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HomeMy WebLinkAbout0024 IRONWOOD ROAD - Health 24IRONWOOD, iW. Commonwealth of Massachusetts Title 5 Official Inspection Form 61 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments,`:, pq '< 24 Ironwood RD `a s« -r Property Address Jason Tobias -. Owner Owner's Name information is required for every Marstons Mills MA 02648 11/02/12a page. Cityfrown State Zip Code Date of Inspection `t t.rT, C_ Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms , on the computer, { use only the tab 1. Inspector: key to move your ��/'• E cursor-do not Kevin Cochran use the return Name of Inspector key. Aardvark Environmental Inspections Company Name PO Box 896 Company Address East Dennis MA 02641 Cityrrown state Zip Code 508-385-7608 SI 13523 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11/02/12 Inspect nature We The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and underthe conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Ironwood RD Property Address Jason Tobias Owner Owner's Name information is required for every Marstons Mills MA 02648 11/02/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes","no"or"not determined"(Y,N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfdtration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Ironwood RD Property Address Jason Tobias Owner Owner's Name information is required for every Marstons Mills MA 02648 11/02/12 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a mannerwhich will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11110 Tie 5 Official Inspection Form.:Subsurface Sewage Disposal Sy;%m•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal:System Form-Not for Voluntary Assessments 24 Ironwood RD Property Address Jason Tobias Owner Owner's Name information is required for every Marstons Mills MA 02648 11/02/12 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a mannerthat protects the public health, safety and environment ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'". Method used to determine distance: This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow t5ins•91/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Ironwood RD Property Address Jason Tobias Owner Owner's Name information is required for every Marstons Mills MA 02648 11/02/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following,in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ El the system is located in a nitrogen sensitive area(Interim Wellhead Protection. Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Ironwood RD Property Address Jason Tobias Owner Owner's Name information is required for every Marstons Mills MA 02648 11/02/12 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS,located on site? ® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins-11/10 The 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of V Commonwealth of Massachusetts Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Ironwood RD Property Address Jason Tobias Owner Owner's Name information is required for every Marstons Mills MA 02648 11/02/12 page. Cityrrown state Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings,if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Ironwood RD Property Address Jason Tobias Owner Owner's Name information is Marstons Mills MA 02648 11/02/12 required for every page. City/town state Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes,attach previous inspection records,if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the UA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Ironwood RD Property Address Jason Tobias Owner Owner's Name require required is Marstons Mills MA 02648 11/02/12 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: 11/17/00 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4.2 feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Septic Tank(locate on site plan): 3.3 Depth below grade: feet Material of construction: ®concrete ❑metal ❑fiberglass ❑polyethylene ❑ other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,500 gal 2- Sludge depth: it t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 <i, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Ironwood RD Property Address Jason Tobias Owner Owner's Name information is required for:'every Marstons Mills MA 02648 11/02/12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts kipTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Ironwood RD Property Address Jason Tobias Owner Owner's Name information is required for every Marstons Mills MA 02648 11/02/12 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Ironwood RD Property Address Jason Tobias Owner Owner's Flame information is fo required for every Marstons Mills MA 02648 11/02/12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(Iocate on site plan,excavation not required): If SAS not located,explain why: t5ins•11/10 Title 5 Official tnspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Ironwood RD Property Address Jason Tobias Owner Owner's Flame information is required for every Marstons Mills MA 02648 11/02/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 3 ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): This system has 3 infilltraitors surronded by 3 feet of stone.There was no sign of ponding or failure in the stones. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Ironwood RD Property Address Jason Tobias Owner Owner's Name information is required for every Marstons Mills MA 02648 11/02/12 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 L_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Ironwood RD Property Address Jason Tobias Owner Owner's Name information is required for every Marstons Mills MA 02648 11/02/12 page. Cityfrown State Zip Code Date of Inspection D. System information (cont.) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing.attached separately zi 36' t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Ironwood RD Property Address Jason Tobias Owner Owner's Name information is required for every Marstons Mills MA 02648 11/02/12 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators,installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: IUSGS maps show an elevation of over 20.0 feet. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Ironwood RD Property Address Jason Tobias Owner Owner's Name information is Marstons Mills MA 02648 11/02/12 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C,D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 it TOWN OF BARNSTABLE ILOCATION �a,"L,0004 SEWAGE # `.VP LAGE ASSESSOR'S MAP & LOT 'INSTALLER'S NAME&PHONE NO. IdiitWPiF, �Ll O�� � C..t-•u,�s.�✓ SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size k'y o NO.OF BEDROOMS B6� OWNER PERMITDATE: 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 s _ TOWN OF BARNSTABLE LOCATION_ �� TV-OA c.A.,001� SEWAGE # VYLLAGE M14-b'S'}0e A M t(IS ASSESSOR'S MAP & LOT-,&' INSTALLER'S NAME&PHONE NO. '8wS%l;e U Rf 20 to SEPTIC TANK CAPACITY 2-) (UDU U-G(opi T✓ ✓l dCS LEACHING FACILITY: (type) 5b06Ay,ihe-.,s X (size) NO. OF BEDROOMS BUILDER OR OWNER i<< Ft 0✓2 R PERMTTDATE: I y 1 COMPLIANCE DATE:JQ 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) VA 0: Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) B-� Feet Furnished by V?'tT U71 (t S V � c ,5' y©,7 No. —�5 J © Fee_ /. THE{COMMONWEALTH OF MASSACHUSETTS Entered in computer: AL Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for 30igool *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(A)Upgrade( )Abandon( ) ❑Complete System kIndividual Components Location Address or Lot No. Z Lf TrrixiWwD AA Owner's Name,Address and Tel.No. Assessor's Map/Parcel 5 7 .S4nr�c_ Insraller's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. L14/.�A.-*,o ,�c x �!S'2 Leo�' a/e. 02� �S� Z�7 sZr4in r71J/s'Is-w�c� s�-r y 026 7/ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures``,,`t7 Design Flow 0 gallons per day. Calculated daily flow S� gallons. Plan Date ZG-- /3-05 Number of sheets / Revision Date /1 on/-e Title Size of Septic Tank 16,00-PX,07 4 /Y Type of S.A.S. Description of Soil c 1 e-e-66, Nature of Repairs or Alterations(Answer when applicable) e,D�.9 ?EW.,�--P 41 �/�e Li i�r 7 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 issu by Health. Sign Date Zoe-/ �0 Application Approved by Date ` f 2 C� Application Disapproved for the following reasons Permit No. am S 6 cat-O Date Issued '�— Y No. Fee / O Q 5 ,_Tk,"PMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTSYes Application for Migool *pztem Cow6truction Permit Application for a Permit to Construct( a)Repair(k)Upgrade( )Abandon( ) El Complete System Individual Components Location Address or Lot No. z !;OI►WC O Q Owner's Name,Address and Tel.No. � Assessor's Map/Parcel 57 m� SA Installer'ns Name,Address,and Tel.No./ Designer's Name,Address and Tel.No. /�DuSrit�� �/lr1 7�/rc �Ps(i <it,G 1-1A ��A�'—e_ /--,a -r^/,'d I e 02 H V,CK Z j'7 4f q r7 Al/IAAl e..r c Li /s?y 0 2 r 7/ Type of Building: .Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow `*O gallons per day. Calculated daily flow VV5 gallons. Plan Date �p- r 05 Number of sheets Revision Date Title Size of Septic Tank /060-fXr)7 %9 VW /1n00 Type of S.A.S. Y Description of Soil 1*4f4 Nature of Repairs or Alterations(Answer when applicable) /�P,p Ge. 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 this,-B-oard o Health. Sign d Date Application Approved by Date '/d/f7 3 Application Disapproved for the following reasons Permit No. r9o:)S S ?d Date Issued P7 -7 —— ——————————=—=—————————— — ——— —— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (R )Upgraded( ) Aband nte�d( by f��3��e Id f4-4 I A441 f�✓,.r c e Div C- at / � ��ii' �0� has been constructed in acc rdance with the pr visions of Title 5 and the for,Disposal{§ystem C struction Permit No. S Sao dated Installer ��SFl P f/c� J fwL -- - '`'��Designer a $ The issuance of this per it shall not be construed as a guarantee that the syste 1`' ncti as desig ted. Date f" Inspector No. `—�"'"'J �� -------------------------Fee /��� . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Mi!6po!5a[ *patent Construction Perron Permission is hereby anted to Construct( )Repair Upgrade( )Abandon(. ) System located at y V��oti D Q _ /kXrS7awS 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 condit' n Provided:Construction must a completed within three years of the dat of thi Date: /0/l7 Approved by Town of Barnstable oFtHE Regulatory Services NAP - G� Thomas F.Geiler,Director �' • BARNWABIX MASS. Public Health Division �A iG3.9. A�0 Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: a Designer: LA.MdQ& E Installer: do US 614� 54NIWIRYSCAVICE Address: 841,V S. / Address: 490X lA/�S7 �l G` 4JlC f/ FokES-13)j1LL 0,4 On D- D J� ,QDUS r/lz Lb was issued a permit to install a (date) (installer) o� 9 Q septic system at C 1 y /JQU/tl WOO b /\b based on a design drawn by (address) dated /0 —13— D� (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations. Plan revision or certified as-y uilt by designer to follow. 3 y Cclu r-le g C 7 f Z !add A me (Installers Signature) A CIVIL No.39201 (D gner's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 1 1 • •BA--� ble P# Town of Department of Regulatory Services • Public Health Division Date 200 Main Street.Hyannis MA 02601 'Time Fee Pd. Data Scheduled $ozl Suitability Assess ment for Sewage Dis sal Performed By: Witnessed By: LOCATIO ?� RAL INFORMATION Location Address [ �� i Owner's Name �C� J/I PI ( Address � Assessor's Map/P4(cel: 'a tv I Engineer's Name NEW CONS' UdMN REPAIR I Telephone Land Use i7c �y p,�H,T��L Slopes(�'o) S _c Surface Stones �� Distances from: O Water Body ��6o ft Possible Wet Area 7/O o ft Drinking Water Well '!/b V ft l ; Drainage Way 7 Z S ft. Property Line SKETCH:0treet name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to doles) I I 3S C��l • Z i J�2 i 3i7/ —33'� �, I 4�1—0 Parent material(gecilogic)l�A ria © i ii�b �e�IFY Depth t0 B' k g Depth to Groundwater Brandin Water in Hole I Weeping from Pit Face v Estimated Seasonal iI•}igh Groundwater EL io ,o�P�6a'J �v� /3dooz.� �2�Qd D&ERMIN TION FOR SEASONAL HICK WATE TAr3LE NA Method Used: aAL ,RrNdu/�F6 N°t wC�4�•vtis,sro�,. ln. Depth to loll mottles: 1n, Depth d,1�4erved standing;in obs.hole: -- ft. Depth toiwee ing from side of obs.hole: in.Act.fActor fer Or Adjustment ' aetor.�..��•- Adj.f5twundwat�er l.+:va1,,.�. Index Well — Reading Date index Well level - LATION TEST PERCO ' Date/�'.--`S'�e /0 Ga A Observation Z I Time at 9" .3.•.=/-- Hole# Z 3�r� " Time at6" y_..,./Z .- -- Depth of Pere �� ; 39 D i Time(9 -6 ) -- ---- Start Pre-soak-rime.@ - End Pre-soak :$ Z c» Rate hImJ1nch 1 L Z t Site Suitability AsscOsment: Site Passed Site Failed: — Additional Testing Needed(YIN) OriginaL•.Public Halth Division Observatiori Hole Data To Be Completed on Back ***If percolai0n test is to be conducted within 100' of wetland,you must first notify the Barnstable C44servation Division at least one(1)week prior to beginning. DEEP OBSERVATION HOLE LOG Hole# l Depth from Soil Horizon Soil Texture Soil Color Soil Other .Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsistenc %Gravel) Z, b i / / S — 36 > agv✓1 IVYR,/S/G N I�sS/✓� sl�,� 36—J2./ �.�� to v G2.vDJ'p /p% o rLAaBL DEEP OBSERVATION HOLE LOG Hole# 1i Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%Gravel) �jn sr/�d �2�1 /tib4'6 3y-/Z /ado, sR.vh /o 6lz.�� 0 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Oravel l II DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, F Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes J_ Within 500 year boundary No Yes Within 100 year flood boundary No `� Yes Depth of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? Y -- If not,what is the depth of naturally occurring pervious material? Certification I certify that on 6 45 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 3.10 CNM. 15.017. Signature Date Q:SEPTIGIPERCFORM.DOC - i ui p ; O r--q ,V(,:�i ED Postage $ •3 x Certified Fee � i�r 0 Return Receipt Fee I6 � 0 (Endorsement Required) Here.A V M Restricted Delivery Fee s rp (Endorsement Required) rq r-q Total Postage&Fees Lr! E:l Sen To - [ti utreet,Apt.No.; �/` or PO Box No.p'jy Coif 071 Lt�ODL� }!G Qa(d_ -- City------------- ie,ZIP+4 OMMMI /N 6 :rr rr Certified Mail hovides: (as�anay)ZOOZ eunr'OOBE w�o�Sd o A mailing receipt o A unique identifier for your mailpiece n A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. o Certified Mail is not available for any class of international mail. n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. e For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-Delivery,". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix-label with postage and mail— IMPORTANT: IMPORTANT:Save this receipt and present it,when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. f COMMON WEALTH OF MASSACHUSETTS f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 24 Ironwood Road Marstons Mills MA 02648 Owner's Name: William Moretti o�, Owner's Address: Same3, /..,., Date of Inspection: August 22,2005 Job# 05-251 Name of Inspector: PATRICK M.O'CONNELL ±Yi Company Name: SEPTIC INSPECTION SERVICES CO. raj _ "# Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 'Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed b+ed on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a ttpq approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:0��� %1 OF 1�JA v � i Passes ?. •• G Conditionally Passes P TRI ;m Needs Further Evaluation by the Local Approving Authority — M —+= X Fails Inspector's Signature. Date: 8/22/05 i4zFsINBPEG �`�� ��nnn unn�� 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: Tank and leaching pit full to top.Pit in hydraulic failure. System was not designed to accommodate extra flow and solids from garbage grinder,recommend removing or making provisions for grinder when new system is installed ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 24 Ironwood Road,Marstons Mills Owner: William Moretti Date of Inspection: August 22,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Titlra C fncnantinn Fnrm/.ii annnn 2 r Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 24 Ironwood Road,Marstons Mills Owner: William Fioretti Date of Inspection: August 22,2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Titla 4 Inon—tinn G'nrm Oil;mnnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 24 Ironwood Road,Marstons Mills Owner: William Fioretti Date of Inspection: August 22,2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No —X_ _ Backup of sewage into facility or system component due to 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 '/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 _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X— Any portion of 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 1 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. (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.l _Yes_(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 the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. T41..S 1ncnarf;nn Fnrm 4/1 ciInnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 24 Ironwood Road,Marstons Mills Owner: William Fioretti Date of Inspection: August 22,2005 Check if the following have been done.You must indicate"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_ Were any of the system components pumped out in the previous two weeks _X_ _ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] TWA C InonAntinn 5 Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 24 Ironwood Road, Marstons Mills Owner: William Moretti Date of Inspection: August 22,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2003—101,000 gal.2004—105,000 gal.=282 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Tank pumped two years ago. Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: 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) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): .Approximate age of all components,date installed(if known)and source of information: Compliance date: 3/1/84 Were sewage odors detected when arriving at the site(yes or no): No Ti41A C �ncnnnhinn Rnrm�ii c»nnn 6 I Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 Ironwood Road,Marstons Mills Owner: William Moretti Date of Inspection: August 22,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron X_40 PVC_other(explain): Distance from private water supply well or suction line: 30' Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 16" Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:8.5' long x 5.2'wide— 1000 gal. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Liquid level over top of outlet wipe and has been full to top.Tank too full to verify structural integrity of tank must be checked by installer at time of repair. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Titles C incnArtinn Fnrm�ii�i�nnn 7 f Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 Ironwood Road, Marstons Mills Owner: William Fioretti Date of Inspection: August 22,2005 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 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.): Box is full to top. PUMP CHAMBER: No (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.): Title G lncnor4inn Fnrm 611 ti')nnn 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 Ironwood Road,Marstons Mills Owner: William Fioretti Date of Inspection: August 22,2005 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: One 6x6 pit. leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Pit in hydraulic failure,effluent backing uD into d-box and tank. Probed area of leaching pit and found soils saturated. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): T41a f Inen—finn Rnrm ail;nnnn 9 a Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 Ironwood Road,Marstons Mills Owner: William Moretti Date of Inspection: August 22,2005 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. Ironwood Road Water service Driveway 26 23 41 #24 Garage 12 T;f1P 9 Tncnonr;nn I7^r All S IAM 10 Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 Ironwood Road,Marstons Mills Owner: William Fioretti Date of Inspection: August 22,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: A perc test will be performed prior to repair to determine groundwater elevation. Tit;. C T--t;n 17-411 VINW) I 1 e COMMONWEALTH OF TVIASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTEC ONE WINTER STREET, BOSTON MA 02108 (617) 292-55C Q5 s T, DY CON / to Secrets ARGEO PAUL CELLUCCI r0 DAVID�B. STRU' Governor �'3'O,o ,r9 4Co ' siot SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ORM �q� PART A 99 CERTIFICATION .