HomeMy WebLinkAbout0041 KNOWLTON LANE - Health i
i
41 Knowlton Lane j
\ Marstons Mills,
A=,J 03-092-001
TOWN OF$fU�NSTA,BLE
S-WAG ELOCAIFION
s JV` A+SSFSSOIt'S.M.4 'Si
V3LLACyC
I TNSTA7.L 'S t�tAl JPQC3ME No 1
SIEF'll"C 'X' Tk CA-P�':F�CT't"Y
�"• (sae) � � � ; .
LGAtiCkIT1+iG FACILrry.
I dT�AM ..-r—
'
Maxi►numAcl]usercl Gtauttclwatet'l'nbteta rise 13crttorn ufl.eac:htng l��iriUty .m.0 W C�4'
Pv1r�a4e w' *F Suoply V14H wid Lc4ohlno�?aciltly .�sty Vi.It chlsti �7rcrae
as to li Alhin 200 feet of lan tiirig frtciUty)
lacl�ris cy� �Vel�at�t9 aid l.eacittn���cll6¢y{f any vellau&exasf
iAdlin�00 feat, f enalyg Puck
�urlblshC(9 try vG
b z e-
o
Q Ir 'I
r
03 b
3y-
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
x
a'- 41 Knowlton Ln --C
Property Address
Barbara Young
Owler Owner's Name / D
information is required for every Marstons Mills �/ MA 02648 4-30-IIL
page. City/Town State Zip Code Date of WApection
W
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.
A. General Information
1. Inspector:
Shawn Mcelroy `
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S 13971
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
4-30-16
Inspector's Signature Date
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 under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
40* 9
Commonwealth of Massachusetts ,
Title 5 Official Inspection- Form a
a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Knowlton Ln
Property,,Address
Barbara Young
Owner Owner!sflame
information is required for every Marstins Mills MA 02648 4-30-16
page. City/Town 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:
System is in good working order with no sign of failure. Recommend pumping septic tank and leach
pit annually for maintenance and to prolong life.
13) System Conditionally Passes:
❑ one or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes "no"or"not determined"�(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Knowlton Ln
Property Address
Barbara Young
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-30-16`
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired. .
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts -
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 41 Knowlton Ln
Property Address
Barbara Young
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-30-16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank 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
4 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 Y2 day flow
t5ins-3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M °F 41 Knowlton Ln
Property Address
Barbara Young
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-30-16
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 dogged 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
R 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
❑ ❑ 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts ,
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
41 Knowlton Ln
Property Address
Barbara Young
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-30-16
page. City/Town 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): 3 Number of bedrooms(actual). 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Knowlton Ln
Property Address
Barbara Young
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-30-16
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail
Sump pump? El YesYes ® No
Last date of occupancy: Date
I� Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
41 Knowlton Ln
Property Address
Barbara Young
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-30-16
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: N/A
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 I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 41 Knowlton Ln
Property Address
Barbara Young
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 4-30-16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cant.)
Approximate age of all components, date installed (f known) and source of information:
1980's
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 30"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.):
Good condition.
Septic Tank(locate on site plan):
Depth'below grade: 24"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
N
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
12"
t5ins^3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments
41 Knowlton Ln
Property Address
Barbara Young
Owner Owner's Name
information i e
required for every Marstons Mills MA 02648 4-30-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
• F
Septic Tank(cont.) r ,
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness a
3"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? Tape
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date'
t5ins-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
v u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Knowlton Ln
Property Address
P Y
Barbara Young
Ovmer Owner's Name
information is recuired for every Marstons Mills MA 02648 4-30-16
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•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 41 Knowlton Ln
Property Address
Barbara Young
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-30-16
page.. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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.):
Good condition with water at working level and no sign of back-up from pit.
III
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.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal:System Form=Not for Voluntary Assessments
41 Knowlton Ln
Property Address
Barbara Young
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-30-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-1GOO gat
❑ 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.):
Leach pit in good condition and holding water at 18" below inlet invert with no other stain lines.
Recommend pumping annually to prolong life.
