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Home My WebLink About0444 MISTIC DRIVE - Health -7f r i No. I C t Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppYitatfon for Nsposal *pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. yyy,Q,s�, w� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name Address,and Tel.No. Desi ner's Name,Address,and Tel.No. Type of Building: Pp )ASI,177,�--a Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) b� L9 gpd Design flow provided 3CIZ gpd Plan Date i 070-// Number of sheets .:Z Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Certificate of Compliance has been issued by this Boar of eal greed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. �� (`� Date Issued No. > /C) - t'' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Misposal *pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. JiG. I�h j/D r/,Z,4/,d Type of Building, (>r0k),�`1'.y`/-T 7—z ,/✓ Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Otter Type of Building No.of Persons Showers( ) Cafeteria( ) Otter Fixtures t Design Flow(min.required) 2{Q gpd Design flow provided ; gpd Plan Date Number of sheets ,Z Revision Date Title , Size of Septic Tank Type of S.A.S. Description of Soils i Nature of Repairs or Alterations(Answer when applicable) r 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 Certificate of Compliance has been issued by this B ealth S' ned . / Date 4 Application Approved by V Date Application D_sapproved by Date for the following reasons r� Perni�,%I(i. ( � )(,�) Date Issued 1 I � ► o � ---------------- ---------.----------- ----------------------------------------.:--------------------------- ------------- f COMM ONWEALTH MONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by at G 7'' /2 ;' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.c-D dated 1 i Installer Designer j� � �� f�;, gner #bedrooms Approved design flow -9 3zi gpd The issuance of this permit shall not be construed as a guarantee that the system wil'1 fib•eti• �Ielid. Date / 'j Inspect�r ~�" :. ----- -----------.----- -- --- ---------- ----- ---- ---------------------------- No C � ' �G11L tih Fee )0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Coustructiou J)ermit Permission is hereby granted to Construct( ) Repair( 01"' Upgrade( ) Abandon( ) System located at �Ll_ Lr/ ��,'S � /9-. �Ze ► ,\ncN i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction Istlbe completed within three years of the date of this p�iDate1 Approved 04/26/2011 17:07 5084775313 ENGINEERING WORKS PAGE 01 . x Town of Barnstable Regulatory Services SAL Tho�mae�F. Geller,DirectorPublic Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-86� Fax: 508-790-638�3 Date: Sewage Permit#M/N D Assessor's 1VIaplPareel 6 4,i_-o 2y Installer&Designer Cgc i�Form Designer: Si.`a WO r 4 s lie. Installer. �• t° 1 nC Address: 1 z W. c-ra 1cl lid. Address: ` !4G� M az�yy Mass V,clu MA o�c►�t� On C was issued a permit to install a (date) (installer) septic system at `� N� s+�— D �a�+a�s M.�l� based on a design drawn by (address) e dated / (designer) `7`-' 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major doges (i.e. greater than 10' lateral relocation of the SAS of any vertical relocation of any component of the septic system) but in accordance with. State&Local Regulations, Flan revision or certified as-built by designer to follow. Stripou�t(if required)wa. . and the soils were found satisfactory. of PETER T. to er's Si ature McIVIL N0.98f09 C T� "Pesigner's (Affix Design } PLEASE RETURN TO BARNSTABLE PUBLIC ITH DIVISIO . LATE OF COhffUMCE WILL NO_' BE ISSUED UNTIL HQTH THIS FORM AS- B ARF_RFCEMD BY THE BARNSTAHLE PUBLIC TH D ON. THANK YOU. qAojffi.cc fim=\dc4Stercerti&Aicn formcbe Town of Barnstable P#� 1� Department of Regulatory Services Sr•,BLK Public Health Division Date � MASS. a6Jq ,d� '200 Main Street,Hyannis MA 02601 �fD MA'S� • Date Scheduled yLt Time Fee Pd. CJ0 Soil Suitability Assessment for Sewage isposal Performed By: e _` ��A Witnessed By: �� iv, 7 Dn LOCATION & GENERAL INFORMATION Location Address Liqq K;S ;L Owner's Name 1 Address �1� �t3�'iC�►tY� Q�-co �b Assessor's Map/Parcel: Q Zu Engineer's Name NEW CONSTRUCTION REPAIR _ Telephone# — ? ?—�{-1. (o Land Use Slopes(%) 6 _ Surface Stones A) Distances from: Open Water Body 23 ft Possible Wet Area ? ft Drinking Water Well f t Drainage Way ft. Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 33 _ ,-724 L _1h C, - Parent material(geologic) v J��5 Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Ci' Estimated Seasonal High Groundwater :> I 3" DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in, Depth to soil mottles: Depth to weeping from side of obs.hole:-1 in, Groundwater Adjustment 'ft. Index Well# Reading Date: Index Well level Adj,factor, Adj.Groundwater Level � o PERCOLATION TEST We Titne.��._ Observation Hole# Time at 9" Depth of Pere Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak Z-- S I[a-` Rate Min./Inch. Site Suitability Assessment: Site Passed /`- Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTICVERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency. Gravel) 6 (A �` C -cam e A-C DEEP OBSERVATION HOLE LOG Hole# Z� Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. F`• Consistency.%Gravel) IN C_ 1 ✓� s5 �-- -cS / DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Cons istency.%Gravel) r DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(4n) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Flood Insurance Rate Map. Above 500 year flood boundary No_ Yes Within 500 year boundary No'*4�' Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system?. If not,what is the depth of naturally occurring pervious material? Certification 1( 1 Q Q5-- I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. Signature Date ) �' Q-.