HomeMy WebLinkAbout0111 KNOWLTON LANE - Health 1C1.1 KNOWLTON�LANE 914 MARSTONS MILLS
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\i�lis� COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5 -�
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY AS ESSMNT
SUBSURFACE SEWAGE DISPOSAL SYSTEM FO
PART A r
CERTIFICATION
Property Address: III Knowlton Lane
Marston Mills. MA 02648
Owner's Name: Deborah Cullen �� l
Owners Address:
Date of Inspection: October 27. 2005
Name of Inspector:(Please Print) James M. Ford
Company Name: James M. Ford
Mailing,Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
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 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
Need Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: October 31, 2005.
The system inspector shall sub 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
g.pd or greater,the inspector and the.system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
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Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: III Knowlton Lane
Marstons Mills. MA
Owner: Deborah Cullen
Date of Inspection: October 27, 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:
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Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: III Knowlton Lane
Marstons Mills, MA
Owner: Deborah Cullen
Date of Inspection: October 27, 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 CAM 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
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:
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Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: III Knowlton Lane
Marstons Mills.MA
Owner: Deborah Cullen
Date of Inspection: October 27, 2005
D. System Failure Criteria applicable to all systems:.
You must indicate either"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
✓ 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 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.]
No (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 tc determine what will be necessary to correct the failure.
E. Large System:
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 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
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Page 5 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: III Knowlton Lane
Marstons Mills, AM
Owner: Deborah Cullen
Date of Inspection: October 27, 2005
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:
Yes No
✓ 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(3)(b)].
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Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: III Knowlton Lane
Marston Mills. MA
Owner: Deborah Cullen
Date of Inspection: October 27, 2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 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: I
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): end
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
',ource of information: The tank was pumped after the inspection for maintenance
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
✓ 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:
Repair done on 5111198-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
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Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: III Knowlton Lane
Marstons Mills. MA
Owner: Deborah Cullen
Date of Inspection: October 27, 2005
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 18"
Material of construction: ✓ 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: 1500 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 10"
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: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Cement tees were present. The liquid level was even with the outlet invert There did not appear to be anv signs of leaka eg_
The tank was pumped after the inspection for maintenance
GREASE TRAP: None (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 recormnendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
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Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: III Knowlton Lane
Marstons Mills. MA
Owner: Deborah Cullen
Date of Inspection: October 27. 2005
TIGHT or HOLDING TANK: None (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: ✓ (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 D-box was level. No solids were present.
PUMP CHAMBER: None (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.):
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` Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART C
SYSTEM INFORMATION(continued)
Property Address: III Knowlton Lane
Marston Mills. MA
Owner: Deborah Cullen
Date of Inspection: October 27,*2005
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
✓ leaching chambers,number: 4-H-20 maximizers(per as built card)
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.):
The Ieachinz chambers had 2"ofliguid on the bottom. The scum line was at the same level There did not appear to be anv signs
of failure. A video came;a was used to inspect the chambers.
CESSPOOLS: None (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 conditicn of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
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Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: III Knowlton Lane
Marstons Mills. MA
Owner: Deborah Cullen
Date of Inspection: October 27, 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.
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y Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 111 Knowlton Lane
Marstons Mills, MA
Owner: Deborah Cullen
Date of Inspection: October 27, 2005
SITE EXAM
S lope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30+/- feet
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: topographic and water contours map_
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topogrgphic and water contours maps the maps were showing approximately 30'+/-to ground water at this
site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report.
