Loading...
HomeMy WebLinkAbout0113 HIGHPOINT ROAD - Health 113 Highpoint Road Marstons Mills F/R j A = 027 027 .... r COMMONWEALTH OF MASSACHUSETTS EXECUTWE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 l✓ TRUDY COXE Secretary ARGEO PAULCELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - n� PART A CERTIFICATION 2� o Property Address: 113 HIGHPOINT RD. MARSTONS MILLS y Name of Owner H.U.D P/ Address of Owner: 330 MAIN ST.HARTFORD CONN.02106 AT.ADELE BELL (� Date of Inspection: 9/9/99 Name of Inspector:(Please Print)JOHN GRACI 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: n/a Mailing Address: n/a Telephone Number: n!a +u Pass I certify th Ina ersonall i spected the sewage disposal system at this address and that the information reported below is true,accurate and co lehe time of i spection.The inspection was performed based on my training and experience in the proper function and mainte ancite sewage "sposal systems.The system: X s The inpection is based on criteria defined in Title V _ ionally Pass s code 310 CMR 15.303.My findings are of how the system is Further Ev uation By the Local Approving Authority performing at the time of the inspection.My inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector'sre: Date:9/14/99 The Systemor sha I submit a copy of this inspection report tothe Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS. revised 9/2198 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:9/9/99 INSPECTION SUMMARY: Check A, B, C, or D; A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nLa 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced obstruction is removed _ distribution box is levelled or replaced nLa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced _ obstruction is removed revised 9/2/98 Paae 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:9/9/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nLa_(approximation not valid). 3) OTHER nLa rPVkPrI „f I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:9/9/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone If of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. rPvieari 9M9R pans d nf 14 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:919/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)j X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Paae 5 of 11 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:9/9199 FLOW CONDITIONS RR IFC�T�: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):$ Total DESIGN flow: = Number of current residents:Q Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NQ If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):DLO Water meter readings,if available(last two year's usage(gpd): nta Sump Pump(yes or no): NQ Last date of occupancy: nLa COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: nLa gpd(Based on 15.203) Basis of design flow: nLa Grease trap present:(yes or no):M Industrial Waste Holding Tank present:(yes or no): Ra Non-sanitary waste discharged to the Title 5 system:(yes or no):NLQ Water meter readings.if available:nLa Last date of occupancy: nLa OTHER: (Describe) nLa Last date of occupancy: nLa GENERAL INFORMATION PUMPING RECORDS and source of information: n1a System pumped as part of inspection:(yes or no):NQ If yes,volume pumped nLa_ gallons Reason for pumping: nLa TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous Inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nLa APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM IS APPROXIMATF1 Y 20 YEARS 01 D Sewage odors detected when arriving at the site:(yes or no) NQ revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:919/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 2_6_ Material of construction:_ cast iron _40 PVC X other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: 2_ Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ nLa Dimensions: L S'6"H 5'7"4'10" Sludge depth: E Distance from top of