\SBPTIC\PERCFORM.DOC �7 ` , • b COMMONWEALTH OF MASSACHUSETTS 'ST"—J(O EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Z DEPARTMENT OF ENVIRONMENTAL PROTECTION d MZ d F A �O y! TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION / q Property Address: 444 MYSTIC DR MARSTONS MILLS,MA 02648 O ! oc� / Owner's Name: PETER KENNEDY Owner's Address: 444 MYSTIC DR MARSTONS MILLS,MA 02648 Date of Inspection: 9/21/01 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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: X Passes _ Conditionally asses _ Needs Fu . Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 9/21/01 The system inspector shall subm 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 now of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 444 MYSTIC DR MARSTONS MILLS,MA 02648 Owner: PETER KENNEDY Date of Inspection: 9/21/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. 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. n/a 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: n/a n/a 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: n/a n/a 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: n/a CO' Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 444 MYSTIC DR MARSTONS MILLS,MA 02648 Owner: PETER KENNEDY Date of Inspection: 9/21/01 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 h and Public Water Supplier,if an determines that the 2. System will fail unless the Board of Health ( pp t y) 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 n/a "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: n/a Page 4 of 11 �► OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 444 MYSTIC DR MARSTONS MILLS,MA 02648 Owner: PETER KENNEDY Date of Inspection: 9/21/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ X Any portion of a cesspool or'privy is within 50 feet of a private water supply well. X Any poilion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP ,certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I,have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system,fails':The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must.indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ 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 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 syste►it has.failed.The owner or operator of any lame 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. Page 5 of 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 444 MYSTIC DR MARSTONS MILLS,MA 02648 Owner: PETER KENNEDY Date of Inspection: 9/21/01 Check if the following have been done.You must indicate"yes" or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner, occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection '? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of breakout'? X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 444 MYSTIC DR MARSTONS MILLS,MA 02648 Owner: PETER KENNEDY Date of Inspection: 9/21/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 4 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [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)): n/a Sump pump(yes or no):NO Last date of occupancy: n/a COMMERCIALANDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a 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: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1984 Were sewage odors detected when arriving at the site(yes or no): NO 4' Page 7 of 11 f" OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 444 MYSTIC DR MARSTONS MILLS,MA 02648 Owner: PETER KENNEDY Date of Inspection: 9/21/01 BUILDING SEWER(locate on site plan) Depth below grade:30" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 24" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:33" Scum thickness: 0" 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: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE SYSTEM. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a I Page 8 of 11 ti OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 444 MYSTIC DR MARSTONS MILLS,MA 02648 Owner: PETER KENNEDY Date of Inspection: 9/21/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth.below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments q (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.): DISTRIBUTION BOX APPEARS TO BE STRUCTURALLY SOUND PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO . Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a I Page 9 of 11 ,f OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 444 MYSTIC DR MARSTONS MILLS,MA 02648 Owner: PETER KENNEDY Date of Inspection: 9/21/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: nla n/a leaching fields, number: n/a n/a overflow cesspool, number: nla n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): . THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY. THE PIT HAS NOT HAD MORE THAN 2'OF STONE IN IT.EST.2'OF STONE. BOTTOM AT 8' CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a ` Page 10 of 11 '%„ to OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 444 MYSTIC DR MARSTONS MILLS,MA 02648 Owner: PETER KENNEDY Date of Inspection: 9/21/01 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. IA QAa�� At 31 AD Lib 6A 3�L 3a Page 11 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 444 MYSTIC DR MARSTONS MILLS,MA 02648 Owner: PETER KENNEDY Date of Inspection: 9/21/01 SITE EXAM _Slope _Surface water _Check zellar Shallow wells Estimated depth to ground water n/a feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER WAS DETERMINED BY HAND AUGER-NO WATER AT 12'-BOTTOM OF PIT AT 8' ComMONWEALTH OF I)LkSSACHUSETTS EXECUTIVE OFFICE OF E\vIRONMENTAL, AFFAIRS - DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE RNINTER STREET. BOSTON %Lk 02108 (617) 292-550u TRUDY CO.l"E Secretar. ARGEO PALL CELLUCCI DAVID B. STKHS Cotnmiss::,ner Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 0 111f O� PART A CERTIFICATION ," _ _1 Property Address: � � �•L 3)4, Name of Owner Rttw Avl� L�c,vevj CJtC�.