11
LTOWN /OF BARNSTABLE
LOCATION �I �/1 V�^/�7 U/� //-/A SEWAGE# Ci
rF II
VILLAGE _4AS ASSESSOR'S MAP & LOT r'( —
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type). 7 MgXt s — �'1'a 0 (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: 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 leachin facility) J Feet
Furnished by �SpCUg J �OIG
AGAr�jt (.. Auk ,
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TOWN OF BARNSTABLE a L
LOCATION,/// ®` 1,A SEWAGE # 91-zoZZ
'hLLAGE ASSESSOR'S MAP & LOT I Q 1r L9
INSTALLER'S NAME&PHONE NO. 17d- R 7
SEPTIC TANK CAPACITY LEACHING FACILITY: (type)� -� ' '" `G (size),&
NO.OF BEDROOMS
BUILDER OR OWNER J 6
PERMUDATE:!9 -16 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of/Leachinglity Feet
Private Water Supply Welland Leaching Facility (Ifaon site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetland
within 300 feet of leaching facility) Feet
Furnished by
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13 z yC
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No. 7✓ j a Fee 50. 00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓✓
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for Migpoga[ *pgtem Congtrurtion Permit
Application for a Permit to Construct( )Repair(x 4 Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 111 Knowlton Lane Owner's Name,Address and Tel.No. Joseph Wojtkowsk
Assessor'sMap/Parcel Marstons Mills 99 Woodland Drive
16rZ - Z Athol, MA 01331
Installer's Name,Address,and Tel.No. 7 7 5—8 77 6 Designer's Name,Address and Tel.No.
W E Robinson Septic Service
PO Box 1089 , Centerville, MA 0263
Type of Building:
Dwelling No.of Bedrooms 3/4 Lot Size sq.ft. Garbage Grinder( nd
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic System consisting
of 1500g tank, D—box, and four stonepacked maximizers.
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 issue by thi o of Healt
Signed Date
Application Approved by r Date _j6
Application Disapproved for the following reasons
Permit No. 2 Z Date Issued ��—�
TOWN OF BARNSTABLE
s `LOCATION/& ��►'° �b� �A SEWAGE#
VILLAGE ��• ��N/' ��S ASSESSOR'S MAP & LOT I - Z
INSTALLER'S NAME&PHONE NO. 6�1
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)S'7�p �i► (size)/� F.
NO.OF BEDROOMS .
BUILDER OR OWNER• '�°L/
PERMITDATE: S/^I COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching cility Feet
Private Water Supply Welland Leaching Facility (If any we exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands a st
within 300 feet of leaching facility) Feet
Furnished by
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��D �' °!9
No. - 2 si: f Fee$5 0. DO
Entered in computer: ✓
THE COMMONWEALTH OF MASSACHUSETTS p
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS =
ZIpprication for 0i!5poga1 *proem Construction Verin,,it a
Application for a Permit to Construct( ) �$Upgrade Repair X U Abandon p ( pg ( ) ( ) ❑Complete System ❑Individual Components
} Location Address or Lot No. -1 1 1 Knowlton Lane Owner's Name,Address and Tel.No. Joseph Wo j tkowsk
Assessor'sMap/Parcel Marstons Mills 99 Woodland Drive
l4'2 - Z Athol, MA 01331
Installer's Name,Address,and Tel.No. 7 7 5_8 7 7 6 Designer's Name,Address and Tel.No.
W E Robinson Septic Service .
PO Box 1089, Centerville, MA 0263
Type of Building:
Dwelling No.of Bedrooms 3/4 Lot Size sq.ft. Garbage Grinder( nd
Other Type of Building No4Af Pt onq
a Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date- Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic System consisting
of 1500g 'tank# D-box, and four stonepacked maximizers.
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 A of Healt /
i, Signed Yi ° Date
Application Approved by - Date -�V_/e " P
Application Disapproved./for the following reasons
t
Permit No. Z Z / Date Issued
H �COMMONWEALT .O,f MASSACHUSETTS �j� �„G V
Wo j tkowski B`lo(RNSTAB E, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired (Kx Upgraded( )
Abandoned( )by
at 111 Knowlton Ln, Marstons Mills, MA has been constr to in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. "Z 2 dated //—/�,'sCl
Installer WE Robinson Septic Service Designer I . r
The issuance of this permit shall not be construed as a guarantee that the system fu ction as designed//
Date C11-1? Inspector
No. Gj --------------------------Fee _ $50.00
¢- THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Wojtkowski wligogal 664e(Co—ngtruction Vermtt
Permission is hereby granted to Construct( )Repair PM Upgrade( )Abandon( )
System located at 111 Knowlton Lane
Marstons Mills
Installer: W R Robinson Septic Service
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her ifuty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must
be completed within three years of the date of thi nit.
