HomeMy WebLinkAbout0160 KNOWLTON LANE - Health 160'Knowlton: `�-
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jj TOWN OF EARNST L,E
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VILLAGE � 2454 /�VS ASSESSOR'S MA.P&LOT
INSTA:LI.ER'S NAME&PHONE NO.
EMIC TANK CAPACITY
EA,cHNG l~ACILrrY: (tyr) ° � _- . (size) o�
O.OF'BEDROO�ws 3
DOER OR OWNER,
PERMITDATE:—,—..—r -cOW`bAN DATE: -
Separation Distr v-,Betweep the;
Maximum Adjusts 1,Groundwater Table to the Bottom of beaching Facility �...
Private Water Supply Well and Leeching r'acility ( f any wells exist
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(if any wetlands exist
within 300 feet o acbi Feet
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Furnished by
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Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 160 Knowlton Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-26-11
page. City/Town State Zip Code Date of Inspection
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 Service
Company Name
29 Atwater Dr
Company Address .
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
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. 1 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 Furth r Evaluation by the Local Approving Authority
4-26-11
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.
I
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewa Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 160 Knowlton Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-26-11
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.
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
V-01M', 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):
41
f
t5ins•11/10 i ro Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 160 Knowlton Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-26-11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval.of.Board,of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipes) are replaced ❑ Y ❑ N ❑'ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
t
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
}
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
160 Knowlton Rd
Property Address
Bank Owned (Contact David Holt @ Today'Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-26-11
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 add 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 musflndicate"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 town overloaded or clogged SAS or cesspool.
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/ day flow
t5ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
160 Knowlton Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required=or every Marstons Mills MA 02648 4-26-11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS,'lcesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 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`fires" 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
❑ El
Area —IWPA) or a mapped Zone II of a public water supply well
If you have-answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The'system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 160 Knowlton Rd
Property Address
Bank Owned Contact David Holt @ Today Real Estate 1-800-966-2448
( @ Y )
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-26-11
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
• 330
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms):
t5ins•11/10 _ 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
�M 160 Knowlton Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-26-11
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
, f
Sump pump? ❑ Yes ® No
Last date of occupancy: 3-2011
Date
_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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
160 Knowlton Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-26-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
. it 4•t a' k:y rs rv'
General Information
Pumping Records:
Source of information:
N/A.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:y p p 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-11110 Titre 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
160 Knowlton Rd `
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-26-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1994
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 12"tee"
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:V s; feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain)
If tank is,metal,.list age: years
Is age confirmed by.a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 gal
Sludge depth:
12"
t5ins•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
160 Knowlton Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-806-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-26-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 20
Scum thickness
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
15"
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 160 Knowlton Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-26-11
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.):
„tls
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 160 Knowlton Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-26-11
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.): I
Good condition with water at working level and no sign of back-up.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
160 Knowlton Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-26-11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-1000 1-600
❑ I 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.):
Both leach pits in good condition with newer leach pit having a stain line at 24"from bottom of pit.
Cesspools (cesspool must be pumped as part of inspection) locate on site plan):
P ( P P P P )( P )
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
u Title 5 Official -Inspection Form
W Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
160 Knowlton Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-26-11
page. City/Town 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:
t
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 160 Knowlton Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is
requiree for every Marstons Mills MA 02648 4-26-11
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 -
a
r
- q �-
5 3 Y - 4
t �- .?
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
160 Knowlton Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4-26-11
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: 50'
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:
i
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 40'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
160 Knowlton Rd
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information its required for every Marstons Mills MA 02648 4-26-11
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑ System Information— Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
OV
DATE: ,12/17/98
PROPERTY ADDRESS: ,160 -Khnwlto'n Lane
Marstons Mills ,Mass.
'02648
s
On the above date, I Inspected the "ptic system at the above address.
This system conalsts of the following:
1 • 1-1000 gallon •septic tank.
2. 1-Di6tribution box .
3. 2- 1000 gallon precast. leaching pits .
4. Pits t asedlgnsmylrns8bactlon, I certlfy the following condltlons:
S. This is* a title five septic ' s'ystem.-`( a8 Code )
6. The septic system is in proper working order
at 'the present time . ,
7 • .Pumped septic tank at time of inspection ."
