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HomeMy WebLinkAbout0011 INTERVALE LANE - Health 11 Intervale Lane Marstons Mills F/R A = 043 015 -- - ---—� i TOWN OF BARNSTABLE �. LOCATION T ri✓���A L',O�1� SEWAGE # 2/J03— G l7'/ V-'jLL—AC-E ;*54 " Me 5 !4'li/l ASSESSOR'S MAP & LOT 6V3—D/f_ INSTALLER'S NAME&PHONE NO. S_O )a5rV4 9s.1mo- 5 SEPTIC TANK CAPACITY 1000 LEACHING FACILITY: (type) (size) fe NO. OF BEDROOMS wBUILDER OR OWNER Rvr4 PERMITDATE: l 2- 3l- 03 COMPLIANCE DATE: ' - L Sepaation 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- � + � d c �`' .� • No. d 3 _ l9 ` �� Fee d THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Mi5pool bpztem Con5tructfon Permit Application for a Permit to Construct( . )Repair K)Upgrade( )Abandon( ) O Complete System^Individual Components Location Address or Lot No. /� "T' �k �N Owner's Name,Address and Tel.No. Assessor's Map/Parce Listaller's Name,Address,and Tel.No. > Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms oo((,, Lot Size 2® &6 sq.ft. Garbage Grinder K4V Other Type of Buildings No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow '3 1 0 gallons per day. Calculated daily flow -3 ) 0 gallons. Plan Date ! 2 11 o-3 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 2— G �-►��-� Description of Soil, 0 ` 4 C G fa Y 4/1 /21 s a—L ! Nature of Repairs or Alterations(Answer when applicable) Y" Att �LCO'� r2.� t'a% <'. Qtiv► �2P� L�. c f 41' S A7.,e q/� C e_s- t k /3'X 2 - 0141 CO-wL I-*-of t j r cepi,7�e c-n4a( -Y� i'ow yr w L0ZP� 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 b Bo d of Health. Si ned Date Application Approved by Date Application Disapproved for the following reasons Permit No. V Date Issued -- —————————— —————— —————— - ------------------------------- •.,_i / THE COMMONWEALTH OF MASSACHUSETTS• . Entered in computer: t/ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS es Zlpprica.tion for Zigpogar bpgtem� Congtrugiori erntit Application for a Permit to Construct( . )Repair Upgrade( )Abandon( ) El Compldte System Individual Components Location Address or Lot No. //n-vA 6,/\ Owner's Name,Address and Tel.No. Assessor's Map/Parcel,),,7/����OV+)f-CA-1 I ;Vi Installer's Name,Address,and Tel.No. // Designer's Name,Address and Tel-No. n Type of Building: �D Dwelling No.of Bedrooms Lot Size (906 sq.ft. Garbage Grinder Other Type of Building IQiW&n 6e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. s Plan Date 41 Z o-3 Number of sheets / Revision Date r Title Size of Septic Tank r K /my $ A ( Type of S.A.S. •-,1--G>J , Description of Soil, 0 ` Z(S-Gsy%/ 2 = y � C • C(Q S a IL Cl 1-��-,-ov►-� Nature of Repairs or Alterations(Answer when applicable) —C a f l L„�� Z jr r /7,X 2 d,'P - ,'Aw-e i+t 4.e �i�ec�a/ fv ?"'ow ram, �✓ 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�tkus Board of Health. Sig. a ,c Date e Application Approved by Date Application Disapproved for the following reasons Permit No. 3[^7_6 V Date Issued r-I { ----- ——— ---- THE COMMONWEALTH OF MASSACHUSETTS 6,C( 3/O/ S� BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( ) Abandoned( )by at // 7"7 #cd,va Lc L ,"14'1/) has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. i„ .2,_&,0/ dated_ 0 ! I U Installer Designer ✓ I The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date t)U Inspector 1y)i (Z No. 4co — �o r" v v Fee 50 THE COMMONWEALTH OF MASSACHUSETTS D 3_0/-S-- PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS W5pogar *pgtem Construction Permit Permission is hereby granted to Construct( )Repair(Upgrade( )Abandon( ) System located at 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 conditions. Provided:Construction must be completed within three years of the date of this rnut Date:_ �'f 3 I �D 3 Approved l: TOWN OF BARNSTABLE ,r /A LOCATION �l4 b /rS W D G SEWAGE # 3 y VILLAGE ASSESSOR'S IMAP & LdT a`Y3-01-r INSTALLER'S NAME&PHONE NO. ,4'O8—y1U- 9735 /o5�6Q sapr�5 SEPTIC TANK CAPACITY 11900 LEACHING FACILITY: (type) .(size) NO. OF BEDROOMS BUELDER OR OWNER Iq vT & h� O PERMITDATE:_ 2- 3l" 0-5• , COMPLIANCE DATE: 1 EJ WU Separation Distance Betwee-n� 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 Ar i .0 � � Y FAILEJ) INSPECTION �!