Date: �d`//' Approved by
1
NOTICE: This Form Is To Ife Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I, William E. Robinson, Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated Y-16- g concerning the
property located at 111 Knowlton Lane, Marstons Mills, meets all of the
following criteria:
* There are no wetlands within 100 feet of the proposed leaching facility.
* There are no private wells within 150 feet of the proposed septic system.
* There is no increase in flow and/or change in use proposed.
* There are no variances requested or needed.
* If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the
proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) / U ► ��
B)Observed Groundwater Table Evaluation(according to Health Division well map)
SIGNED: A DATE
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
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O�IKE Town of Barnstable
=' an8tvgrast.�,
Department of Health, Safety, and Environmental Services
' 9. r Public Health Division
�E0N1"�A P.O. Box 534, Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
April 10, 1998
Mr. Bernard and Deborah Cullen
Newsherburn Rd.
Athol, MA 01331
RE: Property at 111 Knowlton Ln., Marstons Mills
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located at 111 Knowlton Lane, Marstons Mills was
inspected on April 2, 1998 by John Graci, a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system•has failed urider"the '
idelines of 1995 TITLE 5 310 CMR 15:00 due to`the followiri '
•Discharge or ponding of effluent to the surface of the ground or surface waters due
to an overloaded or clogged cesspool
You are directed to hire a licensed Town of Barnstable septic system installer to submit a
sketch diagram of a proposed system to the Town of Barnstable Health Division Office
(Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance
with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of
receipt of this notice.
You are also directed to bring the septic system into compliance within thirty(30) days of
receipt of this order letter.
You are further directed to maintain the system by hiring"a licensed septage hauler to
pump the septic system to prevent discharge of sewage Or-eflluent into the'buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF T BOARD OF HEALTH
omas A. McKean, R.S., C.H.O.
Agent of the Board of Health
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FIRST NOTICE
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RETUF�'Y:D _
d SENDER:
■Complete items 1 and/or 2 for additional services. I also wish to receive the
�+ ■Complete items 3,4a,and 4b. following services(for an
a► ■Print your name and address on the reverse of this form so that we can return this extra fee)'
card to you. 8
■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address
permit.
Sd ■W nte'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery N■The Return Receipt will show to whom the article was delivered and the date
C delivered. Consult postmaster for fee.
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3.Article Addressed to: 4a.Article Number
be �� a � Q Z ZD3 1/Q8 5GD
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z 5.Received By: (Print Name) 8.Addressee's Address(Only if requested I ,
LU¢ and fee is paid) r
6.Signature:(Addressee or Agent)
PS Form 3811, December 1994 102595-97-B-017s 'Domestic Return Receipt I
VEA Town of Barnstable
.� Department of Health, Safety, and Environmental Services
Public Health Division
�Fva 367 Main Street, Hyannis MA 02601
Office: 508-790-6265 Thomas A McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
TO: &YA�rk CJ
r oac DATE:
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located was
inspected on _P� ( 2�� S$ by A arc; , a Massachusetts licensed
septic inspector. -
The inspection of your septic system showed that your system has failed under the
guid roes of 1995 TITLE 5 (310 qMR 15.00) due to t lowing:
AU
4 o�a
Or ti�¢ PI�nTn o t
You are directed to hire a licensed Town of Barnstable septic system installer to submit a
sketch diagram of a proposed system to the Town of Barnstable Health Division Office
(Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance
with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of
receipt of this notice.