��r 5�,1�� _i�� Address of Owner:h Date of Inspection:• ,�+ // , �/ Name of Inspector:(Please Print)/ [ Cyr Q 'l tD ELK U I am a u r DEPa��p..//proved system inspector pursuant to Section 15.340 of Trtle 5(310 CMR 15.000) Company Nam e: 147Y— �r i Elt r^r_r}^_e—' &,ON A.TCA Mailing Address:��_A,, .r 7 �g1..4.- 1�5 N — emu' 41'� Telephone Number: �S _L f 3-FE. /4,,= • Z--G CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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: X_ Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails 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 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 of Environmental Protection. The original should be sent to Ore system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS ( f 1999 70;Wua E revised 9/2/98 page iorii 4i Primed on Recycled Paper Rw r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 'roperty Address: Jwner: Date of Inspection: INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or 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 complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Irr . ~ 1'f revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if t e system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 0 CMR 15.303(1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AN SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a alt marsh. 21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PU IC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC H LTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption stem(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorpti system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorp on system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absor tion system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well w er analysis for coliform bacteria and volatile organic compounds indicates that the well is free from'pollution from that facil' y and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determin distance (approximation not valid). 3) OTHER. 1 revised /9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as described i 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determin what will be necessary to correct the failure. Yes No _ Backup of sewage into facility or system component due to an overloade or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surfac waters due to an overloaded or clogged SAS or cesspool. _ Static liquid level in the distribution box above outlet invert due to n overloaded or clogged SAS or cesspool. _ Liquid depth in cesspool is less than 6" below invert or availabl volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT d to clogged or obstructed pipe(s). Number of times pumped_. _ Any portion of the Soil Absorption System, cesspool or rivy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 fee of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zo e I of a public well. _ Any portion of a cesspool or privy is within 5 feet of a private water supply well. _ Any portion of a cesspool or privy is less- an 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If th well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic tom ounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of a following: The following criteria apply to large syst s in addition to the criteria above: The system serves a facility with a d sign flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environm nt because one or more of the following conditions exist: Yes No the system is withi 400 feet of a surface drinking water supply the system is w' hin 200 feet of a tributary to a surface drinking water supply the system i located in a,nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water sup p well) The owner or operator of a such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department f r further information. revised' 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: N ` l 04y3TL Iv, Owner: Date of Inspection: Check if the fcllowing have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks an&the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with 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, excluding 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 on the site has been determined based on: Y _ Existing information. For example. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) The facility owner (and occupants, if different from owner) were provided with information on the propermaintenanco-of Subsurface Disposal Systems. revised 9/2/98 Page Sertl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty AddressAL1 q IA451"(J Owner: Date of Inspection: :FLOW CONDITIONS RESIDENTIAL: Design flow: _g•p•d•/bedroom. Number of bedrooms (design): Number of bedrooms (actual): Total DESIGN flow-5w Number of current residents:S"Ll Garbage grinder(yes or no): j Laundry (separate system) ( es or no):�: If yes, separate inspection required Laundry system inspected ye or no) Seasonal use (yes or no): D Water meter readings, if available (last two year usage (gpd): �y Sump Pump (yes or no): 0 Last date of occupancy:-"fir COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd I Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: v System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: TYF 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed Of known) and source of