�I
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
c�M 41 Knowlton Ln
Property Address
Barbara Young
Owner Owner's Name
information is Marstons Mills MA 02648 4-30-16
required for every
page. Cityfrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 41 Knowlton Ln
Property Address
Barbara Young
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-30-16
page. City/Town 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
0
i
io _�96 6- 03
97
/ny _ 3 c,,
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
I
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 41 Knowlton Ln
Property Address
Barbara Young
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-30-16 '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water ,
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20'+
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:
USGS and town maps show groundwater at greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 41 Knowlton Ln
Property Address
Barbara Young
Owner Owner's Name
information is requi-ed for every Marstons Mills MA 02648 4-30-16
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Z Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
.s
TOWN OF BARNSTABLE
LOCATION 4 S C SEWAGE #
VILLAGE Moys-6-►"as M, )Ls ASSESSOR'S MAP & LOT /-0 %�
INSTALLER'S NAME & PHONE NO. /�jtl
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)
�+? NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER ��f��/1,.4 f / o�✓ _ 5
DATE PERMIT ISSUED:
DATE .COMPLIANCE ISSUED: I
VARIANCE GRANTED: Yes
p
� D
�_ �;�
f� - ys y . .
� si��'"
�=s���
D-a���r_
�:.�s��j
;= ��:5
'AR CEL NO...
NOA�-----��-? Fimic l......_...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ® HEALTH
r���✓ oF............
Allp irtatiou for Uiipu.i al .irk Tomitrnrtiun Famit
Application is here made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal
System at:
......... .............--•-•........................... •---••--_--- --- .........
..
Location-A r ss No.
-----� . -_�. 1� .......... .........
" Ownez / ss i
t-a Insta er j �iC^���^�' � �`• Add 7-
V O ��
d Type of Building sizeot.. •• ......Sq. feet
U g— .Expansion Attic ( ) Garbage Grinder ( )
Dwelling No. of Bedrooms.................�______.______.._..
'k Other—T e of Building No. of persons..................> _--,__ Showers — Cafeteria
d Other fixtures ----------------------------------------------------------•••--•-••......-• = ;
•.
W Design Flow................_----_----•------_..--•_-gallons per person per day. Total daily flow.....................sue-.................gallons.
1:4 Septic Tank—Liquid capacity../010..gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench—No....................• Width.............._..... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
a
Percolation Test Results Performed by...................10W '41 ... d s � .... Date______ ._. " _..
Test Pit No. 1 ....__.minutes per inch Depth of Test it.................... Depth to ground water-_______________.__--_-.
Test Pit No. 2�1!___-------minutes per inch Depth of Test Pit.................... Depth to ground water.......................
O -t ��'� � F --------------------------------•-----------........_-----
Description of Soil--------•-----•-------------------------------- .-•----........_....
..- --
i
W -----•-------------------------- •-•---•••-•----•-•...•••-•---------••----------._...•-•----------•---•---------•-•...._.._.....---••--•-----•-•-•-•-•••......••••=...................................
UNature 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 iTT i.. '�of the State Sanitary Code—The undersigned furti:er agrees not to place the system in
operation until a Certificate of Compliance has been issued by t oM�w
p
Signed............. .......... ••••......-• ------. -•��
�� ......
Dat
Application Approved BY --------------- --------------•------••---•-•-
----
Date
Application Disapproved for the following ksons:--••---•..................................•---------•--•--------••••-••--••--••---•-•-......Da-••••--•-------
-..................................................................................................................................................-----------------..................................
Permit No...1.611-7............................ Issued..........................................Date_ ........
Date
Date
No.0....-----.... • Fes$ ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O-F HEALTH
................OF......... ✓fit. ia............................................
Appliratiuu for Biipusal VvOs Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct k) or Repair ( ) an Individual Sewage Disposal
System at:
............I -�_..�?.--- -��h,,'.:��_P..- � .. .�...�.....�- -' ---- ....-•---..
c
.. ._y ... ...................... ..._......_ _. ..._. ._....
Location-Address ✓ or Lot No
Owner
A'dd�ess
Installer �+ Ad s
Type of Building , Si- Lot f�.-. —3........Sq. feet
U Dwelling—No. of Bedrooms.................__............_......Expansion Attic ( ) Garbage Grinder ( ;1
'4 Other—Type of Builditl No. of persons____________________________ Showers — Cafeteria
QIg Other fixtures ----------••---g-•--•---•• -•-• ---•-----. .......- ......-•----•--•--. .............................••� ......------..�.....c
d -
W Design Flow............................................gallons per person per day. Total dailyflow..................... __ ......__gallons.