You are also directed to bring the septic system into compliance within thirty (30) days of
receipt of this order letter.
Y are further directed to maintain the system by hiring a licensed septage hauler to
You y
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean,R.S., C.H.O.
Agent of the Board of Health
vmm�rinWuu.a�
SIN
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
John Gt-aci
One winter Street,Boston,Ma. 02108
D.E.P. Title V Septic Inspector
P.O. Box 2119
ef Teaticket, MA 02536
WILLIAM F.WELD (508)564-6813
Governor
ARGEO PAUL CELLUCCI
Lt.Governor X&ARZ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
PART A
CERTIFICATION &
tp j9,9
Property Address: 111 Knowlton Ln.Marstons Mills Lot 4 Address of Owner:
Date of Inspection: 3/25198 (if different)
Name of Inspector: John Graci Bernard and Deborah Cullen:New her"um,Rd.Athol MA 01331
li am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number: =
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes This Inspection Is based on criteria defined In Title V
_ Conditionally Passes code 310 CMR 16.303.My findings are of how the system is
performing at the time of the inspection.My Inspection does
_ Needs FuOlther Evaluation By the Local Approving Authority not Imply any warranty or guarantee ofthelongevgyofthe
X Fails septic system and any of Its components useful life.
Inspector's Signature: Date: 412199
The Sys-em Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
I
One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair,passes inspection.
Indicate yes,no,or not determined(Y, N, or ND). 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 conforming septic tank
as approved by the Board of Health.
(revised 04127197)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 a Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 111 Knowlton Ln.Marstons Mills Lot 4
Owner: Bernard and Deborah Cullen:Newsherburn Rd.Athol MA 01331
Date of Inspection:3125199
_ Sew.aue backup or.breakout or hioh.static water level observed.in.the distribution box is due to a broken.
orobstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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 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 APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Cther
D] SYSTEM FAILS:
You must Indicate either"Yes"or"No"as to each of the following:
x I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
_ -X_ Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
x — Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
x_ SAS is in hydraulic failure.
{revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 111 Knowlton Ln.Marstons Mills Lot4
Owner: Bernard and Deborah Cullen:Newsherburn Rd.Athol MA 01331
Date of Inspection:3125199
D]SYSTEM FAILS(continued)
Yes No
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
— Numbers of times pumped
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
—X. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
x Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
_ x the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone it of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 111 Knowlton Ln.Marstons Mills Lot 4
Owner: Bernard and Deborah Cullen:Newsherburn Rd.Athol MA 01331
Date of Inspection:3125199
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
,c_ — Pumping information was requested of the owner,occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
— flow rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this
inspection.
x — As built plans have been obtained and examined. Note if they are not available with NIA.
x — The facility or dwelling was inspected for signs of sewage back-up.
x The system does not receive non-sanitary or industrial waste flow.
—x— — The site was inspected for signs of breakout.
x All system components,excluding the Soil Absorption System,have been located on the site.
x The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected
for condition of baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge,depth of scum.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
— — unacceptable)[15.302(3)(b)]
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 111 Knowlton Ln.Marstons Mills Lot4
Owner: Bernard and Deborah Cullen:Newsherburn Rd.Athol MA 01331
Date of Inspection:3125199
FLOW CONDITIONS
RESIDENTIAL: d/bedroom for S.A.S.
Design flow: 330
g p
Number of bedrooms: 3
Number of current residents: 4
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL:
Type of establishment: nia
Design blow:o gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: Ne
Last date of occupancy: n1a
OTHER:(Describe) rda
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
rtla
System pumped as part of inspection:(yes or no)No
If yes,volume pumped:o gallons
Reason for pumping: rda
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool ,
Privy
Shared system(yes or no) ( if yes,attach previous inspection records,if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components,date Installed(if known)and source Information:
1986
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04)27197)
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 111 Knowlton Ln.Marstons Mills Lot 4
Owner: Bernard and Deborah Cullen:Newsherburn Rd.Athol MA 01331
Date of Inspection:3125199
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 2'
Material iof construction:x concreate_metal_FRP_Polyethylene—other(explain)
If tank is metal, list age nla . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: Les"H57^w4'l0^
Sludge depth:9"
Distance:from top of sludge to bottom of outlet tee or baffle: 19"
Scum thickness:"
Distance from top of scum to top of outlet tee or baffle:5"
Distance form bottom of scum to bottom of outlet tee or baffle:5"
How dimensions were determined: measured
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
Septic tank and all components ere structurally sound and functioning properly.Recommend pumping every two years.