- 16' 3 y DATE :_ 10/21 /03---------- PROPERTY ADDRESS:-- 1 1 -Intervale_Lane RECEi\/rD -- _ eg1 tcn§_mi11Z___ - ] 2003 Mass 02648 Nov -- - - -------------------- TOWN OFiSr,r; .,)I ABLE HER.-TH DEPT. On the above pate, I inspected the septic system-,at the above address. Trnis system consuls of the following; 1. 1- 1000 gaiion 6egt is tank. 2. No Di.6t2i&ut.ion Sox. MAP 3. 1- 1000 ga ion /?2ec26t .2each.ing 12.i.t. PARCEL PA 8aseo on my inspection, I certify the lollowing conditions: PA ` O 4. 7h.i.s ih a tit.Pe Live .se/2t.ic zyztem. (78 Code) LOT 5. The .6ei2t is .6y.6tem -.z .in hydnau.Q.ic �a.i&/te. A new 2each.ing anea needs to ge in.3ta__f8d. 6. Naate wate2 .ie at the .eevee o� the .invent 12:i.l2e. o� the -geach.ing/2.it. 7. The -6e/2t is .syhtem n_eed.3 to lie 12umi2ed. SIGNATUR 5AW Name : P . _macomber Jr . ompany : 9jpp.n Son, Inc , _Z - - ---- - - ----- ^ one T„IS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. T Ink s-Cesspools-leachllelds Pumped & Installed Town Sewer Connections P 0 Box 66 Centerville. MA 02632.0066 725.3338 115.6412 COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION .r TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR,VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1 1 Intervale Lane Marstons Mills Owner's Name:R_uth Magnuson Owner's Address: same Date of Inspection: 10/21 /0 3 Name of Inspector: (please print) J.P. Macomber Jr. Company Name:Joseph P. Macomber & Son Inc Mailing Address: Box 66 Centerville Telephone Number: 508-775-3338 CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: !� d /-D Dater / The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000 ,gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I I OFFICIAL INSPECTION FORM — NOT FOR SUBSURFACE SEWAGE DISPOSAL SYSTI�M PA P%T A CERTIFICATION Property Address: 11 Intervale Lane Mar.c;t-Qns mills Owner: Ruth Magnuson D3teof Inspection:D=1?M=k !DsPection Summary: Checlx A,B,C,D nr F Scct'oc D A. System Passes:. I have not found any information which indicates x.r)%t any o-'ii, Qrwi,,; Comments: The zeptic zyztem iz in hydaaaiic �aiivae. A new ieaching a.aarz neerL to R. _j d. D SvVern Condition2fly Phssci: A)b One or more system components as on iteed :0 or repaired Th system, upor conip!,.-tio,ior oic Answer yes, no or not de(?rrniri,d n "tit, for ow fa,-xi!Ig If p;ca_s- 4U The Septic taq is metal jtnd over 23 )­.ars t�r ilic sq::,- jai ti;tj�fl Crnc),) nc'; !1Y IS Sf .7 L!;�ound, tx:hibi!s si.)b5tandid PISS 1 r..CP e C! 11 it by 0-.� i3oafd CX ­ ;stLP-, ;�K is rcPI.cc,i ��io, mc'.21 stp!�.c t-%nk -xill ),5s C i!', thi:: thc lank. is !-5s 0�11) '20 is N D of st-wn(: or 11rc, )ipc($)or du': to Sf:(11CJ1 ("i LACV,"l, ;')YslC111 WH ro 31 0 f B o,--J d c L-11 h): oMmrtiw, is rcniovcd 1 1 1,�. J. of If • a r, r 0 Y it! JIc"!I'! at C rC;)h-vJ N*D 2 f Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 Intervale Lane M.arstons Mills Owner:Ruth MagllLsnn Date of Inspection: 1,0/21 /0 3 C. Further Evaluaticn is Required by the Board of Health: 46 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. S}stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not fu3ctioning in a manner which will protect public health,safety and the environment: / a 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,safety and environment: ,b The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. �d The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well—. Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatil: organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are riggered. A copy of the analysis must be attached to this form. 3. Other: A� 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A `/ CERTIFICATION(continued) Property Address:1 1 Intervale Lane Marstons Mills Owner: Ruth mag;iIjEjoo Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ cu of sews a into facility ors stem component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface o the ground or surface waters due to an overloaded or clogged SAS or cesspool _4AfLO, Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool / �J_� j Liquid depth in eesspoe}is