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HomeMy WebLinkAbout0490 MISTIC DRIVE - Health 490 Mistic Drive,'— Marstons Mills A l i 061=021 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M y` 490 Mistic Drive Property Address Steven & Barbara Paglierani Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/27/2015 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. Important:When filling out forms A. General Information on the computer, , ✓ -1 1 use only the tab 1. Inspector: I I key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection my Company Name 74 Beldan Ln. Centerville Ma 02632 Cltyrrown State Zip Code 774-2484850 smjonestitle5@gmail.com SI4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3/27/2015 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 490 Mistic Drive Property Address Steven & Barbara Paglierani Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/27/2015 page. Cityfrown 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: The dwelling located at 490 Mistic Dr Marstons Mills is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a 1000 gallon precast leach pit. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-3/13 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 , 490 Mistic Drive Property Address Steven & Barbara Paglierani Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/27/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): I 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 490 Mistic Drive Property Address Steven & Barbara Paglierani Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/27/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **-This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 490 Mistic Drive Property Address Steven & Barbara Paglierani Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/27/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 490 Mistic Drive Property Address Steven & Barbara Paglierani Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/27/2015 page. Cityfrown 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? *' ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information `- Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 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 490 Mistic Drive Property Address Steven & Barbara Paglierani Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/27/2015 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: 2013= 122,000 total = 334 gpd 2014= 127,000 total = 348 gpd *includes irrigation system Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 490 Mistic Drive Property Address Steven & Barbara Paglierani Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/27/2015 page. City/Town State Zip Code Date of Inspection D. System Information cont. Y (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 490 Mistic Drive Property Address Steven & Barbara Paglierani Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/27/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: original system 1988 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 2.5'-3'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 gallons Sludge depth: 61@ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , yy� 490 Mistic Drive Property Address Steven & Barbara Paglierani Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/27/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 3„ Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 3" 611 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Inlet cover on riser Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •'' 490 Mistic Drive .Property Address Steven & Barbara_ Paglierani Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/27/2015 page. Cityrrown 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.): Tig