information: Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 ,Psgc6(if II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ((}} �� SYSTEM INFORMATION (continued) 'roperty Address: IM U."d T V Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:) (locate on site plan) Depth below grade: Material of construction: concrete_metal _Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: �b�21Joi Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:- Scum thickness: &4 Distance from top of scum to top of outlet tee or baffle: r,Otl Distance from bottom of scum to bottom of outlet tee or baffle: tld tl How dimensions were determined: 0. ,�t�6-�i�+.LL 'omments: (recommendation for pumpinq,conditi n of inlet and outlet tees or baffles, depth of liquid levelL46 in rel ion to outletinvert, struct el integrity, JJd evidence of leakage. etc.) �1L t t; i GREASE TRAP:- (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (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.) revised 9f2/98 Pygc7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM h. PART C SYSTEM INFORMATION (continued) 'roperty Address: ly S N." Owner: 1 Date of Inspection: TIGHT OR HOLDING TANK: ev (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete _metal_Fiberglass _Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes— No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: .. s (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if Ieve.I and �'biljon' i �otual, evidence of�lids rryovers, evidence f leakage into or out of box, etc.),,,, PUMP CHAMBER: (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,•condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) toperty Address: o`f,5 ICs Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):4ij (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: it leaching pits, number:11LLi leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note conditi n of soil signs of hydraulic failure level of onding, damp soil, cond' 'on of vegeta 'on, aAft .) r ., • I A i CESSPOOLS: W (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'broperty Address: 444 W i s h fi )wner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 1 � z 3 tit-33 62-- 5V revised 9/2/98 Page 10of11 i ,• w.1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) roperty Address: Owner: Date of Inspection: NRCS Report name-ty - — --- -- Soil Type— — -- -- Typical depth to groundwater_____ __ USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope NJ Surface water jvP Check Cellar;')2-J Shallow wells 14A. Estimated Depth to Groundwater tto Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established th High Groundwater Elevation. (Must be completed) ��5; ��.�du�dV' (:J revised 9/2/98 Page 11of11 t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONME DEPARTMENT OF ENVIRONMENT OTE nON ONE WINTER STREET,BOSTON MA 02108 92-5500 �. R WILLIAM F.WELD r 3 0 19 TRUDY COXE Governor 9? Secretary ARGEO PAUL CELLUCCI AVID B. STRUHS Lt. Governor A Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: �,44 /��S T �r. /��y.l,,�, �(„-� S Address of Owner:7[e� Date of Inspection: P `1 (If different) Name of Inspector: MA. y ,$_\ Company Name, Address and Telephone Number: 71•C��ox oZ��y i'lr.Sn�`- Mn, oZc.y°� CSuL'a� '111-1�a2d 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 Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: C �a� Date: O \ The System Inspector shall submit a copy of this inspection report to the Approving Authority 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 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 as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: 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, 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 11/03/95) A i� Printed on Recycled Paper or SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A R CERTIFICATION (continued) Property Addre y�ti c ` tr Owner:�� ' L; Date of Ins ection: 41 B] SYSTEM CONDITIONAL PASSES (continued) Sewage back p o breakout or high static water level observed in the distribution box is due to broken or obstructed a. _ �+'"� tpipe(Olpir ue�o?a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Boardof Health broken pipe(s) are replaced obstruction is removed istribution box is levelled or replaced _ The system required umping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with app val of the Board of Health): brok pipe(s) are replaced obstru ion is removed C] FURTHER EVALUATION IS REQUIRED BY T E BOARD OF HEALTH: Conditions exist which require further eval ation 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 H TH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALT AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a rface water Cesspool or privy is within 50 feet of a b rdering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEAL H (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER TH T PROTECTs THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorptio system and is within 100 feet to a surface water supply or tributary to a surface water supply. 