less than 6"below invert or available volume is less than h.day flow _2/Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number — �of times pumped�. y 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 t/ water supply. ,Any portion of a cesspool or privy is within a Zone 1 of a public well. �1Z y portion of a cesspool or privy is within 50 feet of a private water supply well. y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply e system is within 200 feet of a tributary to a surface drinking water supply — = the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY kSS : ,: SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION 1,'O PART B ` CHECKLIST Property Address: 11 Intervale Lane Marstons Mills Owner: Ruth. Macrnuson Dstc of lospectloo: 1 0 21 03 Check if the following have been done.You must Indicate' " " �.des or no as to esch Yes No Pumping information was provided by the owner, occupant, or Board or Hcalth Were any or the system components pumped out in the previous two wcc;:s _ Has the system received normal flows in the previous two week perio J ? Have large volumes of water been introduced to the system rcccntly or as p:-e c•f u:;s '..: :.. _ Were as built plans orthe system obtained and examined?(If they wtra not _ 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,=uding the SAS, located on site ? _ Were the septic tank manholes uncovered,opened, and the interior cf tllc of th baffles or tees, material of construction,dimensions, depth of 1:,uid, d: �t _ Was the facility owner(and occupants if different from owner)proviocJ maintenance of subsurfw sewage disposal systems ? • The size and loeatlon of the Soil Absorption System (SAS) on the site has t>een Ycs o r. Existing information. For example, a plan et the Board of y Determined in the field(if any of the failure criteria rcl_�cd is unacceptable)(310 CMR 15.302(3)(b)) • 5 Page 6 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 11 Intervale Lane mars tong mills Owner: u h Magnuson Date of Inspection: 1 0 21 03 RESIDENTIALFLOW CONDITIONS ,... Number of bedrooms(design):J— Number of bedrooms(actual): DESIGN now based on 310 CMR 15.203 (for example: 110 gpd x M of bedrooms): AY Number of current residents: -I— Does residence have a garbage grinder(yes or no):.,0 Is laundry on a separate sewage system ( es or no):;F!:5 fir yes separate inspection required) Laundry system inspected (yes or no): P Seasonal use: (yes or no):_ Water meter readings, if available (last 2 years usage I� the we ei ha.3 not Sump pump(yes or no):kil Feen .tez.tecl in .the /1a•3.t Last date of occupancy: % .twe-eve month.6. It .6houid &e COMMERCIAL/INDUSTRIAL clone at .thi.6 .tame. Type of establishment: See /2agez' 6A 6B Design now(based on 310 CMR 15.203): 0,4 zDd Basis of design now(scats/persons/sgft,ctc.): Grease trap present(yes or no): Industrial waste holding tank present (yes or no): Non•saniury waste discharged to the Title 5 system(yes or no): Water meter readings, if available: ) Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records , Source of information: t3 �p Was system pumped as pan of the inspection (yes or no):�1 If ycs, volume pumped: 13 allons — How was quantity pumped determined? A)A ReLson for pumping: TY)sE OF SYSTEM t/Septic tank,44w44ox, soil absorption system l8 Single cesspool JJe Overflow cesspool Privy 5 4) Shared system(yes or no)(if yes, attach previous inspection records, if any) Innovative/Alternstive technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) A�91'ight tank �A Atucb a copy of the DEP approval /1/' Other(describe): ,/a¢ Approxim a a¢e o components, date installed (if known)and source of information: a -7 Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 11 Intervale Lane Marstons mills Owner: Date of Inspection: 1 0 21 03 r BUILDING SEWER(locate on site plan) Depth below grade. 