandoned( ) tby. )(.( 40 E4 0 at I ('(�-� J ) has been co":; with the i of Title 5 and tie for Disposal System Construction Permit N Installer [`',t, L� (i l l Designer _nep DO, #bedrooms 3 Approved design flow 33 D y 44 gpd The issuance of this permit shall otb onstrifed as a guarantee that the system will fun ion dmigged Date Inspector � f �i' .i"'• %7'� ;/� - -" -. - -- No. Q�L1- y Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal *pstem CConstrULtion permit Permission is hereby granted to Construct( ) Repair(d ) ( Upgrade( ) Abandon( ) System located at 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 ynust be completed within three years of the date of this permit. Date C"'` I!�/ Approved by i (9-wn of Barnsvtable -Reaulatory Services 4 4 Thomas F, Leifer,Director MOM. 4 Public- Realth Division Thomas McKean, Director '700 M2&8tu•eet,B[y.%nz&,AIA 026.01 Office. 546-5624644 Fax: 503-790-6304. Installer &Designer Certification Form l lPermmiit4 7-0d_ �4 Assessor's 1�1 a \Parcel b �� ]@ale. � � � Sewage � � • \ 4 l�esii�nnero VJO�J�. r Tnn� �Illlem: �� CGt✓ 0 Address: Address, � � Pj- On was issued a permit to install a (date) (installer) a design h� yo based off. drawn by .septic.system at [-� � 9�-d ff (address) Cim �l I0, dated r (de or) 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't e: distribution box and/or septic tank. s• 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. � �W OF M,% DANIELA. �yGN OJALA �. o � (Inst is Signature) CIVIL N o No.46502 �p�F 1 SSrONAL E� (Designer's Signature) (Affix Designer's Stamp Here);: PLFAS 3 T'tT Ai TO B T TABLE YURLIC 1��.I.,`IR DIVISION. CERTInCA:TE OF a oyff.LIANCE �L i�o BE r� CED UN—IM BOTH TKIS FO. 't1 A140 A&BUILT CARD ARE RECEM D By TBE BARNSTABLE PUBLIC HERALTH DIVISION. TE YOU. NOV/07/'2014/FRI 08:43 APB COMM Water Dept FAX R 5C342'8330C" P. 001 103 Centerville-Osterville-Marstons Mills Water Department ,,., ,■ P.O. BOX 369- 1138 MAIN STREET DEPT. OSTERVILLE,MASSACHUSETTS 02655r ` TEL. 508-428-6691 FAX. 508428-3508 Fax Transmission 11/7/2014 Board of Health 1-508-790-6304 3 pages,including this cover sheet. Memo ATTN:DONNA The attached 2 sheet are the Water Service Application for:25 Heath Row as requested Best regards Beth Flick COXal Water Dept. 508-428-6691 bflickZ.commfiredistrict.c orn 3 NOV/Oii 2014./FR I 08:43 pig COMM Water Dept FAX No. 5084283538 P. 002/033 f:>enEervil(e-i_)stervil�•I�1a1'st3ns �'�iils >� c�al-t>rtteltt _�� �•� PA lROX 369- t 138 MAfiN ST EET OS"t'ERVII L E. 11ASSA(_% ;SE[T-S 02654 stx-E: OS 1-7 dTFS f:(ii' Wir •=?ii.�FL�:C)Pt.';i?LnCt�4�fi$.`•:(:d\L-4ti .•.�;VS+t�T�� jn T.1tiy� �):;'1'FN SLir'[KJ`l'�4�fiiRT' �. s*oNs� TFL, 1:,.�08-42,�6691 -FAX NQ: C'EiNTEAK,'iLi.EGOS',TERVILLE-MA.RS'TON,SMIL,Ls.TlltE DI$TR a WATER DEPARTMENT W,kT ER SERVICE.APPLICATION <s •:� Date -- � :` "" .s:%+ - - � 1. I Fer6y make application to the Centerville;-Dstervilte-NSarstons Mills fire District, Water Depaiti.nent(tte"Department' for:Seater service at Lot No. shown on Land Coerrt I'iail.No._ .or on plan recorded in Barnstable County Registry of'Deeds at F3oc>lc Page ,beisij i`n=..1 0. T�'";Street ,aria shown as Ba:a,6talile Assessor's flap 3'''' ' 2.. By the execution liezecit the undersigned:represents and wa.riarits that he has ro. :and, trndersta:icis,and agrees for hir�lselr;his heirs, successors and assigns to ahi.de by,the Rotes arid:Reguiatioas(,f.the Water Department as in effect.frorri time to time. No applications shq. l belimade.saeking any installatio��i2�vio afion o£any law,mile or regulation,iaOuding the state b tildirtg and.state and:oval health codles, and Withont lirrritirg.the.generality offthe foregoirrb,tip coruzecV o is will lie.niaiie to vi afer service fines l cated:xvithin 20 feet of any septic System or liz:rt thereat. No corinectiom will Gee. ruaie.to water service lines located within 10 feet.of electri.c,.telephone, cable or gas lines or to water sehice lints;v4iie) pass under electric,telephone, or gas.lines. 