GREASE TRAP:_
(locate on site plan)
Depth below grade: nra
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: rda
Scum thickness:nla
Distance from top of scum to top of outlet tee or baffle:rra
Distance from bottom of scum to bottom of outlet tee or baffle:We
Date of last pumping;,,
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
We
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2-6"
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction lineP-
Diameter: 4"
Qsimments: (conditions of joints,venting,evidence of leakage,etc.)
(revised 007)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 111 Knowlton Ln.Marstons Mills Lot
Owner: Bernard and Deborah Cullen:Newsherburn Rd.Athol MA 01331
Date of Inspection:3125199
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rda
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: we
Capacity: nla gallons
Design flow: nla gallons/day
Alarm level:_nra Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rds
DISTRIBUTION BOX: x
(locate on site plan)
Depth of liquid level above outlet invert: nla
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
Dlet hdlon box needs to be replaced
PUMP CHAMBER:
(locate on,site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)- es
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
rda
(revised 0427)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 111 Knowlton Ln.Marstons Mills Lot 4
Owner: Bernard and Deborah Cullen:Newsherburn Rd.Athol MA 01331
Date of Inspection:3125199
SOIL ABSORPTION SYSTEM (SAS):x
approximated b non-intrusive methods
(locate on site plan,if possible;excavation not required, but may be y )
If not determined to be present,explain:
nia
Type:
leaching pits,number: 4'Wleaeh pit vAth3'ofstone
leaching chambers,number:rda
leaching galleries,number: nia
teaching trenches,number,length: nia
leaching fields,number,dimensions:nia
overflow cesspool,number:nia
.Alternate system: nia Name of Technology:_nra
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
system rails.system Is ponding.system Is pastthe offsedve depth or leaching.
CESSPOOLS:
(locate cn site plan)
Number and configuration: nia
Depth-top of liquid to inlet invert: nla
Depth of solids layer: nia
Depth of scum layer: nia
Dimensions of cesspool: nla
Materials of construction: nia
Indication of groundwater: nla
inflow(cesspool must be pumped as part of inspection)
nia
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
We
PRIVY:
(locate on site plan)
Materials of construction: nia Dimensions: nla
Depth cf solids: nla
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rds
(revised 0427)87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
111 Knowlton Ln.Marstons Mills Lot 4
Bernard and Deborah Cullen:Newsherbum Rd.Athol MA 01331
3125198
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
I�� IQ
AA ` 6
A� 19,
Ac 1
(revised01/7197 Flo• 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
111 Knowtton Ln.Marstons Mills Lot 4
Bernard and Deborah Cullen:Newsherburn Rd.Athol MA 01331
3125199
Depth of groundwater 12,
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
X Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS maps and charts
(revlsed04W197) Irate 10 of 19
I ' TOWN OF BARNS TABLE p
LOCATION L o-r �,/ AVYOW L Tom/' SEWAGE #
VILLAGE ,M�+/[.S?o-rs IW,;I-LS ASSESSOR'S MAP & LOT
2/
INSTALLER'S NAME & PHONE NO. Qfwc%
3q g -siiq
e
SEPTIC TANK CAPACITY /000 6 ,
LEACHING FACILITY:(type) /% (size) 41X 3 S�roye
? r
NO. OF BEDROOMS � PRIVATE WELL OR PUBLIC WATER Pa/d L i c
BUILDER OR OWNER /*\/i c f:bL a /moo".ig S
DATE PERMIT ISSUED:
DATE . COMPLIANCE ISSUED:�"� � �✓G
VARIANCE GRANTED: Yes No
�2�A-2
1
��
7
�=
�,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA�TH
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System,at:
A.