10 — / Lite 4" PVC /2.il2e .z<h2ough Materials orconsrruction:_cast iro XV40 PVC Bother e�Cpla ):_out the 4ybtem. Distance from private water supply el or suction line: �G Comments (on condition of joints, venting, evidence of leaks e, etc.): jo.int.s aR/2eaa tight. No eu.idence o i4eakage The ayztem .is vented thaoug the Zoo/ vent. SEPTIC TANK: t/(locate on site ) Ian /OGt'J p Q� D4Pth below glade: ty_ � Material of construction: ✓oncrete:metaljCZfiberglass.d�polyethylene ,D othcr(cxpIa in) _ If tank is metal list age:d&Is age confirmed by a Certificate !fi of Compliance (yes or no):-!L)4(artach a copy of certificate) Dimensions: � Sludge depth: �I Distance Isom top of slydge to bonom of outlet tee or battle: Scum thickness: /y Distance from top of scum to top of outlet tee or baffle: Q_4)e) Distancc from bonom of scum to bonom of outlet to or baffle: How were dimensions determined: o Commcnts (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet inven, evidence of.leakage, etc.): Once 31iztem "i,6 u aade. Pump the zept.ic tank evezy 2- 3 yeaaz. LaZei R aui-Ppi ez a2e .in /2iace The -tank iz a 2uc u/ea y Bound and .shows no `ev-idence o� eeak�;ge. GREASE TRA91160ocate on site plan) Depth below grade: Material of construction..�60concrete4meta64:�fiberglasseZpolyethylenef,/,dother (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet fee yr baffle:' Distance from bonom of scum to bottom of outlet tee or baffle: �( Date of last pumping:- &A Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural inlegHty, liquid levels as related to outlet invert, evidence of leakage, etc.): 1i2ea,6e taal2 43 not �aeaen 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 1 Intervale Lane Mars ons Mills Owner: Roth Magnus Date of Inspection: 16/21 /0 3 TIGHT or HOLDING TAN"Ae(tank must be pumped at time of inspect ion)(locate on site plan) Depth below grade: Material of construction:.LJ4concrete',1�4 metal4�Lfiberglass.l_if polyethylene4�9 other(explain): Dimensions: ,/ Capacity: �(�jR gallons Design Flow: gallons/day Alarm present(yes or no): &�d Alarm level: __,6H Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): T.iah.t o�z hoPding tanks ¢2e no•t flee-6en . DISTRIBUTION BOXrl wi (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 1,0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D;i_.s.>`_a_.i_9Ui.i0n Pox •i,3 no•t PZebent PUMP CHAMBER4,4V4(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no):�� Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): �rlm2 champ 2 -iz not 122e,6en•t 8 �� ' -��_�uux�' �-----'---�--------------'-'----------- ------- -' ' � � � � Page 10 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C -• SYSTEM INFORMATION (continued) Property Address: 11 Intervale Lane Mars ons Mills Owner: Ruth Magnuson Date of Inspection: 10/21/0�_ _- SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. i i i y \ ` r 0 i o 10 Page I I of 1 l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 11 Intervale Lane Marstons Mills Owoer:Ruth Magniisnn Date or Inspection: ln f 2 t /n-i SITE EXAM Slope Surface water Check cellar Shallow wells r Estimated depth to ground water feet Please indicate (check)all methods used to determine the high ground water elevation: y rS Obtained from system design plans on record • If checked, date of design plan reviewed 0/21/0 3 y�S Observed site(abutting property/observation hole within 150 feet of SAS) ya Checked with local Board of Health•explain:4h F-u�i.Pt y£S Checked with local excavators, installers-(attach documentation) y LAccessed USGSdatabase•explain: htt12://town. Pa2nztagie. ma. us. You must describe how you established the high ground water elevation: sed: Sah�zety 9 Node-P. 12176194 q ourzd watea elevation-6 agove z8a ievzi. sed: L'SG ^Av t con we e-P data, June 1992 sed: 11SG.' - Tnrhn.rriO Q,uQllo}}gin 92-000 1 %-Pate #2 Rnnua-P gitoun 2 wa e e evat-.onh -92 Leaching Pit 40 :cc( GroundwatcrM Feet Below Bottom of Pit High Groundwater Adjustment 1.1 8 ft per Fnmptcr Method Therefore, the vertical separation distance between the boao of the leaching pit and the adjusted feet. J groundwater table is f�(7 I1 �a•w.mr..-n���•.•-..nrww•wr.w�•..�.wtr�+wnw++n..ri+n+wwr�r���1�•�-w�w wT .Tv��T_. ,- TONN OF _RarnGtahl P WARD OF HEALTH j SHISH FACE SEHAGF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I .^•Tn-7••.