ht or Holding Tank(tank must be pumped at time of Inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 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 490 Mistic Drive Property Address Steven & Barbara Paglierani Owner owner's Name information is required for every Marstons Mills Ma 02648 3/27/2015 page. Cityrrown 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 01* 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.): Distribution box was video inspected and found to be in good condition, no rot, water level was even with outlet invert. Pump Chamber(locate on-site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .490 Mistic Drive Property Address Steven & Barbara Paglierani Owner Owner's Name information is required for every iMarstons Mills Ma 02648 3/27/2015 page. Cityrrown State Zip Code Date of Inspection ID. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was video inspected and was found to have 2'of available leaching with no sign of past hydraulic overloading. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 490 Mistic Drive ` Property Address Steven & Barbara Paglierani Owner Owner's Name information is Marstons Mills Ma 02648 3/27/2015 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 , y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 490 Mistic Drive Property Address Steven & Barbara Paglierani Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/27/2015 page. Cityrrown 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 i i I I B i a O Z n3 A i3Z 31 A pry `i 5 ay = sz t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 490 Mistic Drive Property Address Steven & Barbara Paglierani Owner Owner's Name information is Marstons Mills Ma 02648 3/27/2015 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 1 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 490 Mistic Drive Property Address Steven & Barbara Paglierani Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/27/2015 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 9/13/21, 12:56 PM ShowAsbuilt(1700x2800) i TOWN OF 13APNSTARLP - LOCATION Laf '°`. e �35 M ,: D,- SEWAGE p. a-3,3� VILLAGE S—d%c.A.7 Lakes _ ASSESSOR'S MAP&LOT INSTALLER'S NAME.F.PHONE NO. �� rJ C jr SEPTIC TANK CAPACITY LEACHING PACILITY:(type)_ (size)_ /coo NO.OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER P�61;c. BUILDER OR OWNER_$ e! ASa6c7Q4ES DATE PERMIT ISSUED: DATE COt1PLIANCIIISSUEDL_�-L(- �S VARIANCE GRANTED: Yes No GSc, 9 y /08 �. 191 https://itsgIdb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=061021&sq=1 1/1 (� 00, No..-. - .-......3_.f �.. i IC$....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 0 ------ --....OF.......................................................... D i Applirta#i n for Uii#usFal Workri Cnomitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .....! xd....3.5----.�A-3 i l.r. ... .�al�ll. •-/�►1`'n,. � t-t, 5, as.., -g- Location-Address or Lot vo. �-�- �g ...'�`� It :... r�t9l..... f..: j- Owner Address .............................. ....... D= .... s ue d!►_ pZc y 75� Install8r Afldress d Type of Building CXV I G� M- �'©` /s�oa� Size Lot._/__,*•..__I......Sq. feet U Dwelling No. of Bedrooms..............�_____.--_-___-•_____ .Ex Expansion Attic a g— ---- p ( ) Garbage Grinder ( ) aOther—Type of Building 74-S4 j,r��jSZ No. of persons____________________________ Showers ( ) — Cafeteria ( ) Other fixtures ________________________________ W Design Flow...........................................gallons per person per day. Total daily flow.........3L:i_2i..........................gallons. WSeptic Tank—Liquid capacityZOOCkallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area________---_____•---sq. ft. Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed I 1.X :__.