Heavy scum & solids layers were present .
#. The 'second leaching pit is :dry ,
SIGNATUM7,
Name : J . P. M_acomber i • .'
Company:_`• P. _Macotuber �& on—jac • .• ' .
• 'i r
Addrea s'--B•aac_66---_—.:a—
L e Lltq,9ji_9 Z,3*2 ' • '
Phone: '
THIS CERTIFICATION DOES NOT CONSTI`TUTE A GUARANTY OR WARRANTY
JOSEPH P, MACOMBER '& SON; INC.
T+nks-C@ i4pooh,L&achf l@lds
. Pump+d L Init11164 '
Town Sower Connections
P.O. Box 60' Cenlervllle, MA 02632.0066
77.5-333$ 7764412
i
COMMONWEALTH OF'MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET,BOSTON MA 02108 (617) 292-5500
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
prtyAd&.; 160 Knowlton Lane Nameofowner George Paquette
Marstons Mills ,Mass. 02648 AddressofOwnw: 160 Knowiton Lane
Data of Inspection: 12/17/98 Marstons Mills ,Mass . 02648
Name of Inspector:(Please Print) Joseph P.Macomber Jr .
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
cornparry Name: J. P.Macomber & Son Inc .
MatTingAddress: Box 66 Ce11tervi 11 e ,Mass 02632
Telephone Number: .p,2 7 7 5—3 3 3 a
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:
asses
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspecttoes Signature: Date: 0611 Y,
��4
The System Inspector shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this Inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department ofrEnvironmental Protection. The original should,be.sent tova
system owner and copies sent to the buyer,if applicable, and the approving authority. .
NOTES AND COMMENTS
The leaching pit covers should be raised to within 6" of grade .
The first pit is 3 ' 6" below grade .
The second pit is 4 ' below grade .Pits are in series . � � f ''� ��
Box is 18" below grade . e
2 1 1998 1'
TOWNOF94MMU
�. 1001 DEPE A*
6 ti
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revised 9/2/98 Page Iof11
��}Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddress: 160 Knowlton Lane Marstons Mills ,Mass .
Ormer: George Paquette
Dxtze of Inspection: 12/17/9 8 `J
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 W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING W A MANNER WHICH 3NILLPRQTECT THE PUBLIC HEALTKAND SAFETY AND THE ENVIRONMENT-
4e Cesspool or privy is within 60 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
/t 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.
�I The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 60 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance •41,4 (approximation not valid).
3) OTHER
1/16
revised 9/2/98 Page 3of11
I
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address.
160 Knowlton Lane Marstons Mills ,Mass .
Owner: George Paquette
Da"of 4rspec'On: 1 2/1 7/9 8
D. SYSTEM FAILS:
You must Indicate either"Yes"or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No,
Backup of•sewage intofecilit�nor-r/atem component-due tto an overloaded orcbggedSiASorceaspool.
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 distrib lion box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in oacspesl is less than fi" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped-0.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
2 Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
2 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. 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" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
�Q 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 N A
^1? the system is within 400 feet of a surface drinking water supply
/V9¢ the system•is-within 200 f"tofa-tfibutary4oasurfaoe•d4nking.wst�i•supplY
AO the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further infor nation.
revised 9/2/98 Page 4orn
1
i SUBSURFACE SEWAGE DISPOSAI,SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 160 Knowlton Lane Marstons Mills ,Mass .
Owner: George Paquette
Date of InspecS-:l 2/17/9 8
Check if the following have been done:You must indicate either"Yes" or"No" as to each of the following:
Yes Now
Pumping Information was provided by the owner,occupant,or Board of Health.
.None of the system compoaants hasbaeaasceiaiag weemsi flow
rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this
Inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, *Cluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction,dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System orrthe site has been determined based on:
Existing information. For example, Plan at B.O.H.
_ Determined In the field Of any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
(15.302(3)(b)]
_ The facility owner_(and.ocr pants.Jf ditfaraot trout.ommarj w&rz4mzuidad with lnfnrMat orian thA proper Matat f
SubSurface Disposal Systems.
t
I
revised 9/2/98 Page 5orIll
J
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 160 Knowlton Lane Marstons Mills ,Mass .