•::a-T. "^.trnJn r�191.1ff r�wll�r�A•nTrr-t1-11TR�W"Wr--rVV"Vwf TWO"ww" WNW 9 •I�+rrr r-�. �. .1 -TYPI OR PRINT CI.CAALY- PIIOPERTY INSPECTED STREET ADDRESS 11 Intervale Lane Marstons mills ASSESSORS MAP, BLOCK AND PARCEL # 4'YO--016' OWNER' s NAME Ruth Na-gnubon PART D - CERTIFICATION NAME OF INSPECTORJoseph P.Macomber Jr. COMPANY NAME J P Macomber & Son Ind. COMPANY ADDRESSBox 66 Centerville Mass . 02632 Streft Tovn or City State tIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578 7w TIFICATION STATEMENT CI certify that I have personally inspected the sewage disposaj system at this address rind that oe information reported is true , accurate , and o.mplete as of the time of -inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site selvage disposal systems , Chick one : Systeui PASSED , The inspection t+hich I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or Lhe environment as defined in 310 CMR 16 - 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of his form , System FAILED The inspection Which I have con cted has found that the system fails to protect the Public health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , Inspector Signature Date l .and copy of this c rt.ification must be provided to the OWNER, the BUYER where applioable ) and the I30ARD OF HEAL1-II, * If the inspection FAILED, the owner or•"operator shall upgrade he aYste within one year of the date of the inspection , unless allowed ortrequiredm otherwise as provided in 3.10 CNR 16 , 306 . partd - doc LO' CATION SEWAGE PERMIT NO. VILLAGE 4w Sid 7s //s INSTALLER'S 4 A V E 8 ADDRESS . j��.c. 179./r1. ORS MAP NO: _ 'AR EL NO.: 8 UFLDE R OR OWNER f-4A MATE C 0 M P L ! A N C E ISSUED r, /Wo ,'�n / �l'ac�i Pit Q Ewa s o� 7,=sr w o� . well Fic$...fsTt..r.. ...... i THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEAL H OF........ .. .. ............ . A pliratinn -fur Uiipuiitt1 Worka Tomitrnrtinn Vaniit Application is hereb `made for a Permit to Construct J, \/or Repair an Individual Sewage Disposal PP Y ( �/I P ( ) a P System at: - -----------------------•--------------------------------------------------------- cation-Address or No. ------------ // e /� ! (d er /`/'/S/rJ v/S: d..... 9� Installer Address Type of Building Size Lot^.&4.(a_-_---_-_Sq. feet Dwelling—No. of Bedrooms.--_--__ ...............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ o. pel-soiis.._._.�----------------- Showers (/ ) — Cafeteria ( ) a Other fixtures ----------------------- -------�"-� ----- --------------------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow-------- --------__-__--____-.--.......gallons. WSeptic Tank—Liquid capacit A ..gallons Length---A------- Widt...... Diameter................ Depth.�...... x Disposal Trench—No. .................... Width,----------------- Total Length.................... Total leaching area.A/1.6........sq. ft. Seepage Pit No _. - Diameter.....6 _......... Depth below in ' Total leacliiii area..--.-__.----__-_sc ft. � �---------- P � -���, g � 1- z Other Distribution box ('—' Dosing tank ) /A—/e_ l � Percolation Test Results Performed by..__.-------�-.--._j _I1_..'/�_Pe......................... Date---- ------ a - l Test Pit No. 1. ......minutes per inch Depth of Pest Pit-----/"2_------. Depth to ground water..----.`7-0.�_._...-. Test Pit No. 2----------------minutes per inch Depth of Test Pit____________________ Depth to ground water--.--._--__-__-------. - Description of Soil. S;N Y-----------a•.....4� -----------1�----c-i�`��f rr ----------------- ------•---- x W VNature of Repairs or Alterations—Answer when applicable......------------------------------------------------------------------------------------------ -------------------------------Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with The provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance hAbee ' d by�board of health.SignC %lla?�¢C C ----- ---------------- -- ate Application Approved BY---•- -- --- ----- - ---- - �/f� 7 Date Application Disapproved for the following reasons:.......................------------------------•------------------------------------------ ------------------- .............................................................••----------•-•-----•---------•--•-•--•--•.....