4 The system'has a septic tank and soil absorption stem and is within a Zone I of a public water supply well. — within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption s stem and is wrt p PP Y _ The system has a septic tank and soil absorption sy tem and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for colifor bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the present of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• 3) OTHER (revised 11/03/95) 2 ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: t,,e�, 2 Date of Inspection: D] SYSTEM FAILS: I have determined th t the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination ' identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewag into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or pondin 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 . tribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is I s than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 imes in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption stem, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is w hin 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is withi a Zone I of a public well. Any portion of a cesspool or privy is within 0 feet of a private water supply well. Any portion of a cesspool or privy is less than 0 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has n analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, am onia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the crite\(Large The system serves a facility with a design flow of 10,000 gpd or gr System) and the system is a significant threat to public!health and safety and the environment because one or morewing conditions exist: the system is within 400 feet of a surface drinking water s the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) \ The owner or operator of any such system shall 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 11/03/95) 3 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Owner: (, Date of Inspection: c1 Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _LXOAs 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, excluding 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 on the site has been determined based on existing information or approximated b non-intrusive methods. PP Y The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: k Date of Inspection: l FLOW CONDITIONS RESIDENTIAL: Design flow: `3'50 allons Number of bedrooms: O Number of current residents:Q2 Garbage grinder(yes or no): V—c Laundry connected to system (yes or no): 1, S Seasonal use (yes or no):�I—zo Water meter readings, if available: (t;:N Last date of occupancy: st.lar COMMERCIAUI NDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING ECORDS and source of information: —% omw System pumped as part of inspection: (yes or no)Ln If yes, volume pumped: gallons 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: << Sewage odors detected when arriving at the site: (yes or no) -1 (revised 11/03/95) $ r„ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 446 Owner: 1 ' rpre_v Date of Inspection: SEPTIC TANK:14tS (locate on site plan) _ Depth below grade:_A2tl Material of construction: ,Xconcrete _metal _FRP —other(explain) Dimensions: lb(6 Sludge depth: ©" Distance from top of sludge to bottom of outlet tee or baffle: `'Y% Scum thickness:_^It Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 161, 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.) Vso tiz!C8 L Kmy"C-r- 1 J tA •Qum 0t GREASE TRAP:�1I� locate on site Ian) ( p Depth below grade: Material of construction: _concrete _metal FRP —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: 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.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ( Owner: . a Date of Inspection: TIGHT OR HOLDING TANK:_0 (locate on site plan) Depth below g.ade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: q3 (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:Oa (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/35) 7 ii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:z 44 Owner: Date of Inspection: !//y� SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible, excav tion not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_JW'q leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition o soil, signs of hydraulic failure, level of pond i condition of vegetation,etc.) c c) i C UYX�..- V CESSPOOLS: o (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: N� (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.) I (revised 11/03/95) 8 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner. Date of Inspectio : 04111115� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' I t-j y y z 3 l'r 11 --3S' DEPTH TO GROUNDWATER Depth to groundwater: " l O feet method of determination or approximation: 1p uvzvti (revised 11/03/95) 9 I r �s .A No....::�.................. Fxs....:......................... . .,. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH D (U fel ..............oF......... Appliration for Biipoiittl Works Tomitrnrtion runfit Applicati e*made for a Permit to Construct O() or Repair ( ) an Individual Sewage Disposal System at ... .......... &Locasi2L- o AddreLot(o? �. ..a7G.......l s....... ....................�.......... r Address W ................................................. ._.................••.............. ._....................•••-_................ I aller Address Type of Building Size Lot !_ ��_,FP0....Sq. feet U Dwelling—No. of Bedrooms............. .........................Expansion Attic ( ) Garbage Grinder ( ) ..... No. of persons........................... Showers — a Other—Type of Building ��l�. p rP ( ) Cafeteria ( ) dOther fixtures ..............• •-••••......••- W Design Flow........... ......................gallons per person per day. Total daily flow._.......373.0.....................gallons. WSeptic Tank—Liquid capacity./4.01Ckallons 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 ( J) Dosing tank ( ) `� Percolation Test Results Performed bY.......................................................................... Date------....--------•••-r•�•-•--•-•-•---- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.._.1v ...... fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..../ .___. ..................................................n..•-•---•---••-•-.............••-•------.....