Type of Building Size Lo .... 40�!..Sq. feet
Z Other Distribution box Dosing tank
4 Test Pit No. I it.. w:eaer..�� .
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL I TI 11 5 of the State Sanitary Code—.The undersigned further agrees place the system in
operation until a Certificate of Compliance has been issued by t board of
Date
_____
Date
Date
~~~—^~-~------------------------
No.l&...... Fzs........._....
.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... 0...........y'`� -,,4...............&- -
Appliration for Disposal Works Tonotrurtion Errant
Application is hereby made for a Permit to Construct (,.�') or Repair ( ) an Individual Sewage Disposal
System a ' ) `.. ....�% �G ` yZ0/ 21>........... .-- - .. ......
...... �l�:7 ocation:Ad r s. .��;t:��.._. � "` .. °7 N1 7/11.t� /C
...
er
W - ?... ----�4� 1. _/ 44—'1 .................... d ...
W
Installer Address
�n.........
d Type of Building Size Lot....A.................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garb rut er ( )
Other—Type T e of Building No. of persons............................ Showers
Aa YP g ...---....-•-•.............. P ( ) — Cafeteria ( )
111 Other fixtures ........................•--••••--••••------•--
W Design Flow............................................gallons per person per day. Total daily flow....................�.�1�.........gallons.
WSeptic Tank—Liquid*capacity../ gallons Length................ Width................ Diameter................ Depth................
x 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..................kle!g.��... .... Date.....-_ ?21
W Test Pit No. 1. ._.. ...____minutes er inch Depth of Test Pit.................... Depth to ground water........................
r P P eP
Gt, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Descriptionof Soil............................................... ...........f t............_(Jf.. /•• f
V -------------------
-•......
..._....-....----------------------
•------------
----•-- �--•-"-- ...........i..................................................4'' . .E F�.�?-�Z e'`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 TITI:I 5 of the State Sanitary Code—.The undersigned further agrees n o place the system in
operation until a Certificate of Compliance has been issued byZthn board of hea tSi ed.. ...............•. ..42-- ......... _.... ......
at
Application Approved BY------------- ll!� ----- �.,,4 ?--- •-
.- Date
Application Disapproved for the following re ons:.......................................................................................................----
----------------------•-•----•--..........._..----------.....---••-------•---•••••••--•.......-•---•......••-•-•-••--------......---•-•--..._.......---......--------------....-••••-----•-•----••....._
GG'
Permit No. Date
�......_....1. ......_ Issued---------------------------------------•---.........._
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF .. EAL..�TH
. � .OF.................................. ....................... ...�... ...�...�..�.......................... II
Tntif iratr of Toutplianrle
THIS IS TO CERTIF , That the Individual Sewage Disposal System constructed or Repaired ( )
12 Installer
.................•-..............................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.....)..b... . ..�_.......... dated----- s....ff.&..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........... - •�- .�cry^ ................................. Inspector.....................................................................................
A P �� �U j E COMMONWEALTH OF MASSACHUSETTS -
vu a BOARD OF HEALTH
qq..L.�'. .� -r OF.............. ? 'G' '..---------
No
Fat*...........:...........
Disposal Works Tono#rurtion f rrmitt
Permission is hereby granted..._.....r -' � '-- '�!% -
----------------------- --------•---•--------------•-................................•--................._---
to Construe (..x or Repair ) an Individual Sewa a Disposal System
atNo.............v� ------.... ..._.. .1N. `ti....................� ' .:.-f` '..L.L �.............................................street 1 -- -j
as shown on the application for Disposal Works Construction Per, 't NoA). Dated. .. Z S
Board of Health
PATE..................... .....................................