sludge to bottom of outlet tee or baffle: 22 Scum thickness:4' Distance from top of scum to top of outlet tee or baffle:2 Distance from bottom of scum to bottom of outlet tee or baffle: nLa How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK IS STRUCTURALLY SOUND RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: nLa Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:j3La Distance from bottom of scum to bottom of outlet tee or baffle nLa Date.of last pumping: nLa Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) rs SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:9/9/99 TIGHT OR HOLDING TANK: MQ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: nla Capacity: nLa gallons Design flow: nLa gallons/day Alarm present: NQ Alarm level:jaLa- Alarm in working order:Yes—No—: NQ Date of previous pumping: nLa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): M Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa Done R of 44 _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:9/9/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: jiLa leaching galleries,number: _nLa leaching trenches,number,length: nLa leaching fields,number,dimensions: nLa overflow cesspool,number: nLa Alternative system: nLa Name of Technology: _uLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURAL OUND AND F 1tiTIONIN PROP R V TH PIT WAS EMPTY AT THE TIME OF THE INSPECTION. CESSPOOLS: _ (locate on site plan) Number and configuration: nLa Depth-top of liquid to inlet invert: nLa Depth of solids layer: nLa Depth of scum layer. nLa Dimensions of cesspool: nLa Materials of construction: nLa Indication of groundwater: nLa inflow(cesspool must be pumped as part of inspection)Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:nLa Dimensions:nLa Depth of solids: nLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa t revised 0/710R SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:9/9199 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a 6a c ��I AC 3y 19 17 � �4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:9/9199 NRCS Report name: n/a. Soil Type: n(a Typical depth to groundwater: n(a. USGS Date website visited: n1a Observation Wells checked: MQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers XUsed USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12+FEET j i - i Page 1 of 1 McKean, Thomas From: WAMDOC@aol.com Sent: Monday, March 31, 2003 1:43 PM To: McKean, Thomas Subject: Re: Newly Discovered Graci Error from 1999/ 113 Highpoint Road M.Mills Tom-- My view is that this is"old"and can't be used. Wayne 3/31/2003 TOWN OF BARNSTABLE LOCATION //3 #i' 14 Pot.►f- tzo&d SEWAGE # Zco 3-Z-Fo VILLAG ASSESSOR'S MAP& LOT —02-1 INSTALLER'S NAME&PHONE NO. A,4c.W,4 60/1 9?/- 7 Y/a SEPTIC TANK CAPACITY off'/000 61*11 n s��f*c -FMks LEACHING FACII.ITY: (type) a- -l00 GA-//rn 6.1%,OAAWKS (size) /2x a-f NO.OF BEDROOMS 2 BLTII DER R OWNER eS 2 3 a o 0 PERMTTDATE: 6���3 COMPLIANCE DATE: 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 y 13 Nome z : G A a 7 ' 3 z 60' CIA -it 3 7 io " ° A ► - L 7q' F•Z �3' No. 'V — 3 ® Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: " Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplicatton for Migonl 6pstetn Congtructton Permit Application for a Permit to Construct(c()Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. //,3 Hi JA R,n¢ YZwYl-d Owner's Name,Address and Tel.No. k,ws"s <<<S C",l.s e-lee M4,1 Assessor's Map/Parcel (('3 Oi jk tat FL-4F 4 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. iA5st,.