Owl: George Paquette
Date of 1"specoo":12/17/9 8
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 1/0 g.p.d./bedroom.
Number of bedrooms(design): Number of bedrooms(actual): '�
Total DESIGN flow vy0 ����L
Number of current residents.jw
Garbage grinder(yes or no):�/
Laundry(separate system) (yes or no):&;. If yes,separate inspection.required
Laundry system inspected (yes or no
Seasonal use(yes or no):,i o �+� pp n Q
Water meter readings,If available(last two year's usage(gpd):�AUZ add
Sump Pump(yes or no): ND
Last date of occupancy:w�l7
COMMERCIAL/INDUSTRIAL:
Type of establishment: 4U/
Design flow: ofhff 9Dd ( Based on 15.203)
Basis of design flow AIW
Grease trap present:(yes or no)-&4
Industrial Waste Holding Tank present:(yes or no).,y/Z
Non-sanitary waste discharged to the Title 6 system:(yes or no)1
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORD and sou a of information:zWU /;kig
System pumped as part of inspection:(yes or no)AU
If yes, volume pumped: gallons �1 )_�
Reason for pumping: If� xe oWl �7/i/C1� Z
TYPE OF YSTEM
optic tank/distribution box/soil absorption system
.17D Single cesspool
. 'Q Overflow cesspool
Privy
—!a?l1 Shared system(yes or no) (if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank &j4 Copy of DEP Approval
Other
APPROXIMATE AGE of all components, data installediif known)-and Bourse.of4wformation:
Sewage odors detected when arriving at the site:(yes or no)/Va
revised 9/2/98 Page 6of11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address
;160 Knowlton Lane Marstons Mills ,Mass .
Owner: George Paquette
Data of motion: 12/17/9 8
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction:_cast iron Z0 PVC_other(explain)
Distance fro5private water supply well or suction line
Diameter 7
Comments:(condition of joints,venting,evidence of leakage,-etc.)
SEPTIC TANK-,&Vd 9
(locate on site plan)
Depth below grade: �
Material of construction: /concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank Is(natal,list age Js.age.confrmad by Certificate of Compliance (Yes/No)
Dimensions: 0141(1 A/A06 y���/ J✓�'� ���f/��
Sludge depth:
Distance from top of sludge to bottom of outlet tee orbaffie:-6— —'
Scum thickness:_
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottwn of ouU(A tee or baffle:_
How dimensions were determined:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or-baffles,depth of liquid level in relation to outlet invert, structuraHntegrity,
evidenceof leakage,etc.) Pump tank PVPry 2 3 yParG - +TnlPt K niitlat YPPR ara in
f l ThP tank is structurally Roane . There is ee evidenee 9f lealeage
GREASE TRAP: e
(locate on site plan)
Depth below grade:��
Material of construction.4concrete4l4metaW�Fiberglass4l EPolyethylenel44lother(explain)
Dimensions: y
Scum thickness:--A&d
Distance from top of scum to top of outlet tee or baffie:AZi.
Distance from bottom of scum to bottom of outlet tee or baffle:44
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.)
Grease trap is not present
l
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Prop"Address: 160 Knowlton Lane Marstons Mills ,Mass .
OVMW: George Paquette
Dot°of trupection: 12/17/9 8
TIGHT OR HOLDING TANK (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of constructionw�concreteAl�metal�[Qi Fiberglassy Polyethylene4�4%ther(explain)
AI
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes&4 N.,0gj
Date of previous pumping:A/._
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
light or o inQ tan s are not present .
DISTRIBUTION BOX:Z
(locate on site plan)
Depth of liquid level above outlet invert: Alb
Comments:
(note,if level and distribution is equal, evidenoe of solids carryover, evidence of leakage into or out of box, etc.) — —
Distribution box has one lateral .No evidence of solids carry over .
No evidpnro of leakage intn or not of the hnx -
PUMP CHAMBER:s.&t
(locate on site plan)
Pumps in working order:(Yes or No))
Alarms in working order(Yes or No) /Y
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
Pump chamber is not present -
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddreu:160 Knowlton Lane Marstons Mills ,Mass .
owner: George Paquette
Date of InispecbOn: 12/17/9 8
SOIL ABSORPTION SYSTEM(SAS).2-106 94)'10A'
(locate on site plan,If possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits,number: Ot
leaching chambers,number:
leaching galleries,number:_�r
leaching trenches,number,length:
leaching fields, number,dimensions:
overflow cesspool,number:
Alternative system: �
Name of Technology: &642.