•---------•-------...-----•---•---•--•------------•----------------•------------•-•--•----- Permit No............................................. .... Issued..- .(2-/ -7-1 Date ..`.'..Ate Date-'--- ---`-------------------- No............... F .......... THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH `7 p-wU O F.......-X54 ............... Applirtt#inn -fur 43hy ial orkli' Tons#rur#ion Vrrmift ; Application is hereby'made,f a Permit to Construct ( or Repair- ( ) an Individual Sewage Disposal ht y. . __::_ _.________- !� 1 ,� V", m in�"e,� �•,l/e r f r-----� t -------------- ------------------------•----- J�� ✓� ----------------------- / I��f �f / L / / �^nF � //Address/ W -•-•••---••-------•---•-----•--•--•--•-•....-•=::.- ----•-----_••-•-•--•---------------------- ...........................................------------• / ________ Installer Address (pv� ll Type of Building NIP Size Lot..............................Sq. feet U Dwelling—No. of Bedrooms....:..:....................................Expansid Attic ( ) barbage.Grinder ( ) a Other—Type of Building ----:------------------ persons � ( ) — ( ) ___. No. of el sons____________________________ S rs Cafeteria d Other fixtures --------------------- --------------------- .................................................................. --------- Design Flow------------------------- f- - r W g �a_.__.__gallons per pel-soper day. Total-daily flow----------------------A4...... allons. W Septic Tank—Liquid capacity___..______gallons Length ___________ Widtl .c............ Diameter-----..._....':_Depth_..,_____._.... ,_ x Disposal Trench—ado_ ____________________ Wic�i.______...___..._-- Total Length-----__............. Total leaching area_._..................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below®n . _ �_ ... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------------- +l_ /��DPe ''e---------- - • e3- /6---/94_6- - ,� .. Test Pit No. 1_ , _©______minutes per inch ,I i of Test it....._ Depth to ground water....._-. J`a � ... fL4 Test Pit No. 2_____'_._______.minutes per inch Depth of Test Pit____________________ Depth to ground water-,.._-._-._-:_-.-"--.---- : , W p Description of Soll .......... -• ._ < f --------. �t -is f - W UNature of Repairs or Alterations—Answer when applicable---------------------------------- ------------------------------- . -- __ . Agreement: . The undersigned agrees to install the aforedescribed Individual Sewage Disposat System in accordance wifli f O the provisions.of Article•XI'of the State Sanitary Code—The undersigned further agrees not,Ao'place the system in operation until a-Certificate of Compliance has been iss ed by the board of health • --- Signed_ �s--:_ _. - _.;[ at Application Approved BY_.__:> -------- Application - ----- ---------�------------- Application Disapproved for le following reasons-------------- --------��----_------_•-- .................•----_._.--•-•-•---•-----•-""---------•---•--------•--•------"--•--•-•-----"------"•------•-----------------------•----------•---...-•••-----•--------•-•-•------------------•----•-•- Date Permit No. = Issued...................... --------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .:... ... ............ ...OF..... t #t$trtt g n t�rr _ THIS IS T C TI . That the Individual Sewage Disposal System constructed, or Repaired ( } by............. ----- -• -- ....... ..........-------••-----••---••••-•- ••---••-••- ............................. Insta at- •--- =-. �� -........ ---- ----- -•--• - - "-•-- •..-•-"-"-" " -- " - .r..-------"----------- has elt" ns�a)@'ec�in a� 6r ce pr is ns o r e I o The t� Sa� = as described in the application for Disposal Works Co truction Permit No.__ 11_____yy_ � _ _ dated........ . ...... . _ THE ISSUANCE OF THIS CERTIFICATE SHALL. � BEl�1�1'STRUED AS A Gei EE TE4AT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS `t BOARD . OF HEALTH OF............ c ................. , .••----• FEE-•-- t��>Q�ttt . nr � n r#that �rrntt# Permission is hereby granted_..... " -----; .-... -------•----------- -------------- to Construc .