4. The undersigned acknowledges, understarids and.agrees that=he:renr.eri>i1.le=Usterville- lv ar-stoW mills Fire District.includin(Aie Water Depart:aiwit,and:its al,,d their agmis, servants aDd.employees(herein the."l?ist6d').do not undertake,in.corinection NI'i.tli.t%ie provisio^ of services requested Herewith or utherwise,to survey the premises shove or belom,ground,to fscertaiir the ln:;atioh of any taidergrot:ncl obstacles,ir.:cluding i .9.derground electr t, telephone,gas; cable,private water, septic cyst--nz or othfar subsurface installafinn or nivate Brie;:and further±Pion,the.undGrsigr:ed;c maiits and. representsAl-at he/she has exercised due diligen.c-e. tt con)pr rr;g the sketch.referrce,to in P:araaraph.6, below i NOV/07/2014/FR I 08: 44 Alf COMM Water Dept FAX Pro, 5084283538 P. 003/003 ?lie.u:rid.erngme� hercwith and herc6v.rc:l Z41d R2TOCS to:nde-r niN and:hold ILaimles the Certer�il7z C)5:ert rile-i�latstLlits k:i.1ls Fire.Di :1iL''t,its Wat. tr Dvarttnant aad its arid. li? ir aaen -j, serer ivit, and m loyc 5 0:f r d fr t.n.211 lost;costs,c;aiins, ciennanas,aclhil5; aus:es at'aICLIOn aEd',!s rijc)S or.riart or:eillec ,. whI Cher fetal or ecx.:table andi:l W!1.1tclvc.i Lou"A cr L:r.:Trl., a!`1:'in oI'CI:T;L2 11+Ct iiflt'-1 tlfl'�1 f-o:i1 C:'.^ :4m11xtf0:r1 ti`rl:il work, labor or M..kriak p_-os- _.-Ed by or at theregiiesr;dirtictien.orT e.hLst.ot the C'ente�ville..-C�stenille Iatstons Mils Fire Ols'a ct ar.d(or Wa_er Delaartment fhvreof for the dslivery of wafer service to the rrcmI'ses desarihec:.above,excepi to the ext.-nt Sucl are the result.of tYie gneiss negliv.erce or willful Wjidiwt of the said Distinct: G. Builditlg permit, certif fed plot plan, and cop}•of orivl.er's bile geed.. as recorded or filed must be suhrri.itted with.crppl caiiort for new construction,service hi!!c are rharged 4—.rnakri»lS, lldhor.nri/l.'�'T:rss:chuselis SQaleV t2? .Patch, road opetzin perim. and detail of ter alsn ar,e:charged as necessary. Service hills must he paid bek,re water service is activated:ExLv.i)V homes pkas:e.sk:eich.on tine reverse side the precise locution of and'underground featrlr•es, including a►!y utilities, septic,private. well, and locatint3:of where water line is.to he.installed;: new conslrnetion submit sketch Based on certifed plot plan,showing ex.ivinq or intended undergrounrd feWures. Nanif of Qvvner pet Deed 1'itfe Reference: J� a>sr� " Pvt sera Address Future '3iAM—Addtess X.p2 Telepllvne p�.� .��3..�-------•----- Cell,fir rDa-7.tid-/�/d` md,C,.-:Size -Line Size_ SyStenm Develc:pment Chi irge Witness my/our laand(s)duel stal(s)this - �__Lf3y of ��;o r _ ,.20 ry, 0;�'rzei;__'Z"/t'i�r't%'y'/rfZ�k"�rt�Y'.�- ��/e'��f t�r`l�i�'G.�-•n' _-__��—. . . .. ... /-ZIL252 S"gr ature Print Nagle Da e S C Paid ✓ r CZecic. fait by: K�E�0::•le]t:vater>erv,...Spp{,%suon'�'?i�..rS-seise Applimlioi-01.wpd R k ?.. 0111 Town of Barusi.ble Sad y' Department of Regulatory.Services snnxarnnrr Public Health Division Date /e 2 ran h1 200 Main Street,Hyannis MA 07601 Date Scheduled O(%V `— / �v 6 � Tilna� �+eeA'cl. S 11 suit bi °ty flssessment for Se Performed-B : �✓a-V I �� Q/f/� y Witnessed By: 6 1 LOCA/ATION&GENERAL�'ORMATIgN Location Address lb u 7 4 Owner's Name Address Assessor's Map/Parcel: O`L' v T Engineer's Name �0 v�_ NEW CONSTRUCTION REPAIR Tel S Land Use:-4/Da S v�` Slopes(96) a—.S— Surface Stones Nil) e Distance's from: Open Water Body �lo� $ Possible Wet Aren>(a,/ ft Drinking Water Well Drainage Wny ft Property Line ft Other ft SI "TCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands-In proximity to holes) ' 121t� of Vl� C `� �wGS� Parent material(geologic) G/� / �IA 00 Depth to Bedrock Depth to Groundwater. Standing Water in Hole: / Weeping from PltPpee /t// Estimated Seasonal High Groundwater C�/ D JERfWATION FOR SEASONAL.HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: lu, Dtlpdt to sell mgttlas: ln. Depth to weeping from side