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.)
Loamy sand to medium coarse sand - No sign. of Hydranlir fail ,irP
or ponding - Soil is not damp - Vegetation is nnrmnl _ Leaching pits
arP in RPri PG _ ThP RPrnnd i i t i sp rPgPnH g drjr
CESSPOOLS:z1hWe
(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: AM
Materials of construction:
AO-
Indication of groundwater: NN
inflow(cesspool must be pumped as part of Inspection)
Cesspools are not present _
Comments:
(note condition of soil,signs of hydraulic failure,.level of pending,condition of.vegetation, etc.)
Cesspools are not present
PRIVY:le.4VI
(locate on site plan)
Materjals of construction: IV4 Dimensions: /
Depth of solids:—N&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation;etc.)
Privy is not nresent
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
I
Property Address: 160 Knowlton Lane Marstons MIlls ,Mass . /
Owner: George Paquette
Date of Inspection: 12/17/9 8
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
I t4;b
.bt
'.11
. 1 504 1"ou?1 Oq):I
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART C
SYSTEM WFORMATION(continued)
Property Address: 160 Knowlton Lane Marstons Mills ,Mass .
Owner: George Paquette
Data of Inspection: 12/17/9 8
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
bserved.Sit,(Abutting prope y, bservation hole, basement sump etc.)
!,"Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Water Contours Map .
Gahrety & Miller Model
12/16/94
revised 9/2/98 Page It of11
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Barnstable
1 UHN OF BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I
� F•••rn�r•:-:ct—r.tr>.�.-rr+.rirnt•rt.•nn rn�rsrrn�ten'►�tti*-tven�.�ertsr��rr+last newnse�w-rers tsenn .++rrr•tr-ter�...1
-TYPL OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRES$ 160 Knowlton Lane Marstons Mills Mass .
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME George Paallette
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr . .
COMPANY NAME J. P.Macomber & 9tn' Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or Crty State LIP
COMPANY TELEPHONE ( 508 1 775 - 3338 FAX (508 1 790 -1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate, and
complete as of the time of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check one:
System PASSED :
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con tcted has found that the system fails to
Protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form.
Inspector Signature Date
One copy of this certification must be provided to the OWNER the BUYER
( where applicable ) and the DOARD OF HEALTH.
* If the inspection FAILED, the owner or"*Operator shall u d
within o•ne year of the date of the inspection, unless allowed ort required
he m otherwise as provided in 3,10 CMR 16 . 306 ,
partd .doc
i
TOWN OF BARNSTABLE 1
LOCATION ��. _ �C � 7�C"C�C SEWAGE # W-1G3
VILL.�GEj.• : '� ?� /�`/��.5 ASSESSOR'S MAP & LOT%C)�)Y=?
INSTALLER'S NAME & PHONE NOA,`1"I" -1;
SEPTIC TANK CAPACITY
LEACHING FACILITYAtype) ,P/% 4�1 (size)
NO. OF BEDROOMS 1-3 PRIVATE WELL OR Pit IC WATEB�
BUILDER OR OWN R
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
_ �/6o R
1
fg
37F v 34 `%44
73
1h. 1006,01 660 6-41
93��IfOWOVED
$arnstable Conserve0on DepeRment
o............- ....... l�'Yy�11�r.q FIzs..............................
THE COMMONWEALTH OF MASSACHUSETTS
s BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Di,�ipm3al lVarkii Timitrurtion rami#
Application is hereby made for a Permit to Construct ( ) or Repair Doe) an Individual Sewage Disposal
System at:
............................ .... •.
Locati n-:\ddress or Lot No.
Owner A dress
w �Lo� Cn.I.S7L,J Gar' ,.Iu.J 7fd�"J `Y
a �.-••--•-----•--•-•......-----•.........---••---•-•----••••--•-•----•------•--•••-••-•-------- ----- --------------- --- -....--•--•-•---------•----------------------
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures -- ----------------------------- -
w Design Flow............................................gallons per person per day. Total daily flow_.__..._._____....._..__.__...gallons.