-hnc.L A S /-1 L.p„r{ so� SQnv,�tA nay. a 2 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building t2 s,d wt-e_- No.of Persons 3 Showers( ) Cafeteria( ) Other Fixtures Design Flow >3.3 0 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank %Oov �.A.stI^ Type of S.A.S. ol~ 5w CAA cast M11 S Description of Soil Nature of Repairs or Alterations(Answer when applicable) LA* 1.a d K �'s�on9 t� SyS�eYn 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 Certifi- cate of Compliance has been issued by&Bord of HeA. i Si Date C Application Approved Date Application Disapproved for the following reasons Permit No. 760 i Date Issued 4J .4 N.. f /l Fee 5 O , THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH,DIVISION —TOWN OF BARNSTABLE., MASSACHUSETTS Yes Zipprtcatiou for 3igpogar *pgtem eongtruction Permit Application for a Permit to Construct(0 )Repair( )Upgrade( )Abandon,( ) ❑Complete System ❑Individual Components Location Address or Lot No. //3 Nrlt, R)w n} 14e,n-d Owner's Name;Address and Tel.No. Ot'l-/S�or�S M!fr'S C► �+/ir{�►S ��cy <<P 1"4 h Assessor's Map/Parcel � ti t2dA 1 s /A Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. wsSu.,nnU CX( 6vA-41Nn A : 1-4"1 Jr'r� ),t low st"-k to• r�.. .G, � 0 2G� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of-Building r?,s,d4J­ No.of Persons 3 Showers( ) Cafeteria( ) Other Fixtures Design Flow 33 o gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /Goo Type of S.A.S. Sacs CA-1 Description of Soil Nature of Repairs or Alterations(Answer when applicable) r,a d t_ <x,'sA q S�4,c S Ae wn 1 .. 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 Certifi- cate of Compliance has been isssuyed�by t ' Board of Health. � Si �G!/ Date Application Approved Date 442 KL/: O 3 Application Disapproved for the following reasons Permit No.' Date Issued �o a �. 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 at has been construct e in accordance with the provisions Title 5 and the for Disposal System Construction Permit No. 100 3-2Fo dated (o 2`f G Installer Designer The issuance 01 thi permit shall not be construed as a guarantee that the system gned. Date 2 3 Inspector �-------------------——---————— ————— .. No. `' Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE., MASSACHUSETTS lfgpogal *pgtem Congtruction Permit Permission is hereby granted to Con true )�Zepair Upgrade )Abandon Y ( ) S stem located at 1 1 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditigns-� Provided:Co tr tion mus be completed within three years of the dat of this pp Date:_ �� U�Approved by 1. I TOWN OF BARNSTABLE LOCATION _/�3 Yf porn f- rzo&d SEWAGE # Zco X'Z8o VILLAGE Ar n c �./f`S ASSESSOR'S MAP& LOT M 'L)2 INSTALLER'S NAME&PHONE NO: X,7-TcWMC f ALi-. ,4 A04 M-7 yid SEPTIC TANK CAPACITY o?-lmg C', 14,1 septic 72haks LEACHING FACILITY: (type) a- soo 6411co d4w&i (size) /Z X a,f NO.OF BEDROOMS cZ BUILDER OWNE cS PERMTTDATE: COMPLIANCE DATE: Z- 0 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 c a 7 ' 3 A• L 60' t3 I C-7�� ay•6" _ s r2 o t.--- 1 7q' j F•'Z �3, ...::::.... 44 WN COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 113 HIGHPOINT RD. MARSTONS MILLS 0 a-j 1, 3 ^9 Name of Owner H.U.13 \ ,P Address of Owner: 330 MAIN ST.HARTFORD CONN.02106 AT.ADELE BELL % d® ('a Date of Inspection: 9/9/99 Name of Inspector:(Please Print)JOHN GRACI RECEIVED 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) S P wd Company Name: n/a 2 4 ��99 Mailing Address: n/a r TDOFBARNS Telephone Number: n/a hF_4L7hDEPr"�LF � r IY ti CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: _ Passes The inpection Is based on criteria defined in Title V X Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. ' inspector's Signature: Date:9/14199 The System Inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM CONDITIONALLY PASSES TITLE V INSPECTION.THE DISTRIBUTION BOX AND ALL THE PIPES NEED TO BE REPLACED. P revised9/2/98 . . Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of inspection:.9/9/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: n/a i B. SYSTEM CONDITIONALLY PASSES: Ve or rrmore 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nta The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal;is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). i� broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced nLa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2 ASHLEY DR.FALMOUTH Owner: HUD Date of Inspection:9/9/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nLa-(approximation not valid). 