( or Repair ( a' CZ Se a os System at No.. •-------- �f � . /w/ ' l •• as shown on the application for Disp 1 Works-.Construction,;,Per it No..................... Dated------ ► �._.. ►.._.______. -2�-Z7 dot DATE ---------------------------- --------------------------------------•- FORM 1255 HOBBS. & WARREN. INC.. PUBLISHERS w _ " 41 - 901 �a `o � S. ,�', 1, _ •,i i Z 1 - • �'/ ! • 1•. ram` r, N To il U I see rl Ck CD CERTIFIED PLOT PLAN NEW CONSTRUCTION ,,.ONLY �— -- -- -- iF TOP OF FOUNDATION IS. FEET ABOVE LOW POINT OF"ADJACENT .0All k1 ,S IAS I 26biAs . ROAD. SCALE : /�� 20 � DATE (E_L_DREDGE ENGINEERING C0. INe I CERTIFY THAT THE -- -- - CLIENT EGISTERED- rREGISTERED SHOWN ON THIS PLAN IS LOCATED R . �" JOB N0.7_C. ON THE GROUND AS INDICATED AND CIVIL LAND p� CONFORMS, TO THE ZONING LAWS ENGINEER � i. SURVEY<Q'R DR. BY: _._--� _. _..._ _.. ` - OF BARNSTABLE , MASS. CH. BY 33 NO +MAIN T 712 MAIN �T ;0 YARMOl TH, MA HYANNIS, `M�: S. SHEET OF . __ DATE REG. LAND SURVEYOR ;. - _20 .i i. MIN. - 5 F.T. MIN _ - - ,._- - : •__ ._ - , - - . -_. .. CLEAN SAND e�I®®, v �uN�Ht I t _ MIN PITCH COVERS _ o` PER FT _ CONCRETE COVER A 10" I IOUID LEVEL 2" LA ' - AST i ii / i - - .. `�-a-�.- �- r•'J I/8'R 3/8" - ° ° , 1�rr ^PfPE ° , 0 1 . • .• o • WASHED STONE SEPTIC TANK DIST. ' • • " ' ° ° 'a 1/4°° R FT 1 . e e • • 1 1 ° ° ' o box ;u: g'- ° °° ': / 1 • EFFECTIVE' ' ' ' 3/4"- 1 1/2" _ ' ' • DEPTH • too ° WASHED STONE .•.n - .. `ram: . .• .'.e.-.'.:w - • .o ° 1 1 e • • • • • 1 ° - ' PRECAST SEEPAGE 1 1 • • . . . . . ` . • PIT OR EQUIV. p • Its • • • • • o / INVERT- ELEVATIONS 6 FT D1A ------ I INVERT AT BUILDING �S FT. 10 FT. DIA. C (SEE TABULATtd '' j 7 INLET SEPTIC TANK � FT -�— • GROUND WATER TABLE - OUTLET SEPTIC TANK _FT. SECTION OF _ -1 L.9T -DISTRIBUTION BOX 1,0 FT SEWAGE DISPOSAL `SYSTEM F ET DISTRIBUTION BOX 91. 8 FT. SCALE 1/41t= /I O" 7fLET SEEPAGE PIT FT. _ TABULATION DIMENSION A J FT. DESIGN CpITER1e - - DIMENSION ® FT. NUMBER OF BEDROOMS 7 ,__ DIMENSION C —FT GARBAGE DISPOSAL UNIT __ - TOTAL -ESTIMATED FLOW $.G ° GAL./DAY - SOIL LOG SOIL TEST NUMBER OF SEEPAGE PITS / ELEVATION DATE OF SOIL TEST SIDE,' LEACHING PER PIT SQ. FT. ern! If BOTTOM LEACHING PER PIT SQ. FT � ° Sw!•so � ® �-� RESULTS !N ITN FSSED BY TOTAL_ LEACHING AREA a6c SO. FT - 3, e► PERCOLATION RATE/ass �• G MIN/INCH • RESERVE LEACHING AREA C` SQ. FT i OF � ii: s ;�ti '4Cy J� ,_"` - + •�,•_ � ' Q @ 4. � - ._ I�ei�e o "L��K s A y e<'�Y)�d os•�P b�a•�� ,� VA i208ERT - "' E LDRE-.E ENGINES .CO,INC. 1 NO MAIN ST. .72 MAIN ST �. M 4,yp suadti rk�, ram` ; . ,>,• O. YARMOUTH Af�43�.�• P Led tlfiST MAS , •: • S•. - _ . JOB NO.nt OF 7. swi..." :. --- ... _�:,ac,•*.�m�.�.��a•:e�t2rs�•-�=�s�' x1�:k++n.A•Fr",a+..cn.'Cf�.�3�1V�,-�C'..�a�R�.....d4,a^'� .1a.�y.. i•��+�r3 sa;.i a..�.�"�`,�*•�?�.yt•.?$..'c3 ..-r... ='-.�i. .:'..8r7is+..�G•wc%� Hip J;Z::E-A1Z -EL VA T IC3" "(=E.1y.E.:JTR-ATIOn{ -t I � I ,_ErLr-3n1T F LF • I{nrol-,rl4iLS .pworc.SPACE x. • 1 •.�-v.[v �G�aS'� REo���<s-�i .. .sod/e OPEr.!ABLE• � -- - ------ -- --' .. - .. - - 4-1-PJ p.C.TL)p u• [ 14•�S .�o _ U0, 0 oar J0 tI N. �: J o GA/AE R.OU/—: i - il o f sE 2 _ ACC 665 P -.1.0` FOR-/hER - -=gfz:tt.Fl lZ,Xi_STING. -HOuSE 22ADgSQ IN 1ZA DATE:Apr rL�O�J REV LSEDI�/.(aY/�003 �TtO N S DRAWING NUMBER ..• � £.CO N.Q. . F LO O rL ..n LA n1 - 31 Intervale Lane N1 SITE PLAN # MAP 043PMOtB X79.14' Design Calculations N SCAi..E: 1 ,�0 YELL WATER ._ s� Number of Bedrooms: 3 (rrlinirnurn per iltle V) BENf'H MARK ON c.e. fnd. IrLL -91.38' (A`:;SIiAdI:•::I) Carbrlge Grinder. NO 9ooa' Leaching Cepocity Required: 330 Gal./Day Leaching Area Required: 330 Gal./(0.74 Gal./Sg.-=446 sq.F-i. �o e6. Proposed Leaching S ructure: 1 251 X 13V X 2'D Leaching Tench I.P. F Leeching Area Provided, � �7 Sq.:`L. r �� x eo.86, LOT 10 " 5 PrOP03ed Leaching Capacity- 353 gpd > '330 gpd, req d. AREA = 20. o / X 84,16' 3)1 ._E LOCUS N 82 x 02.19, NO ,CAL.V. " e 3 GENERAL NOTES 0 1, ADDRESS: , 1 1 INTERVALE LANE 2. A65ESSORS NUMBER: MAP 04.3 PARCEL 015 as ; 90 3. DEV::-OPER'S LDT: LOT 1 CI 4. T'OPO;�l A1'I IIC' INFORMATION WAS CU�tF'iLEO FROM. 90.46' ON THE GROUND INSTRUMENT SURVEY. x 85.9 ' 5. WELL WATER IS CURRENTLY PROVIDED TO SITE. TOWN & WELL WATER IS PROVIDED x 86.72' :0 SURROUNDING PROPERTIES. !SUBJECT SITE TC BE CONNECTED TO TOWN WATER. 