WSeptic Tank—Liquid capacity./ _-_gallons Length________________ Width---------------- Diameter-----........... Depth................
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O Description of Soil------------- •--•-- / vYl------ v ji ... � ,ti/1� -
x
w ... ----•-••----------------•-----••-----•-••-•••-•------------•----••--•--------------••-•-••-•---• ----------------------------- - =---
UNature of Repairs o Alterations—Answer when applicable.--1�_Q_.-------- !'..... J � �.%f
�� T -sue, _ ��".._-5-�ZZ-j z: ._...... .`0....--.. ................................, `-s `...'
Agreement.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environment,V Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliant s b en is ue by th and of health.��
Signed ...... - - - - ................ ........._...
......... . ........ .
. Da
Application Approved By - ` ���... ---- � .......................................... '-----
Application Disapproved for the following reasons: ..... ............................... .. ................................
----------------- ---- -----------------------........�..---------------------------- ---------------------------.-.....----------------- --.............--------------------------------- ------------------
Permit No. ...... --- .... Issued ....... " -------
Dam
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Aplifiratiun for Diupuuttl Wurku Tunutrnrttun rumit
Application is hereby made for a Permit to Construct ( ) or Repair �M an Individual Sewage Disposal
System at:
...
� Location-Address / `—g V J I Z' � or Lot No.
/GIN�1 y Lis C6�f .5 - ZQS o—,,, l /?4-
i Owner Address
W / Crll�GGo777 ,r� i , '417/L Ls.._.
Installer Address
UType of Building Size Lot............................Sq. feet
I.I Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures................................................................
Design Flow................._ ____......_._.gallons per person per day. Total daily flow.--_._._-__� ....................gal Wlons.
WSeptic Tank—Liquid capacityA G!?___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. =t.
Z Other Distribution box ( ) Dosing tank ( )
~' Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...----.-__--__-.__-_--.
R; ....--•••••------------•--•--------•-----------------------••-•-•-•-• .......................................................................................
D Description of Soil-------------r3'` ••...CJ/221 �! ��ut3.Sp' .................................................................t,
x
.._.. •• • ----•••-
x •--•---------------------------------------•--••-------------------•-........----------...--•--••••----•••-•......--------------.-
U Nature of Repairs or Alterations—Answer when applicable-- D-------------- 100 6q ' 411 Z=P O ) G�W-
`= f `-5-'?�,�J L.................••-- `{ � �`= ``'J ' _5
---••--•.............•---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance hats b en is ue by the-board of health.
Signed ....... -/�. ............ ......... ............... ....`r /!7/%._.
Dace
Application Approved By . ��.� ------------------ ........
Dace
Application Disapproved for the following rearonr- -------------------- ----------------------------------------------------------------------------------------------------------------
..............----. ............................-�..._.....------------------........-...........----------........._........------........--- ----------------------------------- ----------- ........................................
- �e
Permit No. ......./... R--� ....... Issued ......._ ..:. /.....f,
Dace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Terttf rate of Tompliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �>e}
yC --------------- -
.... ..................----------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
y .. dated � �7 Z'
the application for Disposal Works Construction Permit No. �`�._r•-'_ ... /
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARi4NTEE T AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. — ..." "'........ --------------- Inspector( -+ ..... �� ' .r_.,... -.........
le,
------------------------------------------ -------------------------- — --
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/ TOWN OF BARNSTABLE
No.1... .. _! FEE... .........
�iu�uuttl Turku �ua�utr�tiun �rrmit
Permission is hereby granted_______________. ....... .....':....... ... _..
to Construct ( ) or Repair an Individual Sewage Disposal System
at No.................................. r„f) /_1A1GW L77Z f 5 r ..... // ` � r
sty /
as shown on the application for Disposal Works Construction Perm --No�:*'____b„d.`�.,�`1l__ Dated_____ ...........