3) OTHER nLa f revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:9/9199 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance n/a_(approximation not valid). 3) OTHER Wa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:9/9199 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ills. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised.9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:919199 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. r revised 9/2198 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:919/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):;I Total DESIGN flow: IU Number of current residents:Q Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): MQ If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NQ Last date of occupancy: n/A COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: n&gpd(Based on 15.203) Basis of design flow: nla Grease trap present:(yes or no): �lQ Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available:n& Last date of occupancy: Wa OTHER: (Describe) nLa Last date of occupancy: nLa GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no):MQ If yes,volume pumped nla. gallons Reason for pumping: nLa TYPE OF SYSTEM XSeptic tank/distribution boxisoil absorption system Single cesspool . `Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A�Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nLa APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM is APPROXIMATELY 20 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:9/9199 BUILDING SEWER: (Locate on site plan) Depth below grade: 2'6_ Material of construction:_ cast iron _40 PVC X other(explain) Distance from private water supply well or suction line: TOWN Diameter: n1a Comments: (condition of joints,venting,evidence of leakage,etc.) n/A SEPTIC TANK: X (locate on site plan) Depth below grade: 2' Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) Wa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO n& Dimensions: L 8'6"H 6'7"4'10" Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 22 Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle:-X Distance from bottom of scum to bottom of outlet tee or baffle: n& How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK IS STRUCTURALLY SOUND THE TANK NEEDS NEW'- PIPES GREASE TRAP: (locate on site plan) Depth below grade:. Material of construction:_concrete metalp Fiberglass Polyethylene_other(explain) Dimensions: n/A Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:j3& Distance from bottom of scum to bottom of outlet tee or baffle n& Date of.last pumping: n1a Comments: (recommendation for:pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) nld revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:9/9199 TIGHT OR HOLDING TANK: MQ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: n& Capacity: Wa gallons Design flow: n& gallons/day Alarm present: NO Alarm level:jiLa- Alarm in working order:Yes_No_ NQ Date of previous pumping: nLa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nta DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:nLa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) SYSTEM NEED A NEW DISTRIBUTION BOX AND NEW PIPES TO SEPTIC TANK PUMP CHAMBER: NO (locate on,site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO, Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nta revised 9/2/98 • Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:9/9/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: jaLa leaching galleries,number: 1lLa leaching trenches,number,length: nLa leaching fields,number,dimensions: Wa overflow cesspool,number: n& Alternative system: n& Name of Technology: jVA Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY THE SYSTEM NEEDS NEW PIPES FROM