__..___ Date___._.wl.:-1.2.-"��_��......... .. Test Pit No. I.......a2......minutes per inch Depth of Test Pit.../.19Y_. ___ Depth to ground water._/_��t�___.__. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (x •---•-----------------------------------------------------------------------------------------------.........................................................O Description of Soil•---�+C�i_v'`1....... ff/�.�r....................•--••------------------------------------•------•--------------------------------.....---------- . x W UNature of Repairs or Alterations—Answer when applicable---------- ........................................................................ Agreement: The undersigned agrees to install the aforedescr dividual Sewage Disposal System in accordance with the provisions of i?1 LZ 5 of the State Sanitary Cot—The ndersigned further agrees not to place the system in operation until a Certificate of Compliance has bee ued by t1p boarq of health. Signed..... -•--•....... . ...................OM.•-•----•-•-•---.............. Da Application Approved By................. ► - -•�_ � //'' /te ` Date Application Disapproved for the following reasons:-----•-------••----------------•----•--....-•--------------•-------------------•----------------------...--•---- ....•.............................--•---------........................•-•.................................._ -----•--•-•--- Date PermitNo...: - --• .......... Issued....................................................... Date r` a No.... V'4 Z THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........-...... ------------_---------OF.................................... Appliratinn for Disposal. Works Tonstrurtiun rrutit Application is hereby made for a Permit to Construct' ( ) or Repair ( ) an Individual Sewage Disposal System at: ......�.i3e..... ......1: .A t.1.�.._.: .i 1.I1. 7.....[ �/112.'•.J e v ....! h1.! I__.'.....................L:_Ctk.. ...................................... y_ f Location--- !Address or Lot No. , , .._1i.,tl.n. A�i f'f ... M . ......... kJ_e ti; :!l'�i T Owner Address .........Y .il..... Ct dl.7 e°:/? :�-Y-f��----------------------------- ...i _... t .G_t..;:,I....� / Installq A ress d Type of Building T)a U C-O a"q d ...Sr _.. feet a./ �1 Size Lot__./___f?�_._____. U Dwelling No. of Bedrooms..............a......_....... ._...Ex Expansion Attic a g— -•--- p ( ) Garbage Grinder ( ) aOther—Type of Building of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ---•-------------------•----------•----.......-•---------••-•----------...._..--------- W Design Flow............................................gallons per person per day. Total daily flow---------`k.1-{-_-----..................gallons. WSeptic Tank—Liquid capacity..C._�gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----_--------------- Diameter.................... Depth below inlet......_............. Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed - ........... Date......f...:.I__Z 1_4-......__.. W ,a Test Pit No. .......... per inch Depth of Test Pit_...f"'�-Y..�.. Depth to ground water---/]&A,IC6._---. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ Ix x ---------------------------••-••-•--•--.......------------.....------...-------•------..._..__....-----•----._._...--'-----------O =- escr tion of Soil...../ ------ �� ---••.........................•-•------------------•----•------•••.I ' _ .:: �. W .. r:, UNature of Repairs or Alterations—Answer when applicable........... tV. .................................................................... .. ..--•-•-------------•---••----•-••------•--••-•---------•------•----------•-•---------•---•-••----.......