� Name of Owner ` Property Address: •�t{ f�'ONw'c:OD GREGG �'�` � �• Address of Owner: Date of inspection: &-1yg5• Name of Inspector:(Please Print) eow,42D C, l?,gyS%-/ELQ I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: �aLr�IQ�C QC�Usi/ELF Marring Address: G,A W OOO 111E _1&4Nfxti t6q ME QQ-5-63 Telephone Number: 5071 r gggr 63:­% 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 ar.d 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 _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: � _ Date: �o The System Inspector shall submit 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 owne 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 f r revised 9/2/98 Paget of11 t $� Printed on Recycled Paper i' i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: RD►U(IUOOD Owner:GRRZ Date of Inspection:,�_�O-, 1 1 1 INSPECTION SUMMARY: Check(& B, C, o/ A 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: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes, no, or not determined(Y, N, or NO). Describe basis of determination in all instances. If "not determined",explain why not. _ 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). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ 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 1 Page2ofIt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:Jq .l post OCID Owner: 6R6('6 Date of Inspection: 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. 11 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 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 and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less well is free from pollution from that facility p 9 than-5 ppm. Method used to determine distance-- - (approximation not valid). 3) OTHER revised 9/2/M Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA PART A CERTIFICATION(continued) Property Address:uZ q ,7 90/V L V00.0 Owner: Date of Inspection: )Q_Rco 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 _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality y ualit analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for c oliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. I 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 the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public _ water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: q i Roti`iL'ecp Owner:6-R666 Date of Inspection:_ v jq7 Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. 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. As built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components, a have been located on the site. 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: Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)) Th6JEc5lity owner (and occupants, if different-from-owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1100AUDOD, Owner:VR � Date of Inspection: 0� I FLOW CONDITIONS RESIDENTIAL: Design g.p.d./bedroom. Number of bedrooms (design): Number of bedrooms(actual): 3 Total DESIGN flow 330 Number of current residents:Q Garbage grinder(yes or&):AV Laundry(separate system) (yes or /UO: If yes,separate inspection required Laundry system inspected ( es ors Seasonal use(yes or(9): Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or(000 Last date of occupancy: 7010tiP45 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present:(yes or no)_ Non-sanitary waste discharged to the Title 5 system:(yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last Cate of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: ,T �ic� �t c« t� �fiM INSPscrIo� System pumped as part of inspection: (yes or If yes, volume—*limped: gallons - Reason for pumping: 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: i / li/'S o�c/ ASC�JicT APPROXIMATE AGE of all components,date installed(if known)and source of information: Sewage odors detected.when arriving at the site: (yes or QI VV revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: a y _TRON(A 000 owner:6RE66 Date of Inspection: BUILDING SEWER: (Locate.on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK: (locate on site plan) Depth below grade:t5tU o Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age t1_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: ` ,,LX I�1n�1���1� 'S��'1 r1 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:1.