D-BOX TO PIT CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: n& Depth of solids layer: nLa Depth of scum layer. Wa Dimensions of cesspool: n& Materials of construction: n&, Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)nLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa PRIVY: (locate on site plan) Materials of construction:Wa Dimensions:Wa Depth of solids: nta _Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa revised 9/2/98 y- Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:9/9199 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a �qC 8 6 Vecit �g �J AA P �c revised 9/2/98 ` Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 113 HIGHPOINT RD.MARSTONS MILLS Owner: H.U.D Date of Inspection:9/9/99 NRCS Report name: nta Soil Type: DLa Typical depth to groundwater: nLa USGS Date website visited: nLa Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12+FEET • ,t revised 9/2/98 Page 11 of 11 McKean, Thomas From: McKean, Thomas Sent: Monday, March 31, 2003 9:32 AM To: Weil, Ruth Cc: Wayne Miller M. D. (wamdoc@aol.com); Sumner Kaufman MSPH (sonnykoff@aol.com); Susan Rask RS (srask@cape.com) Subject: Newly Discovered Graci Error from 1999/ 113 Highpoint Road M.Mills On Friday March 28, 2003, the homeowner brought it to the attention of our staff that John Graci submitted a "conditionally passing" report to the Health Division (report dated 9/14/99) indicating the distribution box and all the piping need to be replaced; while also submitting a"passing" report for the same septic system to the owner Charles Coleman (report dated 9/14/99, no revision date). A copy of the"passing" report for the septic system was received at this Office on March 28, 2003. Could this information be used to originate a hearing for Mr. Graci this April or May?Or is this considered old information which should not be used for a future show-cause hearing? 1 No... ✓.—_..r�'r2.`.� ....� Fps..... ....... ' THE COMMONWEALTH OF MASSACHUSETTS 'BOAR® OF HEALTH ce'o... ...........0F...BAe.! 'r 4 App iration for Bi-gVviia1 Workii Tomitrurtion Prrutit Application is hereby made for a Permit to Construct (VII-Or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot (90 ...�i� ....k A&.. .G_�!`ti.............•-•--•---------•----._..._ _............. �7"..e��....... ?4&..../.........._. Owner A A M Address W �Y� Installer Address Type of Building Size Lot��4._._..______ U yp g 0 _ _. Sq. feet Dwelling—No. of Bedrooms.............................................Expansion�ttic ( ) Garbage Grinder ( ) �. No. of ersons__________ _______________ Showers — Cafeteria p., Other—Type of Building _________________ p � ( ) ( ) a' Other fixtures __________________________________ W Design Flow...........1e_0....................gallons per person per day. Total daily flow__......4:�.aO.....................gallons. 04 Septic Tank—Liquid capacity/A®®.gallons Length Width._.4.°...._ Diameter.�'r..._. Depth.j.�.'�! Disposal Trench—No. .................... Width....................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------/------- Diameter____!,____ _______ Depth below inlet.__44._............ Total leaching area_Z-0.0....sq. ft. Z Other f)istribution box ( ) Dosing tknif ''' t�I ft S�/4GCD®V.'. " Percolation Test Results Performed by _0_ -�-.__--`--------------------------------------------- -- Date__-' - -------.-.--./..._____.. Test Pit No. l._"'. .._._minutes per inch Depth of Test Pit-----�63_...... Depth to ground water-------"____________. Gi, Test Pit No. 2..._—.•-____minutes per inch Depth of Test Pit.... Depth to ground w _ --_____. Description of Soil-----• - �...0-1�. g •---1. . ��• ��o��y�� �.. D/ ..................... .ite€Ui�r ----Co .r _S 'vim-�---------- -- Z Noy---------- ----•-•______________________•- _________ __ V ____.