--- Agreement: The undersigned agrees to install the aforedescrib dividual Sewage Disposal System in accordance with the provisions of I T:.,. p 5 of the State Sanitary Cod — The dersigned further agrees not to place the system in operation until',a Certificate of Compliance has been i5`iied by th boar of health. Signed ------•... . = - -•--•-•-- ------------------- A lication Approved B Date �•--••-•-•.................. Date Application Disapproved for the following reasons:--------•-----••----•--...-•----•-•-------••-------------••---•--•----•-----------•--------------------......._. --------------------------•-------------•---.--------.........-•--•--------------•--•------••--------------- Date PermitNo..---?1a.:.... ......................... Issued-------------•----••-----------..............--------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - I ....... v�....OF...........LI��._��� �: .a... TleriifirFa#r of ToutpliFanrr THIS IS TO CERTIFY, That the dividual Sewage Disposal System constructed (--<or Repaired ( ) ,rrl:.....C'�a 1..... by---------------------- . ?.fir.� .::T........:........ .. .,�V 4...f"�. ---- �`'��---e'-G------------------------------------- Installer at---•--•--•------•�:-<1.. =. = ....1�1..! = / ' -�' ------_-- has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...... ............ dated............................. .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................... .-.��. ............................... Inspector....................... • •--.li�)........................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH :�:�7. ...............O F...-.......... s�,•x.< .ell ............................... No....0gt ..-.•. FEE. Disposal Works Tuns#ra Uan rrutit Permission is hereby granted------..... '" '�--•------....__.-----------------------------•-•----•------•--•-----•---------.. to Construct (>- or Repair ( ,) an Individual Sewage Disposal System at No.. 1� -�� mo d.:' .. .\`� 1!:.........&._:../.�!!------. Street as shown on the application for Disposal Works Construction Permit No..�\�;__,��_�f_ Dated.......... ..�?f-�N'_.�...... t -- ' ...• ....... Board of Health DATE'_/ARREN. -.:! ------------------------ :. FORM 1255 HOBS & INC.. PUBLISHERS ... .. . .... DN ------ ---- . . .. ......... TERRACE+ w _ WOOD DECKI 78'-Z' I e'-4' O 11A1►tY 12�-i1 O O IJ'-0' 4'-4" ® 4'-4' © %•-0" O 3'11'..4' 6 4" oZ `1 R.NO-ABOVE c { b- 7Z`JACUZL TUB �O 6 z6 ' DML 'a q ° BREAKFAST ®® KITCHEN —1 0 1•QFfi'6' O ®A --0` n LINENFAMILY ROOM ®° teal RA!ING MASTER BEDROOM VAULTED CEILING -_____ _______.-__1_ it•-6' 11•-.y^ t y : O 3'-2, i WALK IN CLOSET 1LL NEN n b -- RAISED t � - y'6•z5.6'. HEARTH ° BATH ��¢ Id -- 6'c'rxttNNCH DOOR NI- 1 om PANTRY 2'ti'x6' DOOKS ROOKS 6'0" �/Z ROUND-ABOVE w AREA 3'0'ARCH.GPHG. 4 CLOSET _ r GATHEDRRqq+L.CSUNG 11 .(AOdVE) LIBRARY/BEDROOM DINING 1 FOYER LIVING ROOM 3 �! 1 a , 2'G':6'6 1! SLATE J o ,! BEDROOM #2 BEDROOM ly3 12-2" 8` i9'-10' .2'-10" + I CLOSET OE .1 ,I -0-- F----l- } di; I , 7' 0" 12'-0' 7' 0' 1. 11'-4` 11'•-4' 3'-0` 3'-0- 40,-o., ® E. 201-0. F 14,-6. ..-_. .. 104--6" FIRST F `�- 4100 . � TOWN CF BARNSTABLE LOCATION Lce �5 �, Stt,C— SEWAGE #. 33� VILLAGE �.�d•'c N La d�GS_ ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO._��,t„ Cc ) c ,� 3`l8 -DEi3S j SEPTIC TANK CAPACITY i LEACHING FACILITY:(type) (size) 6 %000 NO. OF BEDROOMS_ PRIVATE WELL OR PUBLIC WATER 6(,e. BUILDER OR OWNER DATE PERMIT ISSUED: �1 DATE COMPLIANCE ISSUED=I VARIANCE GRANTED: Yes _No� i ��. e7�.� 10 S YS TEM PROFILE NOT- TO SCALE _ TOP FDIC t FINISH GRADE-0 Z- FINISH GRADE OVER FINISH GRADE OVER DIST. BOX 91 . SEPTIC TANK -OZ . FINISH GRADE OVER LEACHING PI T 00. 0 VARIES "M� 0' o,� .o. p' .'o:{; •,':•,.�: :a:e'e't;e:�:i.,..e..y ?:. •e; i.�• •.r�• " " .� ?a 12• MAX �I s• :e.:d. •••.:< •o.