-7(NcNS Scum thickness: Distance from top of scum to top of outlet tee or baffle: //l,'G/-15 ��C�s Distance from bottom of scum to bolt n of outlet tee or baffle: How dimensions were determined: / Hm me-MAC Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relatio to outlet invert, structural integrity, evidence of leakage,etc.) SCf�I(� ' NK '1 CCEf/ C0 pTse/RVSgC /a/lJ AX /,;L "T •rEE OiUCQETE 0t l GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (reconmendation 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.) revised 9/2/9.8 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) oWperty GI� GG '� Roru u;ooD Date of Inspection: TIGHT OR HOLDING TANK: II II II (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:)�, (locate on site plan) pp Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) O/PC /il/- 0,045r p/i� 00" PUMP CHAMBER:_ (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.) revised 9/2/98 Page 8of11 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:'�Ll T ft N wroo 9 Owner: 6 RC-VG Date of Inspection: -a it©Aqclo� SOIL ABSORPTION SYSTEM(SAS): ) (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits,number: Q&67 sik" F'OO r (c/cff pe r leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields,number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil condition of vI etation, etc.) unvio 'i vEl- NAS Atmoisr Ngl� FUEL CESSPOOLS:— (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool-must be pumped as part of inspection). . ......___. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:al}.T pn(ti017D Owner: GaeGG Date of Inspection: 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) i �3 a Yi 0 revised 9/2/98 Page 10 of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:• �L R�W��p Owner: GRCG& Date of Inspection:'a.��-� � NRCS Report name Soil Type_ Typical depth to groundwater _ USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells` Estimated Depth to Groundwater�© 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 Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2•/,98 Page 11of11 :LOX-AT: ®N SEWAGE PERMIT NO. -�0 YO-h wo J d I VILLA E ff/V INS'TA L.LE 'S rAME ADDRESS Y C f UIIDER OR OWNER DATE PERIMIT ISSUED DATE COMPLIANCE ISSUE-D 0 32 THE COMMONWEALTH OF MASSACHUSETTS -- BO H EALTT Appliratiun for Diapwial Worko Tonutrnrtiun Prruat Applica ' n is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ... r.w- , . • . - .--- ...... Locati. -- ;re �� or Lot No _......... ../li: � ........ ✓ /2 S ...............6•:: ........ ...' ..�..::.�.f ! .....f v.. W �� r Aess ...._....... ...... ... ......................•.................. Installer Address U Tyoe of Building Size Lot_2�7r.1.._..Sq. feet Dwelling—No. of Bedroom . .........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building r` J_F !4®No. of persons............................ Showers a g - -- - ----------------••-•-- --�• ( ) — Cafeteria ( ) dOth t res .............................. -•----------....----••---•-•----....-----------...... � ....Ions. W Design Flow.......: ..................................� gallons per person per day. Total daily flow............................................gal WSeptic Tank—Liquid capacityf gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width_.�_--............ Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No.___._.__.1..,....... Diameter......_ __j... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Lr, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................... ..-•--••-••-•--•••--•-----•.....................•-•--............................---------------•--........................................................... 0 Description of Soil........................................................................................................................................................................ x U •-•------•------•-----•••-••---••--•---•--••-•--•...................................•-•------.....-•-•------•-------....---.._..--•----•-----•-------•-•---•••------------.....-----•---•--------------- w .............. ....................••••-•----•....----...----•-----•---•-•-•-----•-------•-•---•--•----•-•-------------------•-•----•--•-•...•-----••--•--••----•----•-•-•-......----------------...... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•------•----.............---•--•-------•-----------..........---............--••-•------------------------------.......----•-----------------------------•------------•----• Agreement: The undersigned agrees to in al ��.or escribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the S atef Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee iss d by ned to t [oar o ealth. . ..� Application Approved eefollowing ---- -•..........:....•------•---....._.....-•--....................... .-- ... .C_. Date Application Disapprove reasons:---•--••---------------••-------•---•-----------------...-----•---------•--------•--------=--•-•--•---...------ ......................................•-•.........--•-------•---••---------•--•----...--•--............--•--•---•--------:f:-........................................................................... Date PermitNo......................................................... Issued......................................................... Date ............... THE COMMONWEALTH OF MASSACHUSETTS -- BOAR® HEALTH Appliration for Bhipwial Morkii Tomarnrtion Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at.p ...�--•�e Al GCjDC� �........... 'J /�'1'` �A r .......... ..-.�........................ .............................. ............. . ....................... � ...:5.......... Locatio dream ,,...-+� or Lot No r .��� rs- ... .._.. /... u.------ ---------------�Z --�..... .........�. T ( / ger A ess !���l /�. i/�lTf . I/� :................... ............ .................... ....................... -•-.. ......_-•••--................•...._ ..----...... -. PQ Installer Address Z" 7O / Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedroom, ..... .Expansion Attic Garbage Grinder ( ) aOther—Type of Building tl f. .?!'4!No. of persons............................ Showers ( ) — Cafeteria ( ) Oth t es ----------------------------•-------•--• . ----------------------------------•----•••....._. -- Q .................. . ....... wDesign Flow.......:...................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity`10q. alIons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width___. .j..__._._._ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----------/....... Diameter........ ..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+ -----------------------•-------------------•--•-•----------..........-----------•......----•-------..................................... .----- ................ ODescription of Soil........................................................................................................................................................................ x w UNature of Repairs or Alterations—Answer when applicable................................................................................................ ----------------------------•----------------------------------•-•-•---------------------------........--•-•-------.•--------•------•-•-----••••----•••----•-----....-••--••--------•--......-••--.••-•- Agreement: The undersigned agrees to instaI1_jbt_afbzedrscribed. Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the S`t to Sanitary Code-� The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss d by thlio d'M 1aealth. ,r igned. .............rY�T Application Approved By.._.. ---- ...... ..e='. ...........................•--- ---•,l -._� �..... Date Application Disapproved r e following reasons---------------•--•--------------•---------------------------...----------------•-•-------- - ------•---•---•---------------•••--•----•-••.........--------------•----•....-------•--................-- Date PermitNo....................................................•.. Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS _.B F HEALTH ........16W.0...........oF..........:.. CtAK)S(.0.. �. ............................ ,r� Tntifiratr of Tu pliantr T�I ....05 ERTIF That the In j V, l ewage Disposal System constructed ( or Repairedby- .--••• _. ------------------------------•-----......---•--•-•---..... .-----•• ---------..........------------ --------------- Installer has been installed in accordance with the provisions of TLT F 5 o�T79he State Sanitary Code s bed in the application for Disposal Works Construction Permit No. ' __-_ -,*�._ ..._.. dated..� _..: .._. .................. THE ISSUAN OF THIS CERTIFICATE SHALL NOT BE CONSTR S A GUARANTEE THAT THE SYSTEM WljdL F NCTION SATISFACTORY. DATE Inspector- nspector ---------•------•-------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No. - "' a ...........................................OF...................................................................--.,.............. 1/f FEE........................ unPertn mission ish "by granted---- -- ........... - ---- ----------------------------------•. --------...to Construct ( air ldual,Sewage isp stem atNo...--.---- ---- ,--••••---- --- ---.-- -- -----•--------•----------•....................•--•----------------................ S eet as shown on the application for Disposal Works Construction Permit No........... ated.......................................... L ................................ .... ---••--------------------•-••--------•--•-----•----.......... / Board of Health. DATEf• / --•-----•-•--------------------------•-- FORM 1255 A. M. SULKIN, INC., BOSTON ���►�G�L FA.Mk�`( LU1JDi'2 / / FI-ONM = I I o x 3 = 33oG t?o e� I� �jEpTIG TP�K = 33ox15o'/• = 497G.P I I woo o G At_. I G.O + i dip o�5Po5�� PIT V5C- J o BoTToti1 AQUA= . 50 5.t=._ 1- 0 II 'I OT A 1., p E 516N 2,4 5 G.P D. — ,l j -T oT Al,, p t>11-`( FLo w -:7 3 3o6.PQsc.� _ � rN o�1 E55� PE G_ 2Co�ArIoW A'TC : I'�Inl 2MIN I� 1r--' ,� 's L 7 ' / TALI% p� AZcA 0 of M� ,:'�r �P`1N F M,��y 1' cv RICHARD � f ALAN A. F W. BAXT[R H JONES o n LJ No.24048� p No. 25100 I2 O I 0�4wQd ��• �� I Q/S -S • 4I/D SURq 0 ' I I TOP FNbeCoo -r E`'-r f7. 000 ^ ' I 4N 4 S� IG � I3 DIST. INS. � EpT1G IOC I Z �XL TK ,( C, AN I UUU IN 4 ,I LCAGtI , INV. IHV. PIT SG•Z SG-d- ,o. II u/ITU i 3/i- l%. 5-ry i A E4 c . - �11�►7. � 1, —*) CE2TlFIGD PI-0T P�AP1 , . PRUFIL� I I'Z (.!o SCALE r7 GA L.E Ill GO 'PATE E szEN GE No rz � TF1 a.T 'f N E �n�IJDA.TI o�•1 5110 4YN c T Fy u .pSOW (2; 1& �-YS P WITNIH- ooD F S t+�11�1 IOE: A1.1c> 5'E'�'6Ac.IC rL6Rv� R.CMENY> Q ` -(o W►� o AR�1 ST�g ,ca N ►S �D7"' c)/STFJL �v s L.00NTED '1 lT ►tJ NE GL t I DATE�� �.