of obs.hole: (t1, Groundwater Adjustment >c. Index Well# Reading Date: Index Well loyal Adj,Actor- -,,._.Adj.Groundwater Leval PERCOLATION T +'ST make— Tun Observation l Hole# ( Tlmo at 9" Depth of Pere Tlme at G" start Pre-soak Time @ _ Tima(9"-6") End Pro-soak Rate Mln./Iach Z C)h;17/,Th - Site Suitability Assessment: Site Passed S(tg Failed: Additional Testing Needed(YIN) A Original: Public Health Division Observation Hole Data To Be Completed on Back------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable ConseVvation Division at least one(1)week prior to begilaulug. Q:\SEPTIC\PERCFORM.D OC DEEP.OBSERVATION BOLE LOG Hole# �` Depth from Soil Horizon Soil Texture .Shcl Color Soil. Other Surface(in.) (USDA) (Munsell) Mottling (Structure, Stones;Boulders, o i ten ti 96'Cravell �- (0 L S 10 3/z DEEP OBSERVATION HOLE LOG , Ti01e# Z Depth from Soil Horizon Sail Texture Sall Color Soil ti Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stanes,Boulders, onsis en clo Grave 0 A s .R 3�2 d-fi) Q SL l a R y DEEP OBSERVATION TIOLE LOG Hole 0. Depth from Soil Horizon Sall Texture Soil Color Soil Other* Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. C0515trTiry,%Cowl) DEEP OBSERVATION MOLE LOG Dole# Depth from Soil Horizon Soil Texture Soil Color 5011 Other Surface(in.) (USDA) (MunnO Mottling (Sruetura,Stones;Boulders. Co si ton Flood Insurance Rate Map: Above 500 year flood boundary No Yes . _ "Within 500 year boundary No V+ Yes Within 100 year flood boundary No. �7 Yes Depth of Naturafl y_Occurring Pervious Material Does at least four feet of naturally occurring perviou material exist in all areas observed throughout tho area proposed for the soil absorption system? y e If not,what is the depth of naturally occurring pervious material? Certification -al I certify that onS/� (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in�10 CUR 15.017.Signature VJ Dath- I oNlI// Q:\5EPT1aPb1ZCP0RM.D0C ASSESSORS MAP PARCEL NO. a. No. ."' �� 0............... . lY THE COMMONWEALTH OF MASSACHUSETTS b BOARD OF HEALTH (03 &C.tn4U ,�vvftratiou for Uiiivoii ai parks (�onstrurtiurt ramit Application is hereby made for a Permit to Construct ( ) or Repair (-V-) an Individual Sewage Disposal Syssttem't at: ! t Hear, ► oe.� Cl�?6 ?!.__ � s ------------------------•-----•----...----...---------------...---------..................---- •--••...•-- A 9 RG 71?--°b.4 Lo-cation--Address � � � .I C��sLqt�No. KI S_•-•--•--•-•--- Owner �' A Address a ....OIL... ----------•------•--•-----•-------••-------------•--.............-• ��0 1�l�iin �p..px-..._..W� s I .garinar� ............ Installer Address QType of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Q, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ............................... . . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity.-______-_.-gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No.__._--.•_-•._•---_-. Width.................... Total Length.................... Total leaching area-----------_........sq. ft. Seepage Pit No----------_-------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date...........----......................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_--____-_____-_------._- fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------•--•--------------•-----------•-•---•---------------•---•---------•----...---•--•-•---................-•-------------•-----------------•--------•..... 0 Description of Soil........................................................................................---------------------......................................................... x V --•-----••-•--••-------•---••••••-----•••------•••--•--•-------•---•--•-----••-••--...--•---------•-•--------------•--------•-------•-------••--•--••-••---•-•--•--••---•-••-•----•---••----••--------•- W ------------------------------------------------------------- ----------------------------------------------------- ' U Nature of Repairs or Alterations—Answer when applicable._,4 xts ___ La.Cl_. 