-•-••-•--------•.......----••---........-••--•-------.•••-- xDescription of Soil..-Q�. ________.. � T.. Qc.�........... w .................................. --•.la......... _ ....-••••........................ . .•••-.....-•-•....-----•-•---•-••-•......... •-------•- 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 provisions of iIT?L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been,'ssue4 by the boayd of health. ,�igne ••• ........ ••--•..................... a..-- Z� P Da Application'Approved BY . .......... /11..._/o ........................... Date ........... Application Disapproved f e following reasons:--••--•------------------------•---•....................-----....--••---------••-•--•-••••-•..._.............. -•-•.................................•---.........-••------••----...-----....-•----.....--•-••------......-•---...............---•---------------•--••------------------•------------•---•••-•-••--•••--- Date PermitNo......................................................... Issued... ........................... I'ai Date i THE COMMONWEALTH OF MASSACHUSETTS / y BOARD OF HEALTH/ � .................OF......... .......'` ....'"!..........------.....---......._........._ Appliration for Biopoii al Workii Tonotrnr#ion Vamit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at Loca�i Addres or Lo .► ..Wit. - .. �: _..--_.... ...�. ._..- R .... ........... r Address W -- :_. ............................................ ................................................................................•---------_......_ I Iler Address Type of Building Size Lot .,FQ0_...Sq. feet Dwelling—No. of Bedrooms..____._.__.._________________________Expansion Attic ( ) arbage Grinder ( ) Other—Type of Building .__ No. of ersons____________ _____________ — a YP g � ---- -- P � Showers. ( ) Cafeteria ( ) Otherfixtures ---• ••••--•-----•----•-------••-••.....-••-•--------••-------•-•-•------ -------•--•••• -•--- -:. ..........•-•--• W Design Flow...........S-V......................gallons per person per day. Total daily flow__-_____--3-'a 7 __.gallons. WSeptic Tank—Liquid capacitv_IV:VjQallons 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 (•f) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..... :..... Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.... s.�®k Description of Soil--- st '? '.7- '-`ue��d�oi -------------------------•----•----------`-.......................................................... V .... •____J -� --------------•-•----------------•-----•-••-•••-------•-•-----•-----...__._......----•-•------•---._....._..-- 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been 'ssued by.the boa�d of health. ined -------•--_....._.. .. a Application Approved BY -- --..._-------------- - .............. r� �' !'.._.._.. ----•---_____---•-----•----------- Date Application Disapproved f e following reasons:------•------------------------•----•--...----•--...._..------•-•--•---•-------.....------......--•-•...._••--- ..---•-...._.-..-•--•---•....................•-••--•••-•---------•-••••••--------••••-•--•--•--•---•-•----•----•-•------•-------...-•---...-•--------•••-•------•--------.......----------•----••---•--- Date. PermitNo......................................................... Issued_....................................................... Date i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............O F........ 1 .. ................................. Trr#if iratr of Tompliantr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (,d(� or Repaired ( ' ) by.................................................. ---•---•-•--•-•-•nstailer...._..__..1. .,y•�,� ,rye -.=!� �- .•----t..._ ! .�.r _. --••---- -- ----- has been installed in accordance with the provisions of T LE j of T}�ez�State Sanitary Cod as vesribed in the application for Disposal Works Construction Permit No. 3-ao.,�_�............... dated_./ l�? .�P.....__„_ ........-........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE SYSTEM LL CTION SATISFACTORY. DATE._Z/L O ... . --•-----• Inspector..... ... .......•-•------•--------..._............_..........----..............-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... ..........OF..f / .... J. ...../ . ..�_ ..............:............ NO.....�........ �4 ....... FEE..ya.............. �io�oottl orko �on��rion .erutit Permissionis hereby granted.............................................................................................................................................. to Cons uct ( -�•or Repair an Individual Sewage Disposal System at No._: + .sWA . /l FLL+9ry/� as shown on theoo../pl.ica // n for Disposal Works Cosruction Permit No.;-...._._ _. __ ated.......................................... Board of Health DATE--_......__.... •---•--•-..._---...••••---•--•-----••-•...... FORM 1255 A. M. SULKIN, INC., BOSTON - F. MOM q Z.o 0 2 0 0 .° 3 2 �- 54 j 7- 3 { f . N � L�733) 5n, At v i /000 7- kit Is I? F ACRE • ' � ' h� Pry e \ \°��dl. 3.v�5�/°!- 7 j /v •.• �u �P��N OF lygss y. o a, - �7?/.✓�-TC -q p '' `) � RSE v# No.10951��0 �F\SIONAL� �'y LEGEND .EXISTING SPOT ELEVATION OxO. Opt �`"�`�+h CERTIFIED PLOT PLAN EXISTING CONTOUR — . - 0 _ . ..— �� RUBE y�� oT .3 Z �sri c. rz�z✓E' FINISHED SPOT ELEVATION U /�°l/a r� 7w ,✓ � 'l o� Ls' FINISHED. CONTOUR 0 ti IN APPROVED BOARD OF HEALTH F�IT �°�; �•• ! ' MA v. DATE . AGENT SCALES /"' °`46' DATES �ELOREDGE ENGINEERING CO. IN. CLIENT = do I4'CERTIFY THAT THE PROPOSED'. 8,3 ? � BUILDING SHOWN ON THIS PLAN ,� i E131STERE REGISTERED J08;N0. ..+ CIVIL LAND ��, �,: t ,._CONF.ORMS .. TO :THE ZO-NING LAWS ,. . ENGINE R DR.BY� Y „Yy s z,n,: OF HA_R1�$TA►BLE ,MASS K 4� �,e�}r .n 712MAI N.-•,ST:F:.EETs,B £` +a4�'. �'I�..B _ �p E •R..;r ;,_•+.-a.,...r+.:'+.