� BAxTEcze IJ`(E INC t REG I SZ EQ6U'►.Au D'S u ?41i5 PLW4 WAS W0r 'd A osTE2VILLE- - (M�ASs .I Iu5'r- - . .. , Sv2\'EY -rNF ('F�TEUtjf; ,- APPLICAhJT Z►'�x 'T'S ,LTy TrL I DRIP EDGE OF SEPTIC SYSTEM PROFILE t SIDING RT 49 56.87t NOT TO SCALE NORTH BENCHMARK: TOP OF EXISTING 6" MAX SEPTIC TANK, EL 54.18 55.68 ADD RISER �6" MAX RT 28 0 T 56 EXISTS 9" MIN, 36" MAX 1.00' MIN, 3.00' MAX LEVEL 2' MIN s 1.17 RISER REQ'D 0.17 52.93 MIN 3" SEEDED TOPSOIL, 2% SLOPE 53.25 -_ UPEL p INFERRED 1.17 1 17 54.93 MAX 55.40t 0.93 2" PEASTONE Q p RI CE 53.01 0.25 52.76 _ 54.09t EXISTS 51.93 J O 0.8 4.00 1.17 --- __-- OVE 0.25 51.75 ti r----- -� : 50.'S6 Q fi$ coo 00 0 00 52.00 51.40 i a" b0�� Od 93 51.23 00 00 0 0 00 . rn 0.8 4.00 Sp.59 �•� ;<; <:. .- 3/4" TO 1-1/2" DOUBLE WASHED STONE I . A o0 000 C 49.00 6" GRAVEL ON NATIVE SOIL OR 51.00 47.91 NORTH EXISTING 1000 GALLON SEPTIC TANK `` '`' ' ""' `' '``' MECHANICALLY COMPACTED BASE 49.91 ST-1000-H-10 DISTRIBUTION BOX 24.75' x 4.83' 5.41 BAY DB-3 OR DB5 H-10 4.00 432 - ADD 1000 GALLON SEPTIC TANK IN SERIES WATER TEST TO 3-500 GAL LEACHING CHAMBERS INSPECT TEES AND REPLACE IF ST-1000-H-10 PROVE EQUAL FLOW BOTTOM OF TEST HOLE 43.59 LOCUS MAP EFE 2.75' x 12.83' x SOIL TEST PERC. 11122 NOT TO SCALE GENERAL NOTES DATE OF SOIL TEST 10-12-05 1) ALL WORKMANSHIP AND MATERIALS SHALL I Q \ C WITNESSED BY D CONFORM TO 310CMR15.00 THE STATE SOIL EVALUATOR TOR BERNARD J. YOUNG _ C PERCOLATION RATE <2 MIN. INCH. ENVIRONMENTAL CODE TITLE V: MINIMUM O REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF C OBSERVATION HOLE > SANITARY SEWAGE, AVAILABLE FROM STATE HOUSE 7 8 BOOKSTORE 1-617-727-2834, AND TOWN OF 2 RELOCATE TV CABLE ELEV.= 54.09 BARNSTABLE RULES AND REGULATIONS FOR THE ELEV. DEPTH HORIZ SOIL TEXTURE COLOR SUBSURFACE DISPOSAL OF SANITARY SEWAGE. 53.92 0-2 0 - - 2) CONTRACTOR SHALL VERIFY LOCATION OF EXISTING UTILITIES. CONTACT DIG-SAFE AND LOCAL 52.84`OR�I5 A SILTY CLAY LOAM 1 OYR54 WATER DEARTMENT 3 BU NAcE 51.09 16 136 Bw SILTY CLAY LOAM 1 OYR5/6 BE NNINGPCONSTRUCTION SINESS DAYS BEFORE O C - ,�iq ALTERNATE BENCHMARK: 3) CONTRACTOR RESPONSIBLE FOR OBTAINING I p 43.59 36-126 C GRAV. CRSE. SAN 10YR6/6 TOP OF CB EL 50.89 ADEQUATE HORIZONTAL AND VERTICAL CONTROL. F„ 4) CONTRACTOR SHALL VERIFY ALL PLUMBING \ C `^�` PERCOLATION TEST DONE AT A DEPTH OF 38 -50 FLOWS TO PROPOSED SEP11C TANK, AND SHALL PAVED �`, NO WATER ENCOUNTERED LOCATE ALL OTHER EXISTING SANITARY FACILITIES ON \ 32.75 PREMISES NO LONGER USED AND PUMP, AND FILL DRIVEWAY OR REMOVE SAME IN ACCORDANCE WITH LOCAL C 24.75 OBSER VA TION HOLE 2 REQUIREMENTS. N5) ALL COVERS OF SANITARY UNITS SHALL BE 1 ST#1 52 ELEV.= 56.40 BROUGHT TO WITHIN 6" OF FINISHED GRADE. ALL \ 35.64 ELEV. DEPTH HORIZ SOIL TEXTURE COLOR MASONRY UNITS TO BE MORTARED IN PLACE. ALL i \ 54.09 PVC PIPE TO BE SOLVENT WELDED. \\1 12.59 54.35 0-3 0 - - 6) UNLESS OTHERWISE SPECIFIED, EXISTING AND E 53.18 3-17 A SILTY CLAY LOAM 1OYR4/5 FINAL GRADES SHALL REMAIN ESSENTIALLY \ 2.83 51.76 17-34 Bw SILTY CLAY LOAM UNCHANGED. 10YR6/4 7 NO DETERMINATION HAS BEEN MADE AS TO O 44.60 34-120 C MED. CRSE. SAND 10YR6/8 COMPLIANCE WITH DEEDED OR ZONING RESTRICTIONS AND/OR REGULATIONS. OWNER/APPLICANT MUST oX G \ 4.00 PERCOLATION TEST BONE AT A DEPTH OF- 48"-60" OBTAIN SUCH DETERMINATION FROM APPROPRIATE 10.00 NO WATER ENCOUNTERED AUTHORITY. \ VA 8) EXCAVATE AND REMOVE UNSUITABLE MATERIAL BELOW THE LEACHING INVERT ELEVATION FOR 5' C NOTES: AROUND LEACHING SYSTEM AND REPLACE WITH \ Gfj CLEAN SAND, IF ENCOUNTERED. 4.00 1. LOCUS REF. DD. 12112 88; PL. 337 1 LOT 20 9) IF ANY DETAIL OF THIS PLAN IS NOT \ /A / / UNDERSTOOD, CONTACT DESIGN ENGINEER AT \ rV 54 432-6360. DWELLING 2. ASSESSOR'S M/P: 57/86 10) 48 HOUR NOTICE IS REQUIRED FOR ANY INSPECTION OR CERTIFICATION REQUIRED. 11) SITE LIES WITHIN FLOOD ZONE C AS SHOWN ON MAP 250001 0018 D DATED 07-02-92. G RESERVE 12) KEEP A BOARD OF HEALTH APPROVED COPY OF THIS PLAN ON JOB SITE DURING CONSTRUCTION.. AS-BUILT ELEVATONS IN BOLD RED MADE, ��aW- 5 60 � - I Do WOOD ST 2 , 56 DECK 56.40 Ne f EXISITING PIT TO BE ABANDONED PER STATE APPROVAL E , AND LOCAL REQUIREMENTS ADD 1000 GS Date DESCRIPTION Drawn Checked EXISTING 1000 GST IN SERIES R E U I S I 0 N S TO BE RETAINED 2'3 2s DESIGN CALCULATIONS SEPTIC SYSTEM REPAIR DESIGN CLEANOUT, TYP. SITE PLAN PREPARED 56 NUMBER OF BEDROOMS 4 FROM TOWN GIS DATA GARBAGE DISPOSAL UNIT NOT ALLOWED PROPOSED AT 56 AND INSTRUMENT DESIGN FLOW SURVEY 4 BEDROOMS x 110 GAL/(BR-DA)=440 GPD. 24 IRONWOOD RD REQUIRED SEPTIC TANK CAPACITY 1500 GAL (MIN), ACTUAL SEPTIC TANK CAPACITY 1500 GAL IIN LEACHING AREA REQUIREMENTS BED BED DR --BOTTOM 0.74 GAL/(SF-DA) M AR STON S MILLS 56 --SIDE 0.74 GAL/(SF-DA) LEACHING CAPACITY SCALE: NOTED DATE: OCT 13, 2005 ((32.75'x12.83') + 2x(32.75'+12.83')x2') x0.74 GALASF-DAY)= 445 GPD RESERVE 445 GPD LA BARGE I GAR KIT ENGINEERING & CONTRACTING,INC. BED BATH BED LR 237 MAIN ST. -ROUTE 28 SITE PLAN WEST HARWICH,MA 02671 BATH � „ 20y 508 432-6360 SECOND FLOOR FLOOR PLAN (NTS) FIRST FLOOR 10 0 10 20 30 DRAWN BY: BJY CHECKED BY: TAIL SHEET 1 OF 1 s T- - - - - - -- -------- _ - _ --- --- - I it i i I I