___� Y --- o-l1 U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------- ___ --___ _.. . p� Agreement: R The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in ac da`nce with the provisions of 4 i:L p 5 of the State Sanitary Code— The undersigned further agrees not to place a system in operation until a Certificate of Compliance has been is by,.the bo rd of health: Sign, 96 Date Application Approved By ! Z-IG/--�------ Date Application Disapproved for the following reasons:................................................................................................................ •-----------•-•---•-•--------------------•-•--------•---•••••••-_----------•----••••-•.......--••-•••••---------------------------•----------------------.....••-•••• ---------------------------------- Date PermitNo......................................................... Issued....................................................... Date i No. Fps.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -"` - ova ...... ......._...... ............ ................... Applirta#inn for Uiipnaal Works Tuavitrnrtinn Permit r Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ... i'/, fib 1201A1 / i` ------•----•----•...................................•---•--•--..............------ -•-•-•••--••......--•---......-•--....--••-•-•••---•••--.....•--• --•----•-•-•--•----•----------- Location-Address ' f�-ri rr C f1r_" r.: ��,,.*rt1 Gu r�rr/r ,T , or Lot /No.�u x/ ✓Z V - ....... .. Owner Address W Installer Address Type of Building Size Lot.� -$7J.v_.....Sq. feet Dwelling—No.- e f-Bedrooms___...... .............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ........ —------- No. of persons.........______________ Showers ( ) — Cafeteria ( ) dOther fixtures -----------------------------------------••......•••-•..............•---•-............-••-------•-••••-•••-••••••••••••••-............-•-•••......•- W fo Design Flow................................................................gallons per person per day. Total daily flow_.......t:.r... .._.._...............gallons. WSeptic Tank—Liquid capacity_��4 gallons Length__s __`__ Width.... .'.,`... Diameter..!� Depth.;'�'�e/...A l x Disposal Trench—No..................... Width.._....__._._._.. Total Length................:+`.. Total leaching area............_-------sq. ft. Seepage Pit No.......... ....... Diameter-___r g-----.---- Depth below inlet...-5....._...... Total leaching area..F 2...sq. ft. Z Other Distribution box ( ) Dosing tank ( )- p --.---- --- r -- `-- •--------------- Date �"�-=~ Percolation Test Results Performed by.-..:_::_:�_:_ .................. Test Pit No. 1.......''.....minutes per inch Depth of Test Pit------�7..I__... Depth to ground..water "__-_._.---_. Test Pit No. 2__..—........minutes per inch Depth of Test Pit.................... Depth to grdt nd r�t{.a�_�r�" . --•-----•---•------------------•---...--••••••••••••-•--••-•••••-••-••.............................._............. '.. �QRldL3 ODescr>ptton of Soil I". r � *" l...;'•„fl a<i.. a. f/ C:�s t� H l..-- /_V . ... C� ......... W c� =i U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------- ��, ..... _ ...................................................--••------------------------•---•---•---•--------••--------•--------._...-------•-••-............--------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in acc ance with the provisions-aiil y g g p y of the State Sanitary Code— The undersigned further agrees not to lace h system in operation until a Certificate of Compliance has been issued by the board of health. Signed.. 0 - J - ---- ApplicationApproved By••••••- ••-••--- -- •........... ........................................ / ) Date Application Disapproved for the f of owing reasons________________ ___ �2 ` ---------------------------------•-•--•--.....--••-••--•--------------...•--------------......._.............•••••--•------------••----••-••......•-_-•.•--•-----•••------------•-------...