FORM 1255 A. M. SULKIN. INC.. BOSTON '
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No.10050
EXISTING SPOT ELEVATION A0 � CERTIFIED PLOT PL.AN'`,
EXISTING CONTOUR 0
FINISHED SPOT ELEVATION =r
FINISHED CONTOUR 0
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NOT: The location of any existing undergi-ound' sewera u
welds, or other utilities shuwn en t.`:is p,ian is approx r
im2te only as determined from records and/or verbal �h��•�'��
information. The contractor is responsible for.the '`. t, F 5•; , Z •�,; ,�, ,
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E1/1( & ELDREDGE ASSOCIATES INC. - CLIENT, /c/E�c f ` i` CERTIFY.; THAT.'THE, PROP4SE.t �(
ENGINEERS-LANDSCAPEARCHITECTB ' J(�B NO. �0.�..33 BUIIDIN.O SHOWN
'PLANNERS-LAND SURVEYORS CONFORMS ",TO, THE; :ZONING: V.AW , ti
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rNve�T CLEv�IT�nN� PIT CaaPAC Ty
/NYERT AT QU/LD/NG FT, 6 /AM
INLET aSEPT/C 7-4NX' 7Q_FT, FT. 01AM. C SEE TiIBUl�1 TION�
OUTLET SEPTIC TANK 7y, I FT. _ `' j
/NI.ET D/STR/EUT/ON BOX 7�• FT. SECT/O/V O F GROuND W,47. TA,5L E
OUTLETD/A'CYIV ,-I- BOX_ 73.E cr . S�NIAGS O15,400 'AL SKS7WM
INLET LEACHING OIT �..�._.FT. TigBULATlON I'
LEACH//VG P/7'
DIES/GN CR/TER/A sc.�L .E %" _ /= O� D/ME/vs/ON A 2. S FT.
O/�fENS/ON $ y.0 FT.
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TOTAL E37/mA•TED FdOrt/_33v G.4L.�DAY SOIL TEST �/ SOIL TEST 2 SOiL TEST - /
NUMBE.P QF L-A-4CRIAa P/TS_,_l f e:*z EK 7G•S• �-E[EY. ,DA TE OF SO/,L TEST ZV St _ .
S/06 LEACHING PER P/T /S sq. --r i
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7-0T/11. LEAC!•/(/YG AREA Zb y SQ• FT, 3 .q �tCOL.4T/ON RATE 1�2 ly/IV. /NCH
R'ESERYELEAGNlNGAREA2Ay SQ. FT.
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EX s IN® SPOT ELEVI4TION 6,c0 Y LOT PLAN -
EXiSTINO CONTOUR --- O ---
CERTIFIED P
FINISHED SPOT ELEVATION [� :LeZ_ _¢_�.�,•c � � r .
FINISHED CONTOUR O - -r...: ..� - „ '1"
NEl'E: The luca•t.iuil of any existing underground' s L abo,
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wells, or other utilities shown ai` tris flan is approx
invite only as determined from records and/or verbal ♦ X
information. The contractor is responsible 'for.the
ve 'ification of the existing locations -in =the.'field_:: SCALES fir �'�U ' DATE: ->��+! d. '.: '�
�.EVY & ELDREDGE ASSOCIATES, INC. ., CLIENT, /Urvc f'` ` I`'CERTIFY THAT'`' THE° PRQPtOSLO�"
EN�i1NEER3-LANDSCAPE ARCHITECT$ JON NO. ��33 BUILDIN.O SHOWN ON THIS `�Pt�" i� r'
' IJ1NNER8-LAND SURVEYORS CONFORMS --TA THE
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SHALL BE BROUGHT To GsrAo.E.c,,,4N EXTRA
ELC-V= S CONCRETE ^+ PYC P/Pt 41,64VYCT /,POt/,d=M/N. P/TCN L /3E USED �I
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INLET SEPTIC Ti4NK I'V•3_FT r Z F7. O//4h'J_ C SEE Ti4841L4TJOA�)
OUTLET SE'PT/C TANK _ZY:L_FT � _
/INLETDI57R14v2r1®N BOX 93�:f)—FT. SECT/ON OF GROUVO We4TERTABLE
OIJTL.FTD/STR/Bl/T/ON BOX��FT,
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L EACH/IV� fP/T
DES/G/V G•R'/TER/Al SCALE D/ME/Vs/oAt A2• S FT.