6. REFERENCE P`:..AN: 1»1.AN BOOK 243 PAGE 39 (� DEFER- CE PLAN: C-RTI E'D PLOT PLAN, LOT `0 YVAKEBY & INTERVALE LANE, M. C.B. fn IN BARNSTABLE, MASS., SCALE: 1"•=30% DA E 4/7/77". BY ELOREDGE ENGINEERING CO. iNC. 7. NO WETLANDS ARE LOCATED WITHIN 100 FEET' OF SAS, _7 8. NO POTABLE WELLS ARE LOCATED WTHIN 150 FEET OF SAS. X 97.34' 92 m CONSTRUCTION NOTES X 9a67' D 1. Contractor is responsible for- Dige saficatirart r and protection of all underground utilities and pipes. 2. The septic tank anj1 distr€Notion box shall be set level on 6 of 3/4'• 1 1/2" stone, 93.96' 3. Bsackf'sll should be clear.. sand or gravel with no 94 r stones over 3" in size. 1-25'L X 13'W X 2.0' D N cr ➢ 4. This system is sub ect to inspection during instollat on leaching trench using Q z b, G•:en =• Harrrgton< R.S. 2 H-10 500 gal. chambers with Ni 92.79' m 5• Thf. contractor- a1:a€I iris€f;1€ this system, in cfcardctrEwe with Title V of the Massachusetts Enviror rnemol Code 4' of stone on sides & ends. ftl21 and the Regulations of the Town of BARNST'ABl-E., -a cO 6. Provide o Acme Pre cast H-10, 5--hole D-•Box and x v, 2 H-10 500 gal. chambers or equal. 1 1 EXIST ING o o :J. No vehicle or heavy machinery shall drive over the #82 WAKEBY ROAD D-WE! LING � septic SysterT: unless noted as H 20 septic *orr,panertts. € a ' % 6. lnstail gas baffle or equal on septic tank Outlet tee end. MAP 043 WATER Ot6 ¢# 1, 0 97• !', 9. All ex?Sting inverts and site conditions Shall be verified by contractor. f-� ViAu. 5 Mki TOWN YATER � Oamf r•T. L•;••:" S9 ri� eegar wag ur,cier r G 10. >-xizAing l;:ach pit to be p;arTtped ear?;; bac kfilled. gas 11. Stripo�.:t required to remove unsuitable soils to approx. 48" below grade, e•_ c I n w a i tel. 969r 5 fee: €aterall araund `ait5. *ill she€l rr,eet : `:t3 CM i 15.';55 s^erificat:ens. 9�30 �" un rgro n u. __. 12. .a i �- .,, b.t d Sao>-}:n F n t „fc: °^- 3aur-ce :r- only) f� a Town grater to be prm ided to w'te. paved I'driveway SOIL TEST 1 y* 98.14' Date of Soil Test.. December 10, 1976 A w �•'y 5.r..,j.J'.o -.�I.wC::t. ?�A..i•'Rz�: .R1• 95W Performed by. R. Bonikis 4•'••°-'•=�' :z:,a: X 9446 ya Witnessed by. Paul C. Murray CONCR E Q Perk Rate: <2 mpi PLAN VIEW �a Test Hole 5' No. 1 96 :DEPTH SOILS ELEV. i C.B. nd ' 0• oo' CL O C3O O „ 34" X 97a93' X 99.04' y wbwA 0 Q l24 t00 24' 84.00' Exis be converted approximate location ExlstAp well `day 2 H-10 500 gal. chambers r igatlon purposes Only. END-SECTION 0o to1oB' SAND H-10 500 GALLON CHAMBER (to be connected) a,All- NOT To SCALE 75.00' 144• 74.00*1 USE ACME PRECAST OR EQUAL no groundwater encountered 02.10' °2 -�NOF qss PROPOSED SEPTIC SYSTEM UPGRADE a � _ PREPARED FOR p,KEBY ROAD LEGEND oo H E I T RUTH F. MAGNUSON W AT 070 TEST H0=1 41 9F �° 11 INTERVALE LANE �fSTEF'' TA'R\P BARNSTABLE (MARSTONS MILLS), MA -10' ruin, from-•--i *NOTE: ALL PIPES ARE TO BE 4• DIA. SCHEDULE 40 P.V.C. 0 EXIST NC, LEACHING PIT TO BE �................_................. ............................ _......................_......._.................................................................................... house to septic tank 1 *NOTE: INSTALL GAS BAFFLE OR EQUAL ON SEPTIC TANK OUTLET TEE. PUMPED & BACK=ILLED Septic tank covom r:x rst.ba .ishe� grrtde overt tyafgm-2X stove awry € Existing House rrttnin s"or tnttthad grar,a 5 HOLE i PREPARED BY: f: v 7 _ Em,of r DST.-ROx Existing Grade Elev.-90't a o EXIS`IN�1000TICTCAL GLEN E. H AR R I N GTO N, R.S. ' j2m . -10 9 LEDA ROSE LANE I U S " 0,02' t fsa 2 Alin. 2•-118*-,l2, x DENOTES EXISTINGCear rG' EXISTING 2' s-.m double-washed n«�• P =s7.a' x,04.46SPOT GCE l MARSTONS MILLS, MA 02648 1000 GAL. tl: 1•r - .44'SEPTIC TANK - oo e e o • 95 EXiST NC CONTOUR { H_10.5 OArn" F : TEL: 508-428-3862 zS. rent ev.= 44' FAX: 508-428-3862 1 Approx. location ' �€ LEACH TRENCH ,o•* 3 . .. . >I r u existing ga` service: rr r 8' CF 3l4'-I l lr STONE E c: w BOTTOAA OF T. #1 ELEV.-74' I SCALE: 1 =20 DRAWN BY: GEH DEC.18, 2003 SYSTEM PROFILE 6"olr3l4' ,/V STONE Approx. Iocction € ; existing electric service Not to sale s DATUM: ASSUMED FILE: MAGNUSON SHEET 1 OF 1