•---•--------- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......I............OF......... ................................... (grrtif iratr of TomptiFanrr F THIS IS TO CERTIFY, That the Individual. Sewage Disposal System constructed ( f or Repaired ( ) by.................... _ d)�L--••---•--------------•••••-••-•-•-•-••.....-•••--.._.._......................................................................................... Installer at..../ •`.1 f /� / .' .??- ,.2 7 H; C// r vr.JT -------------•--------------•-----------.---•-------------------------------•------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----------------------------------------- dated----.------..................................... THE ISSUANCE OF THIS CERTIFICATE SHA V*0O 5$1•CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........... L Inspector.............. 141(...�--•-••••••••......--••••--•--•••--.--•-•- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........."�...•'/...............OF... f.A.v. .T........f..................---............ ... FEE....................... Rapns a1 arks Tnn�trnrtinn Permit Permission is hereby granted --- -- ---= 1--------�--'--Y=•=------_ --=_=------44A—1...... �.�/�Li1 ---------------•-•---•----•--- to Construct ( :) or Repair ( ) an Individual Sewage Disposal System at No.•••-••.4.n..( . -" --=�--�------......��--,?.....�•-�•.-�--7--I-•---- l_/4!/-Jlan-f------------------------- ---------------------------- Street as shown on the application for Disposal Works Construction Permit No-----_-----_------ Dated.......................................... Bo DATE.........................................................-_----------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS �J � � EX�ANS/Or✓ TES?- /✓P- CAC 6 L—AN,0 T,Cts S 7' /2 Ix G.PAD� 0 . D S�BSai� i 1� /yEOiIJ N/Co.41LZSE F� 20, D D Ste. f"T, ND CeouNo bfii7-6 P- ao WELL PDIN 7- r /*-,e�oZJ�ED �VIN OF 414 LIZI- 401 ELE',' SECURES`( Ct-M:NTS^ TO FtN1S gP.ADr- ON !NL.E7 "MANHC)L KOT MANHOLE SHALL 3E S1 LL- `=LEY. 1o2, DU 2°x L" BLOCK OR 181, cotiC-,= _ FIRE 1' I N LET ELEV. ?1.84 INLI=T E-LEV. r---�j OUTLET WAS1 F_D PEASTOME OUT1-ET EL�u - 1 x I �3 �- S HE 14 a e I D'' 112 WA c I G,_D,r o CRUSNED STONE loop DISTRIaUTIOiJ 84X G,AL. SIEPTI-C TANK - PRECAST MIN, 6" SUMP 1 a A 9 a FREE FROM FINES CONCR'6T1= — LEVEL EASE V /'D� O O 4 � SOLID P.V.C. SCOEDULE q0 (aRADE I o aIle v a /4' PER FOOT AI-lGNME1\IT - STRAIGHT LINE PRr--CA ST CONCR-PTf-4 SEE PAC, E , I:'iT' � TO-T'AL SQ. 'FT. oo No. RE-� QUIR�ED � AIR._ SPACE BETWEEN TOP OF ✓''��.�_ VQpuLsq Nov 40IJ co ft ip QED SAf- a, SANI-FARM TEES LEG EXTENSIONS ARE Zf'� 96 S®LID P.V,C. SCI-4EDULE 1+0 PIPE ,8i9��t/sT�4��E �� SS DRAWN by: IF15ACCON p�TEs /2- �$I 2oF2 YOP OF - • FOUNDATION r /orb, 0P EL -� : STANDARD NO TEAS ,_ � ,S - ` :•:• GROUND SURFACE E�_----- . GROUND SURFACr Lr�_ _ __ 1) THIS PLAN IS FOR THE INSTALLATION OF A SEPTIC SYSTE1. . . MIN i OUTLET PIPE LEVEL i 2) ALL WSSTALLATTON PROCEDURES:AND MATERIALS SHALL CONFORM TO 3l0 CMR 15.000, THE'' S'1 /r7VtJIXONMENTAL CODE, nl t� VENT REQUIRED FIRST TWO FEE^ �J �'3 '� TOP EL T7TLE :5, AND THE TOWN OF _ 0!3�,L9,Z41 5-J=__ SUBSURFACE DISPOSAL T10AW. LI UID I,FVF,I Nnt z LAYER sous wnsHEn 3) NO DE71'ERMINATION HAS BEEN MADE AS TO COMPLIANCE' OF AVA1sABLE PROPERTY INFORMATION WITH RECORDED DEEDS D-BOX ve'- ii2� STONE - OR ZONING :REGULATIONS. 10" N /. INVERT EL 14" r= + r' W a << 4) r.� ._ EFFECTIVE _ �C,c.+ST/ Ai01 / SIDEWALL 5) THERE ARE JW KNOWN PRIVATE WELLS ON THIS PROPERTY GAS BAFFZE AT OUTLET INVERT EL S Q SrnNW a - y S INVERT EL 6) ALL C01VERS,'OF SYSTEM COMPONENTS SHALL BE BROUGHT TO WITHIN 12" OF FINISHED GR_4DE, WITH. O-VE COVER OF THE . . .•. .•. INVERT EL _ 3LTWvb G a t, c 1-E 0,r e"5 SEPTIC' TANK BROUGHT WITHIN 6" OF GRADE - a 5 314'- 1 1/2' 'DOUBLD Bow �3 ,5i �. INVERT EL �R s l+ l t. AA,.