/ `E --------- =----------------------------
DATE j� = f Board of Health i
... ,> �`-------------------------- Jl
FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS
/ TOWN OF BARNSTABLE
LOCATION ,� n u, L ®may �f�, SEWAGE # (0 9` zoo�l
C
VILLAGE At/LLA'SSESSOR'S MAP & LOT4
INSTALLER'S NAME & PHONE NO. V IAl c iZ /fit 0 S 39'r^Y2/
SEPTIC TANK CAPACITY
ti
LEACHING FACILITY:(type) r'S1j ,X r l�r�` (Size) 9,X&�v
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATERL
BUILDER OR OWNER&4k U
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: i
VARIANCE GRANTED: Yes No
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ASSESSORS MAP NO: /a3
PARCEL NO..____D _v_7_ a-eerq . FIMS.............. '- -�
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEA TH
L ..:..0 F........... ... .............::....
, pphrFation for 14opnnal Works Tonitrnr#ion Vrrmff
Application is hereby made for a Permit to Construct or Re air ( ) an Indiv' Sewage Disposal
System at........»... Z ..A.J/--+W
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L motion- ress 40 � � r Lo o. ..
......... .. �_ .- �. .. .... �.J [ E k......
.. .....---
� sOwner � .---.--- E - . ....... . .... .d �
Installer Ad
Type of Building Siz ot../- _.Sq. feet
Dwelling—No. of Bedrooms---------`...................................Expansion Attic ( ) G�bage Grinder ( )
Other—T e of Building No. of persons............................. Showers — Cafeteria
a' Other fixtures __________________________________
..gallons per person per day. Total daily fiodv............... ___..........._gallons.
Design Flow--------..............................-----g P P P Y• Y • �
1:4 Septic Tank—Liquid capacity.j? ..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 ( ) ` z
'-' Percolation Test Results Performed b �A -�!k Date........... ... _.��
aTest Pit No. l................minutes per inch Depth of TPit........._.__....... Depth to ground wat _.___._._ ..........__.
Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___-_--_.______---____.
a •-------•-------------------------------'-•-••-••-•-•-••--- .•-- -•-• ---•----
O Description of Soil................................................... =` �'l1' . .......................................
x
x ---•--•---- -------•------------------•--------------------•-•-••-••---.......-••-•--••••••-•••----••-•---•----------------••-•-•-•---•••-•-•-••••-••--•-••-•-----•----••-••---•••-•-•••-----•--...
U Nature of Repairs or Alterations—Answer when applicable.-____________________________•-.-..---•_-.-___--_______-_-.-.----.___-____-__---_---------.-__.
----------------------------•------------------------------•------------------••------------------------------------------------------------------------------------------------------.................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with,
'--�
the provision f"1 T�'1E
s`of 1 T t l of the State Sanitary Code— The undersi ed f s-tl:er agrees not to lace a system in
or, uptili�to of Compliance has been issued b �the board o lth. �`
Signed
Application Approved BY --------.--••-........... e
.........-•----.... ate-------•------
Applieation Disapproved for the lowing reasons:----••--------------------------------------------------------•--------------------------------•---•------•--'--
-------------•--------------------------------...-•--•--•-•--------------.....-----'---------------------•----------------------------------------------------------------------...--•---
r..- Date
PermitNo.......................................................-- Issued-.......................................................
Date
No......................... FRs............._...........
_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O, HEA. TH N
' ffl -----'.`-------- IF.... ....
Appliration,for Diopooal Works Ton ortua ramit
Application is hereby made for a Permit to Construct ),or`Repair-��/^)' an lndivid Sewage Disposal
System at: _
....................... . 4 ....fir I/ ....................� f ti��... =.... ........
cation- dress
_.. J r�.
Owner Ad
In�talier i ,�° f
�f
U Type of Building "' Si ;_6
o _._.....�......Sq. feet
1-, Dwelling—No. of Bedrooms.............-. =.:.... ..._.............Expansion Attic ( ) (Uarbage Grinder ( )
Other—T e of Building �No.roof persons............................ Showers — Cafeteria
a YP g IN ( ) ( )
Otherfixtures ----------••--• ••----••-•-----•••••-••••••.....5.........••= ------------------------------------•---•-••..--j= --
. .. gallons per on(_er d`a Total daily flow.:............
w Design Flow 1-- - ------------l�lons.
g g P P p_1 , Y• Y -
� Disposal TrenchJi >��ca aclty_ _--..��tnns Len Total Length�aoh.....l�.. Total leaching area iameter - Depth................