D/.+BENS/oI1/ $ '/•0 FT.
Nulyl Bt R OF BEDROOMS D/MENS/ON C 1_F T._.
GARBAGED/SPO.SAL. UNIT 0 1 SOIL. LOG
TOTAL E3T/MATED FLOW 330 G.41_ Y SO/L TEST lit/ So/L 7EST-402
NUMBER QF 44-ACH/IVG P/TS_J ,_ fE'[G°K r-ELEi! ,DATE OF SOIL TEST
S/OE L�AGH/NG PER P/T 15' ,_SQ, FT. RESULTS /Y/TNESSED BY Wi'V��`�>G Gem•„ � �,
9oTTOM LEAICN/NG PER P/T // t Sp, ,rT l/1 PtRC0ZATiO/V RAr"-AE/ Z /y//V• N
TOTAL LEACH/NG AREA L6`Y SQ. FT. 3 ."e w/ lRCO LAB/ON RATE/ 2 /`l//V.//NGH
A EsERVE 4EAC,qJN6 AREA 2.s a/_SQ.. FT. s rlod s�`s
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aOB ND., . SNG�ET�OF_� ;
HM ] 71 H E A L T H M A S T E R ] HELP [ ]
R E C O R D ) ACTION I]
For Parcel Number 1021 2191 ] ) Rental Property(Y/N) [ l
Owner Name WOJTKOWSKI, LINDA G TR ] Zone of Contrib (Y/N) [ ]
Location ill KNOWLTON LANE MM ] Contaminant Rel (Y/N) [ ]
Business Name [ ] Area Number
Contact :Person [ ] Phone [000] [ ]
Fuel Storage Tank Permit [ ] Card on File [ ]
Perc Test Well Septic
File/Permit No. [ l [ ] [98-229 ]
Issuance Date [ ] [0410981
Completion Date [ l [ ]
Last Communications [ ] (MMDDYY)
Comments [1500 ST DBOX 4 MAXIM IN 4' STONE ]
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PAR ] Real Estate System - General Property Inquiry] Help [ ]
Parcel Id: 102 219- - Account' No: 370208 Parent : 52061
Location: 111 KNOWLTON LANE MM Neighborhood: 20AC Fire Dist : CO
Devel Lot : 4 Lot Size: 1 . 00 Acres
Current Own: WOJTKOWSKI, LINDA G TR State Class : 101
WOJTKOWSKI FAMILY TRUST No. Bldgs : 1 Area: 2000
NEW SHERBURN RD Year Added: 87
ATHOL MA 1331
Deed Date : 040192 Reference : 7950/233
January 1st : WOJTKOWSKI, LINDA G TR Deed MMDD: 0492 Deed Ref : 7950/233
Comments :
Values : Land: 40000 Buildings : 119000 Extra Features :
Road System: 111 Index: 2029 (KNOWLTON LANE ) Frntg:
Index: ( ) Frntg:
Control Info: Last Auto Upd: 050695 Status : C Last TACS Update : 061693
Land Reviewed By: Date: 0000 Bldgs Reviewed By: AM Date : 0387
Tax Title : Account : Taken: Account Status : Hold Status :
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Next screen [PAR ] Action [ ]
Owners Name [ l
Road Index [ ] Road Name [ ]
Parcel Number [102] [220] [ ] [ ] [ ]
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