5......�/1 --------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i T T ._. p of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed---•-�✓ 61.aWv+�� � --------•----•---•--------- ----- -l�.'_86----- Date ApplicationApproved By.................................................................................................. Da te Application Disapproved for the following reasons--------------•---•------------•---------•-------•-•-----•----•---•---------------------•-••----••......--•----- --•-••-••--•--••-•-•-•••••-----•-------•••--•••--••-•-...--------•--------•...............•--------•••... . . ••--••-•----••••-•-••••--••••••-••-----•---- •---- Date .... PermitNo.__.:..... . ..... �.+�.......... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 77Tb!47 ,...................OF....... J41 n 5 , a�,---------------------..........._....__...----•----- Appliratiun for UiipuuFal Workii Tunutrnr#iun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair (W.) an Individual Sewage Disposal System at: `{ ��...��►-.4Coc.. (Vj rtrt'9n--11'i!�?...._..._....--••..... ..........•-•-------..........----._.....--------......_..-------...--•--•----•-----------.....-•- ....._. Location-Address or Lot No. ..._�A....... G r ... ��... ec� f �=a�' yl(t 1�4-----------------------------•-- p Owner r�1,,{t n Address W A`� l,a �CsY1�Ca_ G -+!(( I)2- sL , i 8�-_Ulprntvt!' ........_.. s ................. Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling=No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ............................... . . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity-_-____-•__•gallons Length................ Width................ Diameter................ Depth_•__-_________.. Disposal Trench—No. ...................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----_---_-------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--_-____________-______. rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 •--••-•--•---•••-------------•-••-•••••---•••-•-••••-•-•-....•-•---------•..........----------------......................................................... 0 Description of Soil........'............................................................................................................................................................... --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W U Nature of Repairs or Alterations—Answer when applicable '?=_sQ___� _ - � L �t...� :fj irpr�Q.. •--------------------.................................................................................. -------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITS : p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued rby the board of health. Signed••. f is:_4e'c,{�r ci±nwsa<�e. ............................ ..... =_ (o._..._ ( r/ Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons:--------•--•---•----------------------------------------------•-------------------------- -••••---•-••••-•--•--- --•-••••-----••-••--••-••••---•-•--•-••--•••-•-•----...--•--••----••••-•- -------------•-----• --��` Date Permit No....... Ca. 1 -----•---- Issued....................................................... Date ,f THE COMMONWEALTH OF MASSACHUSETTS �I16 BOARD OF HEALTH ........c�cs..n......................OF.-....1." C C.hs ab�c� .................................................. Trrfifiratr of Bunt li�anrr THISO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repairedby (. } --- ------ -------------------------•----------------•--••---------•--•-------•••-------------------•--•---------•-- nstaller --•-- ----•--- ---- -----------------------------------------------------------•----------- has been installed in accordance with the provisions of T i i i E 5 of The State Sanitary Code as derribed�in the application for Disposal Works Construction Permit No........ -n4_0---- dated--------- l L-�-�_-'-��-- THE ISSUANCE O THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANT E THAT YHE SYSTEM WIL FU 1 �A 1, DORY. DATE.............. �--..�.J --�--_��_ .................. Inspector--------..-•-O`....•------------------------------------------------------------- A THE COMMONWEALTH OF MASSACHUSETTS BOARD OF �EALTH R.Wn.................OF......�..,. .n ,llL.............. .............. . ,No. _.. ...�.1_D FEE._r d:... DiupuuFal War Tunu#rnr#iun � rAft Permission is hereby granted to Construct ( ) or Repair ( ) an In 'vidual Sewage >sp `_ System street as shown on the application for Disposal Works Construction Permit ------- Dat d.._: ... /-?.-________________ Board of Health DATE....... • ......... ....... e FORM 1255 BBS ARREN. INC.. PUBLISHERS ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH- ... ................................... .....OF...... R:(��}; .T...t4 Bt: .. r ppliratiou fur Diipsal Workii,T11U.Strurtilln Vamit n/ ,ti Application is hereby made for a Permit to Construct or Repair .( ) an Individual Sewage Disposal System at: , ........AclZ.r .= 1_.-.M.r�l� ®nl_ _. lac s.......................... T: 2.2.................................... L ions-Address or Lot"No, At --•---......••.... Ow / Address W . - \ Installer Address UType of Building Size Lot...._.•.._._..._ _- ._...----_._Sq. feet a Dwelling—No. of Bedrooms........... ............................Expansion Attic kj®) Garbage Grinder (uo) aOther—Type of Building ----A)/A........... No. of persons............................ Showers ( ) — Cafeteria d Other fixtures ----------------------------------------------- ----- ( ) pom W Design Flow........,l/L2.............. gallons per r�per day. Total daily flow............ 3.:�...................gallons. WSeptic Tank—Liquid*capacityT _Q�gallons Len r ° ° °1 ° `-gth�_..tt_..�. Width.�_11�...._ Diameter________________ Depth__5.._$___. x Disposal Trench—No. .................... Width......................Total Length.................... Total leaching area....................sq. ft. Z OthergDitriburion bo/..- Diameter...D osing tarilDc(th)below inlet.._.6_'____•...1Total leaching area+a00� sq ft.- �•Y$��LL�` 'L aPercolation Test Results„ Performed by._ Q_NA�C ......,eke.....6 te P/ :AyJZ:X�ate....Q7 V-lL .__�3_l1r1_.6 ,a •Test;Pit No. 1_._'44_7;�n..minutes per inch Depth of Test Pit_....! ......... Depth to ground water________________________ rzq Test-Pit No. 2_.4. ...minute e inch Depth of Test Pit..... .......)Depth t ground water........................ 0 ........................................ Description of Soil....Q."--Y......4x:P eA.1...--- -rJ../3 S,o/ _ 1 1�t-L�------�l �°.......-�=J 3- ---,I A 6!-4)t.1 W.01- x. S4.n1- 1.....---..`....1�1_a_:._.;_4T /� la S./t+2t� 1�------_..S. 14..---------•----------- U . r W ...aQlfl Z>Z71ZPAIS----------d�u ---�3:o.Zh!:-----TC�ST---.1Y L.�w.......... Nature of Repairs or Alterations—Answer when applicable_ ___.._. ..__ •___________________________________________________________________ ram- ...- _ ---- ......................................................... ---- --- --- Agreement �'/�� �� �ed� -e;2, - 0 =� The undersigned.agrees tojristall the a{oredescribed Individual Sewage Disposal System in accordance.with the provisions of i IT Li; 5 of the State:Sanitary Code— The undersigned further agrees not to place the system in operation until a-Certificate,of Compliance has been issued by the board of health. y'+` Si ed.- . ......................................................... � � Da�d_ Application Approved BY------�'� ------• �� � '=-- -----------•--.....-•--- .`. --�--- .................... Date Application Disapproved for the following reasons:................................................ --•--4-�=---------------------- ........................... ....................••__.._._...._._.._........_ ---------- ." r •--•--------•-----•-• _.. ----- Date Permit a----------------- Issued._._._.... / Date THE COMM Y'NWEALTI*OF MASSACHUSETTS . .. ..ciF..... .............. ... ` ._._. ........ (�rdif iratr of r Tourpli itrr t� ^'y. TH I ER FYI t'the Individual Sewage`Disposal System constructed ( �r Repaired ( ) Eby j r , Z, nstall at. Q. =_,f� ---- r .fJ�.°? // r Y/✓/j/4. N: --- -- -- - - -- br ....: has been installed in accordance•wlth the provisions of . j of The-8tate Sanitary Co' as described,in the application for Disposal Works Construction Permit N - •___�:�1......_....... "„dated-...__ ---4_:1� 7J.............. THE ISSUANCE'OF .THIS CERTIFICATE SHALL NOT BEFCONSTRUE® AS A G9JARANT THAT THE SYSTEM Wl FUN TION SATISFACTORY. DATE........ ....................................................... Inspector... f ----------------- ---__. _. ASSESSOR'S MAP NO. . 63 — `l;6 PARCEL ;-1 19 L 0 C A T [014 SEWAGE PERMIT NO. H -A-i VILLAGE INSTA LLER'S NAME A ADDRESS e U I L D E R OR OWNER (Z, H A AC� DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED ------------ 0 a f 4G'*' �, Ivy >e' FEic NO. '"' fir // i •►� THE COMMONWEALTH. O}F�MASSACHUSETTS BOARD #OF HEALTH /'.Av0 rFatW4-,..fvr R-4p sal Works Tnnitrurtiun t1amit T. Application is hereliy,.,made`for a Permit to Construct ('') or Repair ( ) an Individual Sewage..Disposal System at d!M s....................... s - .............:.... Lo on.-Address or Lot No. ........ : � .................................. .........• - --••--•--••..._.........-__.._...___-•••--......--- Owne Address ........... -•-•-•---•------•----••- -- • In ller Address Type of Building Size Lot---------------------------Sq. feet U Dwelling No. of Bedrooms _.._.._..•.................Expansion Attic 4)0) Garbage Grinder (NO) .-� g— . aOther-Type of Building .__ 1.............No.. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ----------------------•- ---•--•-- ------------------------ ------------- wti..+... Design Flow.._,: ✓._d ......... gallons per. eron per day Total da>ly flow...._.. _ ___________________gallons WSeptic Tank=Liquid capacityA4?� gallons Lengt ...b...L. Width'" ~0.". Diameter_______________• Depth. x Disposal Trench No .•.. Width ;;---------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........... ---------Diameter.._.. ... Depth below inlet.._.a�. ......... Total leaching area.-4.0:0...sq. ft. Z Other Distribution box ( Dosin tank ( ) `" Percolation Test Results Performed by. .. 0. Date....4J�Z!_U__E_._,`,1 . aTest Pit No. 1..' '___minutes per inch Depth of Test Pit ..1' ________. Depth to ground water___________ _________ fTq Test Pit No. 2__'4"r__'..........minutes per inch Depth of Test Pit f�t----------- epth to ground water........................ O Descri tion,of Soil �•.. . .� �3 s ...¢_,!' I T v �N J... ....!:r __ `! " .------- ......... +€s. ---•------------------- VNature of Repairs or Alterations—Answer when applicable. ------ -----..' -•-------•--------------------------------------•---------------------------------------...._......-----••-•--•-•-••----••••----•••-•-••----••••••-•--••-•--••--••-••--•••-••••-••••-•-•-........__----- Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisionsof iITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. / Sighed -•-•--= -- ................ ................-----------...--- ----- --•-----•---........ # Date Application Approved B PP PP Y . . .Z:D,7 -.... p. Application Disapproved for the f ollowing,reasons:............... - •-...................................-----------------------------•-••-•-••-------- -------------------------•---•----•---------•-----------------...._.......-•- - .....................................................-.................... Date ................. Issued-.....................................Permit No. Date THE COMMONWEALTH OF MASSACHUSETT.S BOARD OF HEALTH ...... :..iOF. . (Inrtifiraef nntpliattrr TH 5 ` . 0 CER IFY, at the Individual Sewage Disposal System constructed (for Repaired ( ) by---- .......... ........ ... ---- ............................................... ---••--=--------------- Ins to ��'' r � � has been installed in accord: ce with tie rovisions of F of The State Sanit�ar�" o e b Yfescribed in the P 5 ,' „ application for Disposal Works.:Construction Permit N .7 _._l'_,�_/:................ dated_.._ .` THE ISSUANCE OF THIS CERTIFICATE SHA L N®T BE CONSTRUE® AS.A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... = Inspector-,. -----------------------------•---•----....... THEt COMMONWEALTH`.O'F MASSACHUSET�S Gam' BOARD OF HEALTH �w .......... .. 3'Ar! .............OF..... . ,....: ....................:,.--. o4* P-T." PTO._.. ....... . FEE tn�ta� Cl ` uan rrntit Permission is herebyranted_._... _ g. --- to Constr ( or e ( ) an Individ vc>age Di p ;--75o.-Afv?-------�f&A�----------- _02... .... . ....... .N......••- at Nobeet as shown on the application for Disposal Works Construction..Per o _.___ _._._. _ ated_._ e�_`._./: _._._.... ---•• m • .................•----- \ Boar o 'Health DATE ==•----•-•---••. ......••-•••--•-••-•---_•••• •••-......: FORM 1255 HOBBS & WARREN; INC.,,,PUBUSHERS a x . . v w .. t - t ,. p {� . � ' 4 +�! Y r ,,I ,. >y x t - - . } yf f eti +�d� 6..,� _`n'e T 2 . .} t .u. -:n f: - .1 - ._ - 'ary-- D. -,. Y.. ,.. . „ ,bw k4,• i'1..'F e.t ft r 3 s x_,, t ..uS' t l' '-4 - •+.W 'll F e, t iY4 Y S-'� t'.t b_' yy g�' u a ''!;, ,tr.M //�� -� a �^i ,. F a. A ;rs I �� S� 7 �':,c..t�i' y� h,. X "' . - ? 6 . v - jJ` �r,. M� i•g irk i ,� '+ P d R. i...Jeo,N/ .a '.k f 1-- t t ti� y , �• r. f „{,: ?«.;, _ S, +- :ti• I`n' fX _-.t✓ `+w�`4"$ F ,t-F :'�`-�< -t 1, Y '.a} s k x r .,h ::. --,. 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'rpE4 S-0A)E l +j' M A .t _ N' 10LE Co✓E, 72v E?c TE n!D _c � - V%OUS:CO VET: OF F/n//5A/�z� nG ,aDE,' .. # �. ;� :.,, , , �$ �'coves Z%G2az�E f Y '¢�'.�5T/.yZOr - _...�c _ �"�= - ../ .} aY Z � //DE �V�.Q , /vJYNln,�Ui►% —'.� M,"wl _y .won/ >. s, CJ 7,, / '^�---�. " ,Y4�FaOT, /D'M/IV; '« ► 1s1 -e P/T j w ,^9ull ;. _< ^� � � S NE - It/[j 4 ONE a7 :r p •� / �. � ST /iV.iff�T, G.a':L L �� I-� /NVE,-T 0lL4- . C,4 'F?,4'`G/ T>' „ . �E'pT/G T,4 A/& ELEV w t I Du f' { * WATGJd /GN �._. 25�x,a� $t�7irUM `. //V VE,zr y/" s GA C A, ` �'II�''D f C� _ x as a sm.3;+•t �Tx#'H E.{'[-�i ��- x �; .a } _ I�� t / Tag AL ,ct%"�f F �7 _ Fs F:t`•• c _ ♦' SSY9. t/r74+ .,.$• r'.-t' N=• a n .. 1. A/ 1 3 EFL'2 til /+^ s:f,1 4 . s: _, .' �" r 4 R' 'a t t' '?' .sr" , K - / h^ L-:�7/ ,.; .. ,n,,rr.. M .:� >.. - - e.-- - a F.rg n 5 .. I B0.Y . . � 'AND G 4G,;,.. %.T ' �. = m « x g l-0.�- r r a�4 _ © iE Oft;�?�/A/FO�c''�E�:: CO.VCT -T 7 .. - /- ', :.CONG'2ET� T,�E.v�r�/ .3000i'5 ✓,v t F e�G -`�' b s . M -_ x 2DODo K }} /� T f. f"y�, Nt., i "•{, yi •"# Y 4, +:� 3 ` /O � /��/�.��V{u:�. R. �_g - 5 > A� r « p7 7, BE LC�CAT�D; �. �� I '.� -, ", ,"� i, !; :O✓E 2_ S yS T L, CJNL E 5 5 ,- . '0 «. w rz s .. 4 , .2 �T ; . 'yet _ ` ag q !' �JGiJ7�t� �' � v/ �- .� / bl I �I`_ `� Q 7 - �a�3 .`'1i� ' .,�.i; k �u+/y/+' j,}' a 4" ,,/.yyr�-/^/ (�H[fL/lyV}� � r,{'' 'Q . _ ', ` �' - "'fit` ��r`�V� L�14 T� •% E�2 L T/-/ A��E.v 7' p 7�?T `�` - vt /� . .. �t,p/DbV,4G . . ,- . . SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE NOTES MARKED WITH MAGNETIC TAPE OR (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS ASSUMED Airport PROVIDE MIN. 20" DIAM. WATERTIGHT ACCESS COVER TO WITHIN 6" OF FIN. GRADE 2. MUNICIPAL WATER IS PROPOSED o� Race Lane \ TOP FOUND. EL 61.6 PROVIDE INSPECTION PORT TO WITHIN 3" OF FINIAL GRADE 3. MINIMUM PIPE PITCH TO BE 1/8 PER FOOT., o� INIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 4. DESIGN LOADING FOR ALL PROPOSED PRECAST NOTE. 2" MIN. WALL UNITS TO BE AASHO H-LQ THICKNESS REQUIRED Rd' Locus .... . I 4"00CH40 PVC 5. PIPE JOINTS TO BE MADE WATERTIGHT. E ..'2 1ST L EV 2 PEASTONE OR GEOTEXTILE \d 1 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE 0 \ Mystic Lake EXITING 150o cAL FILTER FABRIC EVER STONE TEE SEPTIC rANK•• iEE 70.22' WITH 310 CMR 15.000 (TITLE 5.) EXISTING TUF-171E EF-4 11 PUMP CHAMBER" ' o , C , o 0 0 , o , 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND EFf1UENT FILTER (OR o°0°0°00000 0°0°0°0°0°0°0°0°0°0°0°0°0°0°0° °0°0°0°0°0°0°0°0 °0°0°0°0°0°0° NOT TO BE USED FOR LOT LINE STAKING OR ANY EpUAL) W�MOLDED IN (NEW PUMP PROPOSED) 000000000000 r 000000000000000000000000000000 0000000000000000 00000000000000 69.72 000000000000000000000000000000 0000000000000000 00000000000000 � D�CTOR o00000000000000 00000000 000000o OTHER PURPOSE. 