> w� `f 5"�` N WASHED STONE . - 7) ALL SYSTEM COMPONENTS SHALL RF�NAIN ACCESSIBLE FOR INSPECTION. NO STRUCTURES SHALL BE LOCATED DIRECTLY (7y�icei> 6" STONE BASE INVERT EL I ."L UPON OR ABO VE THE COMPONENT ACCESS LOCA TIONS, WHICH WOULD INTERFERE WITH THE PERFORMANCE, ACCESS, INSPECTION /i 0D Gal Septic Tank BOT719M EL PUMPINTG OR REPAID ' (Typical) c .8) NO DRIVEWAY, PARKING OR TURNING AREA, OR OTHER IMPERVIOUS AREA SHALL BE LOCATED ABOVE A SOIL ABSORPTION � BOTTOM OF TEST HOLE SYSTEaI; EXCEPT WHEN VENTING HAS BEEN PROVIDED. 9) SEPTIC TANKS, GREASE TRAPS, DOSING CHAMBERS AND DISTRIBUTION BOXES SHALL BE .PLACED ON A 6" STONE BASE ZS - - --� TO ENS'URE STABILITY AND PREVENT SET7ZING. 10) OUTLET' DISTRIBUTION LINES SHALL REMAIN LEVEL FOR A MINIMUM OF THE FIRST TWO FEET OF THEIR LENGTIl 11) ALL SYSTEM COMPONENTS SHALL BE CAPABLE OF WITHSTANDING H-1D LOADING UNLESS THEY ARE UNDER OR WITHIN 10' OF DRIPTFAYS OR PARKING OR TURNING AREAS, IN WHICH CASE H--20 COMPONENTS SHALL BE USED N F' 12) ALL BUIILDING SEWER LINES' SHALL HAVE AN INNER DIAMETER OF 4" AND SHALL BE CAST-IRON OR SCHEDULE 40 PYC. / Jennings 13) THE DEPTH OF THE TOP OF ALL SYSTEM COMPONENTS SHALL NOT EXCEED 36" UNLESS VENTING HAS BEEN PROVIDED. Map 28 Parcel 89 / 14) IN THE AREAS OF EXCAVATION, EXISTING GRADES SHALL BE REESTABLISHED UNLESS NOTED AS PROPOSED CONTOURS Existing well servicing lot over 15050' from Locus / 15) IF SOILS' ARE ENCOUNTERED DURING THE EXCA VATION OF THE.SOIL ABSORPTION SYSTEM, THAT DIFFER NOTABLY FROM / Leaching Area / THE DEEP.OBSERVATION HOLE LOG, CONTACT THE ENGINEER BEFORE PROCEEDING. N/F / Colby / 16) CONTRACTOR TO VERIFY LOCATION OF ALL UNDERGROUND UTHJTIES. Map 27 Parcel 105 - - - -- ' - - _ / I 1 I N� I Existing well servicing / Houle I t lot over 150, from Locus Map 27 Parcel 26 i Lea thing Area . / Lot serviced by I I - " � / ���,• To L." Water 1 DESIGN .DATA DEEP OBSERVATION Number of Bedrooms: 3 HOLE LOG Test Hole 1 ' •lo- .ra 6' I I Garbage Grinder: NO EL - °�L'►f PROPOSED LEACHING FACILITY tiI4 _ ( - Design `Flow Two 8,-6 x 4'-8" x 24» deep //�� " "� - - � eY I Dppv soil 3oi1 soil P D( nn :1 Proposed Q ,, (fn (ft) Horison Texture Color (or similar) Concrete Chambers .Q vJ� ,tti i= D-Box, D (110 Gal/BR/Day x Number of BR) (vsDs� (Munaeu) with 4' stone on sides end I r `. ' the ends ��� - ` ~ +' �` SepitiC, Tank: s©� o - y /� �( stone on _ - // (Total Area = 25 x 12.6) 13 L 5A&v loy ..� (Minimum = Design Flow x 200%) l'a A �--- `r ltsAl _ Leaching Area: to-YA71G rr Proposed l g 36�-/3f $$� GZ UAaC 1,500 Gal .B?�j Siidewall: ��nr,� 2Is�7/+a Exist Pit to be - r O S-Tank and filled i, M Sidewalls x ?S _Ft x _��Ft) + / • pumped i O � Deep Obo Hole Date: (o N/F' as required 1 lt�• > i Z, .L / SU sole Evaluator s ro n�E 4 (Z Endwalls x _—��Yt x --,E't) F. Witnessed By: Stiles O csp, Pro•. P - . � ,..- - _ _ - Para Rate: G Z M�B•!�i � Mai 27 Parcel 106 - _ _ - , / ._. / p Clean Bottom. _� SoA'survey Deeoriptian CARVER B .r1 ro . / Geologic Material: OU7VASH v Out; N_ 2 5 /Z•G (0 5 Existing well. servicing o �, . / _ _Ft x _:'t) "� Depth to Standing Water. NA 50' from Locus '�` �.,� \ �Or ��� �'` �� Depth to Weeping Hate, NA lot` over 1 / / / Long Term Acceptance Rate (LIAR). . '�Q mittSeasonal to t color: NA Leaching Area ,� / / �� / High CW. NA MS Observation Well: NA O o b Leaching Area Design Capacity. w''{`� Date of last Measurement NA t� Comments (Shdewall .Area + Bottom Area) x LTAR .. I OF Xdrt ` / . '(I I90363 . 40'��Q�TE4F'dwv — —. — — \ TONAL Existing well servicing / lot over 150' from Locus Lea eking Area mt N/F / Obrien / N F $� o p,o PROJECT LOCATION Map 27 Parcel 107 / / � ��-�° �' / Raftery_ 16' � K11 Exist \� / ��ywAi< y /�ArS .j ♦��5� /� / Map 27 Parcel 28 • C/0, Ldt L) :� / , ,.n ASSESSORS MAP 1z LOT 1_1 _ L�cisting xp_* gervic.ny, / Lot oi,er ISO' fitsm Ios�s 1 jeac hiit jl Ares APPLICANT C, _ � 1 rA �� s 2oA 1v4 Levcly PREPARED B Y A 0f P``e� A & M Land Services 15 Sunset Drive { South Yarmouth, MA 02664 e B(w (508) 394-2723 - 13 o E. SCALE' / DAT _ 1 , REV. LOCUS MAP - D WG. NO. 3p o SHEET 1 OF J 14.4 f�s-r4�nl V /4c P,4 ........... .....................................