W Septicq , p ! g
x P •. g ---•••......-••---..sq. ft.
� Seepage - - - - - - ------ - -----• P �- r i
---- --- ft.
Z Pit
box Dosing tank
( ) Diameter.-- Depth inlet...................i L. Total le�in area..:= --- ----sq
Other Di ,} �
a Percolation Test Results Performed byte----- �r.......... 1 �Date.�._: ... ..v-
,.� Test Pit No. L_______________minutes per inch Depth of s Pit........_........... Depth to ground water________ ......
444 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground-water........................
Z1. .. •-•--•---•--•-----
1
ODescription of Soil---------------------------------------------------- -��...... ---•--.. -�a� �2�== - v'---------------------
x
.------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-.-..-•-,--•-•••---••-•••.
w
UNature of Repairs or Alterations—Answer when applicable...........................................................................r'................
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 5 of the State Sanitary Code—The undersigned further agrees not t9-piace a system in i
operation until a Certificate of Compliance has been issued the board o health.
Signed ............ ..� - t .. �
to
iApplication Approved By---------------•---�-- .................................... ......................
Date
Application Disapproved for the 1lowing reasons:................................. .....................
-------------------------------------•--...---------------------•--------....-------•----------.........•.-----------------------•----.......----...--------------------------------------------.........
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OIF, HE�aw
i
M................... ....................OF........ .................
05rdif iratr of foot fi orr
THIS _ZS TO CERTIFY That the Ind'vidua�l wage Disposal System constructed � ) or Repaired ( )
by e.!�s?. ' �}" ..... -`- --NN i. ? '` ...
F f +�nstaller
-r
has been installed in accordance with the provisions of X-L ,t; 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No 6_-..Loan.............. dated___.__.____.._____________-___----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL F .NCTIO�S'�ATISFACTORY.
DATE----........lQ -- ��� �-'" ..... Inspector....• ..... ... ......... -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
-'
6- oo .....oF.. = -------------------•----........... S aG
�r0 .....•............ E4E.. ........
Disposal Vorkg vnstfudW4 V rmit
-r-•-•-•......•....-• h l.. ...-•-•p•-•--••--••--•••-•-•--
Permission is hereby granted-------------->� . ..--------•--------•-- E'i1 - --•---------....-------........---......
to Construct (/ ) or Repair I ) an Individual Sewage Disposq System
at No-------- ...........------------ I.. ... rC v,�`^� - ----MI•I "
• ......
Street
as shown on the application for Disposal Works Construction Permit N��."��n.g_ Dated.._.._4_j_�s..l.�'_�......
\ ......................................��.X-"'s� a .. --------------------------------..-..s HeaItS`
DATE------------- ----r......................... I /� -'
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS A
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LEVY
No. 10617 P AU L
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0 LEVY
NO.10050
FSSI0
LEGEND N LOT 3 —
EXISTING SPOT ELEVATION Ox0
EXISTING CONTOUR --- p - - - CERTIFIED PLOT PLAN
FINISHED SPOT ELEVATION — --"`—`T
FINISHED CONTOUR 0 Z L.Tu.,,.._4-14AI-4E
MA 7ZS_Tp �1.5 �r�ts .