0 0 0 0 0 0 0 0 0 0 0 0 0 00°0 0°0°000°0°0°0°0 000°0°0°0°0°0°0 5' 94' 77' 0000o0o0o0o0o0o0o0000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 �o .:..:. 69. 69. 67. -:::;,.:� `'''` �;, , . .... .. : •. •. '� � 4" PVC SET AT .005'/' SLOPE � 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. ON 2 DOUBLE WASHED 3/4" - 1 1/2„ STONE �o 9. COMPONENTS NOT TO BE BACKFILLED OR iddle Pon 50' CONCEALED WITHOUT INSPECTION BY BOARD OF . 6" CRUSHED STONE OR MECHANICAL HEALTH AND PERMISSION OBTAINED FROM BOARD COMPACTION. (15.221 [2]) ( 1 % SLOPE) OF HEALTH. EXISTING EXISTING 10. CONTRACTOR SHALL BE RESPONSIBLE FOR FOUNDATION- SEPTIC TANK PUMP CHAMBER 55' D' BOX 7' _ LEACHING . CALLING DIGSAFE (1-888-344-7233) AND LOCUS MAP FACILITY BOTTOM TH 1 ELEV. 62.5' VERIFYING THE LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF "INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK AND PUMP WORK. SCALE 1"=2000'f CHAMBER SIZES OF AT LEAST 1000 GALLONS AND THEIR SUITABILITY FOR RE-USE. REPLACE WITH 1500 GALLON 11. ANY UNSUITABLE MATERIAL ENCOUNTERED ASSESSORS MAP 63 PARCEL 76 SEPTIC TANK APPROPRIATE TO SITE CONDITIONS IF NOT SHALL BE REMOVED 5' BENEATH AND AROUND THE SUITABLE PROPOSED LEACHING FACILITY. 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN LEGEND SAND. W 13. SYSTEM AND EFFLUENT FILTER TO BE 99- EXISTING CONTOUR eoa I �� O MAINTAINED PER TITLE 5 AND MANUFACTURER GUIDELINES X 99.1 EXIST. SPOT ELEV. 99 PROPOSED CONTOUR t_=66.41' t / R=1 .41 0 198.41 PROPOSED SPOT EL TH, 6� SYSTEM DESIGN: TEST HOLE PROPOSED WATER GARBAGE DISPOSER IS NOT ALLOWED 2,7- SLOPE OF GROUND I I / \� \ 0� SERVICE, COORDINATE COL) TOWN, UTILITY POLE / / DESIGN FLOW: 3 BEDROOMS @ 110 GPD = 330 GPD o� FIRE HYDRANT I 1 / USE A 330 GPD DESIGN FLOW / \ N ' NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAININGj � t \ EXISTING I i .r. E,XIS'TlN6� \6") SEPTIC TANK: 330 GPD (2) = 660 LEACHING I =. RAGE 62 RE-USE EXISTING 1500 GAL. SEPTIC TANK ** EXISTING I °PAVED s\F o LEACHING:TEST HOLE LOGS D'eox DRIVEWAY jp- SIDES: . 2[2 (32 + 3) 2 (.74)1 = 207 GPD ENGINEER: DANIEL E. GONSALVES, SE #13587 BOTTOM 2[32 x 3 (.74)] = 142 GPD >•H2 DONNA MIORANDI, RS TM% /� • "\ TOTAL: 472 S.F. 349 GPD WITNESS: I / �i DATE: 10/21/14 9' I 1 I / \ USE (2) 32' LONG x 3' WIDE x 2' DEEP PERC. RATE INCH 2 MIN / I ( LEACH TRENCHES OF PERF. SCH. 40 PVC PIPE AND STONE _ < / � � \ � ' \ l \ \ : CLASS I SOILS P# 14522 �\ ELEV 4 4 5' REMOVAL OF UNSUITABLE SOIL Opp73.0 Q" 73.0 REQUIRED AROUND PERIMETER OF N _ , MIA A A SUITABLEACHLNG E SOIL LITY, DOWN TOAYER. TOP FNDLAYER. REPLACE BENCHMARK \ I 'I APPROVED DATE BOARD OF HEALTH LS LS WITH CLEAN MED. SAND, TO MEET COR STONE PATIO ® 61.6 SPECIFICATIONS OF 310 CMR EL. = 61.1 o 1OYR 3/2 1OYR 3/2 15.255(3) EXISTING 10" 10" DWELLING TITLE 5 SITE PLAN B B ` OF EXISTING POTAB!.E WELL; SL SL TO BE ABAND%ED 1OYR 4/4 , 1OYR 4/4 , 25 HEATH ROW 48„ 69.0 50 68.8 MARSTONS MILLS - MYSTIC PREPARED FOR G G LOT 23 LAKE 074t Sq Ft PERC 4, B&B EXCAVATION / HORGAN A N 1.01t Aa. M CS M CS DATE: OCTOBER 29, 2014 REV: NOVEMBER 7, 2014 (3 BEDROOM) 2.5Y 6/4 2.5Y 6/4 �N OF MASs9 ESN of MASS off 508-362-4541 DANIELA: fax 508-362-9880 ° � �' o OJALA N� �° DAAIEL ��� downcope.com CIVIL OJALA 6502 No.40980 down cope eft h7eeridg, ift. 126" 62.5' 126" 62.5' S ONAL��G\� � oo g� o� R C/V/l engineers NO GROUNDWATER ENCOUNTERED Scale:1 = 30' �_. !� / land surveyors 939 Main Street ( R to 6A) 0 15 30 45 60 75 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 LICE # > 4-262 E