9 Septic Tank—Liquid*capacity./91h ._gallons Length................ Width................ Diameter-----------�;Y.. Depth........__......
Disposal Trench—No--------------------- Width.................... Total Length.................... Total leaching area.............:------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-' Percolation Test Results Performed by..................4��! __ . �_&;? ...............4 l
. ............. Date /
Test Pit No. lft'�;=---------minutes per inch Depth of Test Pit.................... Depth to ground water.._.....................
gZ Test Pit No. 2 :."........minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of Soil------------------------------------------ =— .
W
UNature of Repairs or Alterations—Answer when applicable__---•-----------------------------------------------------------------------------------------
------------------------------------------------------------
Agreement:
The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance wits
the provisions of i T_'=l.
p 5 or the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu d by the.board pf health.
(./ -r✓C.� Signed........... ....:,ll.!...........- ............ .--------------------- ------. .---.... ..
Da
Application Approved BY........d ................................................ ....-�••'-•• :_..
Date
Application Disapproved for the following easons---------------------------------------------------------------------------------------------------------------
.................................•----------------------------------------....---------...........------.--••-•-•--•-•--•-•--•-•-•---•-••-••-----•--•---------••--•-•••••-----•-----------•••-•--•-_..._
1j.1
DatePermit No.. ••6-- ............................. Issued...........................................Dat-....---
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Of HEALTH
.. OF.......d'-�i �M��1 t............................... ............. .................
�ntif iratr of f�unt��i�anrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed� or Repaired ( }
b -�'',,�'*r-• ': =-.R- ...Y ice =------ . ' �4 r:.g '`,�t ,-- ---------------------•------------------------------.....-------------------------------
---
Install
at /t /..----�- �.....�.= - -- --.. ; ----- / ----------------------------------------
,r
has been installed in accordance with the provisions of TIE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. . .: . . ............... dated_... __-._7.J._.-. ...........
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............ ...-. ..,1� . ................................. Inspector..-4r.,__.. ----_---------------.--•-------
Io �, THE COMMONWEALTH OF MASSACHUSETTS
C)4 BOARD OF HEALTH
1V0 .L.........!........ FEE......1 t-.. .........
Disposal Works 01 MI
Permission is hereby granted...... -
to Construct. ) or Repair ) an Indivi.ual ,Sewage Disposal System
atI�'o. W_�-�•.r_"----_-----�=L----------- ..........................................
Str G_
as shown on the application for Disposal Works Construction ermit tNo.___._._ ..__�� ated----------/.... ..��...� ...
........A.�.. ...... s= ------------------------------------•-
(ta�Z 9 Board of Health
DATE. --•--- -•--•-•-•--•-•---•---•------•--•--•--••-•---
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
r
Ily
�DHed l2 .F. _
/ o Fro•, acti t
r
Oil
• p uilbti ��
.
ov
k IN
-
o- � �� 2 yi 0
6 i
;(' SOIL
sop
z
r/ LCAC '
7 ` p,r
g6
V
t 4 DAVID P. Gr
\ MARIANO
CIVIL93
'
No.31115.0
aC\)
01
1 L `tN or iw
PauL.a
r
` LEVY
8b
0
r
e N . 10617
ry
ys 3s3tS.f o 7
LEGEND
EXISTING SPOT"ELEVATION Ox0 �
11�-XISTINO CONTOUR ——— 0 -- - CERTIFIED PLOT PLAN.
FINISHED SPOT ELEVATION
FINISHED CONTOUR --- 0 GD`� (� /S1400140h La ht
NPTE: The location of any existing undo_ �rg;•ound sewerage, IN
wells, or other utilities showli on this plan is approx-
i6ate only as determined from records andjor verbal
information. The contractor is responsible for the
verification of the existing locations in the field. SCALE, "L4�d DATE 12 6�4 -
SLEVY & ELDREDGE ASSOCIATES, INC. CLIENT.L�;c.kw/ I CERTIFY THAT THE PROPOSED '..
ENGINEERS-LANDSCAPE ARCHITECTS JOB NO.