NOTE: The location of any exist ink underg;-ound sewerage,
wells, or other utilities shown on. t;is plan is approx-
imate only as determined from records and/or. verbal �� ��� it wr �� ' •,r �.A� �
information. -The contractor is responsible for the J� ••� •s. i, s
verification of the existing locations in the field. SCALE!----
LEVY & ELDREDGE ASSOCIATES,,.INC. CLIENT. 4/c....414-As I CERTIFY THAT THE PROPOSED :
ENGINEERS-LANDSCAPE ARCHITECTS jOB NO. /o31 BUILDING SHOWN ON THIS PLAN
PLANNERS-LAND SURVEYORS CONFORMS TO THE. ZONING LAWS .;
DR.BY O M A S
712 MAIN STREET Cm. ®Ye Zr PL
NYANN I S, MASS. SHEET+/ OF DATE LA 0 URVEY R
N07E /F E/TNER ?NE SEPTIC TAN�C OR
iEAG.4�uvG P/T A1RE IyORF TN.q.�A/. /2"4&ELOi't/
"-/0 j0I M IAA vRAOE� A 24"O/AM ETER CO/yCRET�- CORER ;
SN.9LL BE 9R000aNT TO GRADE.�AN �XTiPA
Q oPYC pip--
E�eU , ni.S COMCRZT•E /N. PITCH h'EAVy CAST /RO/Y CO{/ER SHALL L3E USED
- 2 • M/N. CO/VC.eL�TE
o- _ G •aoE co llEft CLEAN SANG
UQU/D LEYEL. _
4C.�SY� — z*LAYER c
/RDA/ P/PE o a o -�V "
¢ MIN.P/YP�f 10C�0 GAL': • . • • • o4e
A4,Pen-Orr. S�PT/C TANfC B X � � s 1 • • • • • • � • o , • WA SHPO ST27NE
o • 1 B . • • . • 1 0•0 ••
s f0 o I I eEf"FECT/VGr '• e , 316,
• • • t DEPTH • • I • • o WASfIED STONE
Te,;�.a � •t• 11 • O t • e.d • Cp o
1/3Xh0 s 113 , se • • • • • t . • • • p ••o PRECASTs-',L Aar,
6 • • • a • • • s • • e o P/7 OR ESL//Y.
lNY > E'L�Y�T/Ohre y.q0 C,����i y a DarL ,= s.q
P/T Gil PAC_iTy
IMYERT AT BU/LA/NCr FT.
, ►2 FT -ION S,EPy/C TA/VK FT >
OUTGET SEPTIC TANK
/A/LET D/SYR/L4I/TIDN SOX 7 F3' SECT/O/V ®h' GROUND WIATL•ft Ti48LE
Ot1TLETD/STRIB&rlON BaX'D.Z FT` .S�wAG� O/Sf,Ol�i4 L SY.S 7"�/b9
INLET LEsIC/Jl/VG P/T 6�.9 FT, 7/��U-ATIO V
D.E�/GN CRITERIASCAL-E %s~ _ /= O" DIME/NS/oN Ai 2� � FT.
O/,"Z-AlS/a N/ $ q—_FT.
Nu�98ER OF®EORa4M.S 3 D/HENS/ON G N, O F7
SOIL LOG
TOTAL E�TIM.�sTEd FLOW 330 GAL.1DAY SOIL TEST */ SOIL TEST*,? SOIL '7"E$T
NUMBER OF LOACN/NG P/TS + fFc -v 72•� r-ELPY, oATE of SOIL TEST
S/oF ,[EACH/IVG PER P/T SI- SQ, FT. 73 s RESULTS kv1T1VESSED BY
6o7'TOM L,EACK/NG PEJ? P/T //3 $Q• ACT. I S oo PCRC(0LAT/O/V /SATE A•I L Z WAIII)YCH •
TOTC?L LEACHING AREA 2 SP. FT. Y PERCOLAT/ONRA7Efi�2 /ylN. /NCH
RE5ERVE4e.EACN/11/G AREA 6 SP. FT
Xkk- s
�4@.tNOSM4�ry\ �F�ygsgcy _,LOT /c1 .c.l�w�--��✓ L�.Y�
PAIIA PAUL N MrFeST��/S N/ccs ` $A8nlj7it act
LEVY ' �. A. o _
No: iG537 y ; L E V.Y �,
O ,Q No.10050�0 LEVY & ELDREDGE ASSOCIATES, INC.
EMI 0'
ST r� poi GJ57� � 7/2 MA/N ST. , A/YFAIAII- / fQSS.
S13 FS$f0 AL�a (� NO G,TOUNU7 yV,4r4 ENCOU/VTER�O CLIENT: N�c r�yI�f DATE : ✓�N� I!o'�S
�7 G/QO UJ I P J VA 7ER AT ELEf/ — JOB ND.' J0 3 3 SHEET ZOF Z
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PAUL A. 4GN LO; 2��c. vpy
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N"0. 10617 �Y! o U E V Y
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N0.10050
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I STEP
SS10
LEGEND N__ LOT 3_