� i�`' �M�A I�N F.. "tg' �t K. '9°�? aF .,k�,.'�$ ',G{.':�a%�.�5` _�' r ''! c!"rs�5, get," x 11>t t .. y y^. y{p. N� a ft i +�,.;. ., f t x •"°t•�� 1� .r ! �'�" s'uf Akj' r ` ,}rh a m��'� ;�a +""8 f ,�.�,�"lf�i•i .� - `" .rY.� t�•.,xx'h,'^yt�`5'.��3�u".:. .�„e::ate y�`� r i;°:�, _�... "� ^�?:�„ f.%. _ s.�. .��, ,:'k �s ''"°�.i� '�+ �� • F!^�,L"�e d-,,tr v'' � � � �_''� i +a' ' _ s#ahv:.n3•, � ,h.:..., c'1,..�,�w+�'x�r.'�'�:�e. ,.<.,�.-�'Sfi .- NOTE = /F EiTtitR TXE SEPTIC TA�t/kR /D /�T. MIN. LEACNING P/T ARE .MORE TNAJV /2"B Lopv• GR.�lOarr,�4ETER CONCRrFTYs Cn001.&, + ei"oVC P/Pr SJVAL L &F B Rof'W' I T TO 6/TA Off°..�AN .FFir' 'Rr4 GO/0/GR!?E' MtN. P/TCN h+EAYy C�1 ST IRON CO✓G6R Sh�ALG t3E LS"17 a L'. 1 v COYERS �.�, fr !F/,v .GR/VE=W'4 y A e R MiN. G'ONCRE TE' CO YE.4 CLEAN .SANO Q &ACA,=/CG 4"CAST 27L R AYE IRON P/PF -3/�r M/N..P/TC/1t ` GAL.. q y♦a o 1D ♦ o• or f%4 _ •. •. • ♦ •• • e PEit1? SEPTIC TAMI D/ST. • •. • • • • • • '° WASNED 5704?,E BOX 1I B1 t • to i ♦ b e • � • p • • • • •I • 4 �. .�.d377 • o I DEPTH •&, , a o WASHEP S740NE r 37 T �Sl x Zi , s • o • I • l • ... • • A /C3 x op • • a• a • • . • • • •. • D ,�v PRECAST SCUSAMaE Pt T �9h�4ct II- 40 G.4-L: o, OF • • • i • • . • • • e ' • P/T OR'EQ J/V- r�wvE/c-r �tEY,�-iays -rY. / r /NYERT AT AVIAD/NG ! FT. INLET AMP'T/C T.4/VK t u 2S 6 Z f7: 0/.4M. :. C'CSEE 720"�t77 10U74E7'SEPT/C,.7A* N/{ l- °�• `FT. �'` /0 7..0. /INLET D/SZR/RIIT/ON BOX FT. GRD[/NO: TER TAQLE SECT/O/V OF O{/TLtTD/STR/Bt/7"/ON BQX / �FT INLET LEACN/NG Imo'/.T a g�:4FT •S�N/�4GE L7/SPG�TA L .SYSTEM T��,,�T/DN L EACfH/NG P/T DESIGN CMI TER/A se.rtE %s" _ /=o:"- o/M6Ns<ON A 3 FT. DJINA NSICA B FT iYL/MBER OF 9EDR04MS 3 D/MENS/ON C,, FT;M t G�RQ,4GED/SPO.S,4L UNIT ��"�E SOIL LOG 7-4a7-AZ EST// i'TED FLOif/` 3 3 GAL.�DAY` DSO/L TEST #/ SO/4 TEST#2 SOIL TEST / �S/llMBER QF 40AtX/NG P/7-5 /St f"'1— f 0.7•ss �... Y ,OATF op- SOIL TEST S/OE LrACH/N6 PEM PIT F BOTTOM 404C /NG PER P/T 1 �3 sq, �tT o.. U Z .� RFSLLTS Ja/ITNESSED dY 7?3 E� 26 •� LOB--M PERCOLAT/ON RRTE TOTAL LEAC'N/NG •4REA � Q S FT. y Su.�S v i PENC•OLAT/ON RATIF 2 THR r✓ RESER{�ELEAC'NINc$,A�QEA Zb`Q SQ. FT �v M/N�/NCH Z / � r So IL Tc-s7- P-z6 0 7 OF /vtD is/ �t OF M, � �N M4ss9 T .3 z �'}l5 7- C. -PR,IV E or� ROBERT yG�� ALB /y1.4 RSTO/lOS /g BRUCE ; g _ v No:10951 O w �� FLORED6.@�EMG/N.E'EJP/JyiG CQ,/NC. pO�FGISTE�`,��u CL. 7 S`$ 7/2 MAIN 9T,, NYANN/9, MASS. �9vo V FS ;ONA� (g NDGI*OLIN&7 YYA7X EJVCOCIV7.M—G CL/ENT S 8A ys'lPE D.(TE' //' 4 83 Q GRO uIVO' Lti/s►TER .�1T ELEb!. .IOB NO. HELST'z OF Z- TOWN OF BARNSTABLE LOCATION yyl /'f stf� iye SEWAGE# VILLACIE /tfAl ASSESSOR'S MAP&PARCEL O —O INSTALLER'S NAME&PHONE NO. 17, L Gv-, f>_` SEPTIC TANK CAPACITY /000 LEACHING FACILITY:(type) (size) 2�7X //• 3 NO.OF BEDROOMS. .3 OWNER T PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet j FURNISHED BY 6a� /3 � i A 30 i TOWN OF BARNSTABLE LOCATION SEWAGE# Ol/-/O�J VILLAGE ,q/t ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. i), L. .�7� /76 46y1 07` SEPTIC TANK CAPACITY /000 LEACHING FACILITY.(type) /ar! (size) NO.OF BEDROOMS; OWNER c✓/ PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Wafer Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet r FURNISHED BY r 31 3 5 S� 7® 5 T-6WN OF 1✓ARN_ ST.ABLE LOC AISIy �� J �-� �, -I , SEWAGE 4# Vl%:LAGE31JS t-Al\\S ASSESSOR'S MAP&LOT L�() INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1Ocn5vk I. LEACHING FACILM: (type) (size) SO.OF BEDROOMS BUILDER OR OWNER DATE:��1�5 _COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the . . y 1 Feet � Private Water Supply Well and Leaching Facility (If any wells exist can site or within 200 feet of leaching facility) 0, Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by_ �C�`� rYCE,�I LN o � � A2-33' lbt- 3L A,3 a9` t6 ;- 3, TOWN OF BARNSTABLE LOCATION 7 SEWAGE # / oft VILLAGE /1/S !-�S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1,400 LEACHING FACELn Y:. (type) Y-4 G4/7—(size) /d e NO. OF BEDROOMS �3 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Op M31 k 3� LOCATION . y SEWAGE PERMIT NO. VILLAGE INST LL 'S NAME i AD RESS BUILDER OR OWNER DATE. PERMIT ISS ED ��_ � DATE COMPLIANCE ISSUED �. . r <_ ., c A � o y. �a ( � � a b �� i t �`� 5�� ti TOWN OF BARNSTABLE ) •' LOCA'Tc)N, U SEWAGE # �� -r� 1c_ 1 `PILLAGE 4 MMt IITIA,I,�� ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 2S BUILDER OR OWNER 7e:C J% PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by rk k 3� , g1-OIA& A1_33 92-32 R3-Al' 63- 37 a N -- 98 -- EXISTING CONTOUR ® X W 98 EXISTING EXISTING WATER R SERVICE pGT GRADE 53 -G EXISTING GAS SERVICE pg 203 Old Falmouth U UNDERGROUND WIRES Rd TEST PIT BENCHMARK Q o LOCUS o LEGEND � s ass Drive �o �, 2 \ LOCUS MAP s 200 00 ` \ + NOT TO SCALE 1 3.02 1 do \ \ \ 1 1 1 6 '� \\\ ``\\ C? ©1 1t 1 1 It \ 1 1 1 t I II 1+ \ 1) 1 \ 1 O I It IA I r 1 1 � 1 1 1 r , 1 \ x 54.4 (A G) i ►UN ------- r 0 p ;+ Sr r-------J 1 - 1 (LOT 32) APN 061 -024 OD W; 54,800 S.F.t \ 1 o t N N \ ;� .- �_ .� r -.� • ._� -;.,�• .. . . � --..•.- .. __ ---•.. - ---- _• :_ .-- `- - - .-,.. _,. .. ..... \ - � _-,-- �.� _ _ ,...,,.•-tip - 54.02 "''----__ \\ 60.01 -'3.43 ` sa.28 DECK , � ' (walk out bsmnt.) + .57 / GS/ i /EXISTING HOUSE(#444) 0e: 53.28 (j,j T.O.F.=61.St ` \` s3.95 ♦ S� i 54.06 SHRUBS SNRUB$•....... "" 0.42 +59.71 ` 60.33 E_X;'STIIJG SEPTIC TANK `! PAVED �� o \ + o.v 61.91 �� I I DRI1/EWAY _ sp, SLEEVED SEWER TOP OF TANK, EL.=58.31 1 1 1 ' \ v os INV.(OUT)=56.98± + 1\ �♦ 52so 53.24 \ �\ i + 3s 59.77 ; x 4.,79 ♦ ♦ E / 10' EACH SIDE OF (FIELD VERIFY) \ � `� ♦��`�'`.� 4.31 55,83 \� + c) " ! WATER SERVICE q \\ ` 9`9 +61.4 00 `\ &\\' \ \`\ 52,38 LAMP EXISTING LEACH PIT 1 TO RE PUMPED, FILLED W/ \\ \` a6 z \ `\ 6 , SAND AND ABANDONED 3.9 c� s o \ �� \, +60.86 ' \ C) 11-5q [ �' x 42..y ,1- ) 1 z 50.31 03 o I TP- ' i �♦ VENT ' QS i 52.37 13.49 ?' TP-2 }57.24 BENCHMARK NO.2 , ' TOP OF GAS SHUT-OFF �n 51.43 , rs3 s6.18 +s7.00 ,moo ..0 � EL.