1033 BUILDING SHOWN. ON . THIS PLAN
PLANNERS-LAND SURVEYORS �7-� CONFORMS TO THE' ZONING LAWS"
DR.BY .___-- OF M A S
712 MAIN STREET CH. BYE :; ;
NYANNIS, MAgS. gHEET OF 2 A E . ' L NU SURVEY R:c
'`t r tc�� ,1 .a ly .� .�;.e F �r;. L 3 � h: Y t . ,�': •y
...` • ..
?D FT MIN N07E /F E/T.NCR TN�,'�'.SEPT/C TAN/C...OR ` e
LEi4Cl//NG. .P/T' AAE', : `�G+RE . TIIA'/'/'/2' BEL0.1t/'
>. JRAOE• ,A.24',0/AM ET1rR: CO/yG'R ETA. COVER
— sNALC•ETF aROuGNT. -r'Ol 6RA OAr �AN EXTRA, 4'
CONC#4C'Td. 4'PYC PIPE /yE.4Yy'CAST:/RO/Y COVER SHALL ,ac 41SEL0AlIM—PI I.
�( �`F1S•� = CH
LOVERS /B PF,QTFT /F/N.' OR/VEyti,4Y'
2 JJ, MAN. CD/VCR TE
A o - GhnoE \ CO V.ER CL EA/V SANG
.. BAC/CF/LL
� LQ[/TD LEVEL - •�' . .•„
• •' ZLAYER.
4s`± 4'CAST .:e qF 8 -•Y/8•
IRON P'/PE '/h O O GAL. • • • • • • . • • • e • a, I
='0 M/N.P/TCIII p/ST. 4 WASHEO S7?�NE
I4•PER J'?. SEPTIC TANK ,-• • • • i e a !
qo)e • • • • e • • • • • .•• •. I
�af/. • •� / 1• M
'el
>x.' s .f • •.ty •,!EFFECT/VC f. •; 3 4
r • • •• D�PTh/ ' • • ;II WAS//EO STONE
=-• /sl X z,s : 3 stir s ���r • . � . . . . . , ,
�:1:� . • 1 1 400 a .
Ili r i,o = ► 13,U. • e i • � • . • • • • • i p •�o P�r"EG45 T SEE'PAGE'
lNYG t o y OR EQU/V.
'T e4RV1T/oN5 PITCAr�eT Y: 'oO.S GAS I/ Y ���� �
: .
INYERT AT QU/LD/NG " FT,
y FT OIA/y. I C SEE TABI/"rJOAV)
INLBT .SEPTIC TANK �'O Jar
OUTLET SEPTIC •TANK *4 FT. --1—
INLET D/STR/6l/T/ON BOX 1�Z FT. SECT/-ON OF GROUND W,ITER TABLE
OdTLETDJSTR/BIIT/ON sox 1)7. FT,
/NLET LEACHING PIT `/ Fr. SEWAGE /.'�POSA L SYSTEM 7ABUl-AT/D/V
L EACf!/NG P/T
SCALE /.s ' DJMEN.S/OW A FT.
D.ES/G/V CRITERI�I I - o 10/NX—Ns/oAJ 8�_FT.
/VUIHOER OF 6EDRaOMS 3 D/HENS/OiJ �i �_FT.
G'AReAGE DISPOSAL- UN/T ,VoN� SOIL LOG .SD/L TEST
TOTAL E.?T/hY�TEb FLOW :U0 GAL./DAY SO/L TEST`*/ SOIL TZ ST,*,E
NUM8E4e OF 4eACKIN6 P/rs l r-FLEK Y -EL]si! ,DATE OF SOIL TEST S 2 z/fsG
S/OE ACHING PER P/T/„L iso RESULTS tdlV&
BOTTOM LEaaiCN/NG PER P/T I/3 so. Ar Z� Peet COLAT/ON RAT,� JNCH
/ Z-- MIN
TOTAL LEACHING AREA uOy SQ• fT, t. hCOLAT/ON RA7�=/ 2 MJN.�INCH
RESERVE LEACHING AREA ` 4 SQ. FT.
III OF M�e� r r So•
oa' DAVID P. S
08 av1AR1AN0 � ! L o`f" 6
CIVIL
` 9o�No.31115
F�., T LEVY & ELDREDGE ASSOCIATES', INC.
_(2.2 7/Z "A/N ST. p i/Y•QNNiS. MASS, A
_, __._(. ```�ti V. ® NO 6�gQiJ1JJ yVi4TCR trNCOtJ/VTEREo L'L/ENT:, 6
fr
O.