=53.06 ASSUMED DATUM i `\ E _ +tZ07 .I+-48.4i r .R=2�'7-1• 57,50 r �' .20 I _ � so.9s EDGE s1.r pf- `s.z9 52.59 �- 5011 i PA _� x 54.5 } r Eti1EiV r 1 4 � 49.07 b MI STI�. PRIVE BENCHMARK NO.1 •s1.33 r' RIGHT OUTSIDE CORNER OF START BOTTOM STEP EL.=66.86 ASSUMED DATUM PETER T. PROPOSED SEPTIC SYSTEM UPGRADE PLAN McENTEE 444 MISTIC DRIVE, MARSTONS MILLS, MA CIVIL No. 35109 Prepared for: J. C. Aalto, P.O. Box 339, Morstons Mills, MA 02648 , ,-OWNER OF RECORD �fPSZE� �� Engineering by: SCALE DRAWN JOB. NO. KENNEDY, PETER J & KIMBERLY T OFFS E Engineering Works Inc. 1"=30' P.T.M. 135-11 444 MISTIC DRIVE 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. MARSTONS M LLS, MA 02648 �I7jfl( I (508) 477-5313 4/20/11 P.T.M. 1 of 2 I NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL:55.33 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. INSTALL RISERS 8c COVERS OVER INLET & INSTALL RISER & COVER INSTALL INSPECTION PORT OVER END UNIT T.O.F. OUTLET AND SET TO 6" OF FINISH GRADE SET TO 6" OF GRADE CHARCOAL EXISTING F.G. EL: 60.3(MAX.) VENT F.G. EL.=59.8f � F.G. EL: 58.3t MAINTAIN 2% GRADE (MIN.) OVER S.A.S. L = 45' L = 8'(MAX.) INSPECTION ® S=1% (MIN.) ® S=1% (MIN.) PORT 4"SCH40 PVC 4"SCH40 PVC 6" 10"1 6 4" 11.3" TO EXISTING 48' uOUID INVERT DUEL DD GASABAFFLE� INV.=55.47 PROPOSED INV.=55.30 r4 ROWS OF 4 UNITS AT 6.25'/UNIT INV.=56.98t D-BOX INV.=54.94 EXISTING 4 OUTLETS (MIN.) SOIL ABSORPTION SYSTEM (PROFILE) EXISTING SEPTIC TANK ESTABLISH VEGETATIVE COVER BACKFILL WITH CLEAN NATIVE OR PERC SAND TO TOP OF CHAMBERS NOTES: BREAKOUT EL.=TOP EL. 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE TOP ELEV.=55.33 INVERTS, PRIOR TO INSTALLATION. INV. ELEV.=54.94 2) D-BOX SHALL BE SET LEVE._ AND TRUE TO GRADE BOTTOM ELEV.=54.00 II III�IIIII�II ON A MECHANICALLY COMPACTED SIX INCH CRUSHED STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). 5' MIN. ABOVE BOTTOM OF 3) INSTALL INLET & OUTLET TEES AS REQUIRED. T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH=11.3' EXISTING SUITABLE 4) CAS BAFFLE TO BE INSTALLED ON OUTLET TEE BOTTOM OF TP, EL=46.0 - MATERIAL AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. 4 ROWS OF 4 - 16" (H-20) ADS BIODIFFUSER UNITS WITH NO SEPARATION BETWEEN EACH ROW & NO STONE SEPTIC SYSTEM PROFILE TYPICAL SECTION MS N.T.S. SOIL LOG GENERAL NOTES: DATE: APRIL 19, 2011 (REF#13,245) SOIL EVALUATOR: PETER McENTEE PE 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL WITNESS: DAVID STANTON R.S. HEALTH AGENT BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS ELEy. T P- 1 DEPTH ELEv. TP-2 DEPTH OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS EXCEPT AS REQUESTED BELOW: 58.0 A 0 57.5 A 0 -310 CMR 15.405(1)(b): SANDY LOAM SANDY LOAM 1) A 2' variance to the 3' mo<imum cover requirement, for 5' of 57.3 10YR 4/4 56 8 10YR 4/4 max:. cover. S.A.S. shall be H-20 and vented. B 8 B 8 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR _�_, _. SANDY LOAM _ .. SANDY LOAM - _TO rNSPECTION`AND-APPROVAL BY'THE BOARD OF HEALTH AND THE 1 OYR 5/8 10YR 5/8 DESIGN ENGINEER. 55.0 36" 54.5 C1 36" . - 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING C1 36ER/48" SILT LOAM FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 5Y 5/3 ENGINEER BEFORE CONSTRUCTION CONTINUES. 52.5 60" 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. MED. SAND C22.5Y 6/4 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF MED. SAND THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 2.5Y 6/4 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 46.5 1 138" 46.0 138" 8. THERE ARE NO WELLS WITHIN 15D' OF THE PROPOSED S.A.S. PERC RATE <2 MIN/IN. (IN MED. SAND) 9. ALL AREAS CLEARED FOR CONSTPUCTION SHALL BE RESTORED AS NO GROUNDWATER ENCOUNTERED AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE ' DIRECTED BY THE APPROVING AUTHORITIES. 75" . 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS IN THE .AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE 76 INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. PROFILE 13. POOL SHALL BE DISMANTLED AND MOVED TO PROVIDE ACCESS TO THE EXISTING SEPTIC TANK, IF NECESSARY. ��v t r -1 Q) 16" 11 34" 0- DESIGN CRITERIA SECTION END CAP NUMBER OF BEDROOMS: 3 BEDROOMS 16" HIGH CAPACITY (H-20) BIODIFFUSER UNIT SOIL TEXTURAL CLASS: CLASS I MODEL 16" HICAP UNITS MUST BE STAMPED H-20 DESIGN PERCOLATION RATE: <2 MIS'/IN LENGTH 76" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT DAILY FLOW: 330 G.P.D. EFFECTIVE LENGTH 75" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY DESIGN FLOW: 330 G.P.D. SIDE WALL HEIGHT 11.2" DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. GARBAGE GRINDER: NO OVERALL HEIGHT 16" LEACHING AREA REQUIRED: (330) = 445.9 S.F. OVERALL WIDTH 34" 4640 TRUEMAN BLVD •74 13.6 CF 1=6 HILLIARD, OHIO 43026 EXISTING SEPTIC TANK: 1000 GALLON CAPACITY CAPACITY (101.7 GAL) ADVANCED DUNAGE SYSTEMS, INC. PROPOSED D-BOX:: 1 INLET, 4 OUTLET (MINIMUM), H-10 RATED USE 4 ROWS OF 4 - 16" (H-20) ADS BIODIFFUSER UNITS PROPOSED SEPTIC SYSTEM UPGRADE PLAN W/ NO STONE FOR AN S.A.S. WITH DIMENSIONS 11.3' x 25.0' 444 MISTIC DRIVE, MARSTONS MILLS, MA HIGH CAPACITY (H-20) INFILTRATORS MAY BE SUBSTITUTED Prepared for: J. C. Aolto, P.O. Box 339, Marstons Mills, MA 02648 SIDEWALL AREA: NOT APPLICABLE Engineering by: SCALE DRAWN JOB. NO. BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.7 SF/LF OF BIODIFFUSER) Engineering Works, Inc.nc. NTS P.T.M. 135-11 16 UNITS x 6.25 LF x 4.7 SF/LF = 470.0 SF 9 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. DESIGN FLOW PROVIDED: 0.74 x 470.0 = 347.8 GPD (508) 477-5313 4/20/11 P.T.M. 2 Of 2