-::.:• :.:. ..•.. . •e:..•:,: •o 3 OF 1/B 1i PRECAST CONC. OR SHED PE.4STONE .;�:_ ...,o:• o: RTAR 3., BRICK 22 6BE�OW OUTLET PIPE LEVEL O GRADE o.: FOR 2 FT. MIN. ••a �J.• P. o•. °.e P�9.78 •iz 0 " g'9 53 _ .ts•3 e: .:••f.. o: : C. I. OR PVC TEES 9 (0 :e'o.:► :e. tie d •p ;o; e. e. • o• j BSMT. FLR. 1, 250 GALLON '._DISTRIBUTION BOX � EL .<`�G.00... PRECAST CONCRETE INSTALL ON LEVEL BASE ,3/4" TO 1-1/2" 0 3 '-7" Q o: -.,• : .:o. ✓ASHEO PRECAST e..c.:a... /y�— /O .REINFORCED y s CRUSHED k CONCRETE # ~ STONE o;pA.:s—a.. p .ae•p.e.. ••'i..6. 'p.• �D000: I _ I: ,!: ° 6: b e,d a o 0 0• .e. e e = ! a H— /0 REINF. SEPTIC TANK ° ei INSTALL ON LEVEL BASE +_ NO EXCA VA TE TO ELEV. 16 -r OR _ L OWER TO REMOVE. ALL IMPERVIOUS = - +-., .•�' i MA TERIAL BENEA TH THE LEACHING AREA 2 •_0 " - 2 '-O " REPLACE EXCA,VA TED MA TERIAL WI TH ' _. - 6•_0 •• - CLEAN, CLA Y FREE SAND , 10 '-0 " - EFFECTI VE DIAMETER b L.EA CHING PIT GENERA L NO TES ` 1. AL L EL EVA TI NS SHOI✓N ARE SA SED ON FIELD SURVEY_' INSTALL ON LEVEL BASE ., 00 •�8 •' 88 �O `2. ALL PIPES I � THE SYSTEM MUST BE CAST IRON _ �8 :90 \ 9 Z OR SCHEDULE 40 PVC. C ca - _-P. � } eta✓�.r i'i Ti�� s .:. s e9 le•d E 3. THE BOARD OF HEALTH MUST BE NOTIFIED 3.00.00 .. . ' ° t)4 WHEN CONS TRUE^TIOV IS COMPLETE PRIOR P-56711 - 8Z \ : N = PERCOL A TION RATE.' - • TO BA CKFIL L �• __ 4. ANY CHANGES N THIS PLA7V MUST BE APPROVED 2 MIN./IN. O j BY •THE BOAR . OF HEALTH AND CAPE 6 ISLANDS NITNESSED BY• SURVEYING Co.. 7P✓C. McKEAN T. SO WATER SERV. 5. MATERIALS A 7 INSTALLATION SHALL BE IN W + ►i; , COMPLIANCE 7u THE STATE SANITARY B19BLK�_BRD. OF HEAL TN DESIGN DA T'A `n Z -- ---- DA TE.• s1U1YE_1 Z ,t9.$6 CODE - TITLE V - AND LOCAL APPLICABLE E ' �(1 IP50 GALLON o Q - - - o.`� O RULES AND R ULA TIONS o 0 0 d _ PRECAST CONCRETE o NUMBER OF BEDROOMS '" 4 o h _ d SEPTIC TANK e V 6. NORTH ARROW .S`:FROM RECORD .PL ANS AND - 0 " 3 - O 5- ~ o ti S NOT RO S USED FOR SOLAR PURPOSES GARBAGE DISPOSAL NO a ai I TOPSOIL 6 + �� ) y 7. ;F! 000 HAZARD- ZONE C _ SUBSOIL DAIL Y FL ON , 440 GAL . + I I• • N _ N B. WA TER SUPPL Y� TOWN WA TER 24" SEPTIC TANK �REG� 'D. - 1250 GAL . LOT 35 1 xz• N 1 i SEPTIC TANK PROVIDED 1250 GAL . 45, 00-0 S.-F. a LEACHING REOUIRED 440 GPD. C32 v '. � ,•_ _ E CONCRETE ' • L�1 6 PIT _ / MEDIUM _ goo.oo = SAND � _ N e9'te.4 •�✓ i SIDEWALL AREA 225 S.F. 90 9O -34 225S.F.X 2. 5 G/S.F. - 562GP0 84 �2 �2 _ �Z _ BOTTOM AREA _ 1575.F. • 88 - L EGEND �1S.F.X 1. 2 G/S.F. = 157G`PD 1 LEACHING PROVIDED - 719GP0 _ R0POSE0 EL EVA TION 144" NO GROUNDWATER ——50—— XIS TING CONTOUR - 7BSERVA TION PIT _ SINGLE FA MIL Y RESIDENCE ❑ ISTRIBUTION BOX ��P��N Of MAss4 RICHARD `yam PROPOSED SENA GE DISPOSA L S YS TEM / .. 1AMES �•, Q �.EACHING PIT BERTRAND y No. z9894 PREPARED FOR �} �`rISTER�� - o o SEPTIC TANK �rr�ONAI CAMMET, T CONSTRUCTION R P RESERVE N OF M, LOT 35 MI S TI C DRIVE 4?� IDAVID BARNS TABLE MARSTONS MILLS — MASS. 00.0 PIPE INVERT ELEVATION C�HARLES sN s,ANICKI DA TE.•OGT. 30 19&G CAPE 6 ISLANDS SURVEYING, INC. PLOT PLAN SCALE AS NOTED SCALE., .t "=40' Z 3 �s00 P. O. BOX 334 - MAP SEC PCL LOT MSE i � .i''r1�-� ci Y _ ..-.._.- __.. s PLAN NO. 53518� TF.A TICKET, MASS - S YS TEM PPOF- L x j NOT TO SCALE III TOP FON. FINISH GRADE 407 Z. FINISH GRADE OVER EL .g3.5Q P�0:1 FINISH !"TRADE EVERDIST. BOX -0 ( FINISH. GRADE OVERC SEPTI TANK Z LEACHING PIT ' . 9C?. D ° VARIES � •RZQ7I �C`? 77`,(C�, 3" CF 1/8" 12« MAX ° . . .o. PRECAST CONC. OR r ASliEn PEASTOME ,�P :o..�. BRICK 6 MORTAR e OUTLET PIPE LEVEL TO 12" BELOW GRADE FOR 2 FT. MIN. e 'D '°'=p:0:b-;•° . o .. •00 0• u - -•D �,: ' ' J� s:. a o: 6„ :::• •00 "_':''?'. . ... . .,_._ .? •R.. i 0-. :. D:° b.• a V✓.55 p,.�3 .e:::.+,:o.i ,•o.. ' •O:'p:.b•.',p•.,e.p.o: .� :oD _O'.Q'e•.' D"4.0. �- 84-4 O .b A'.e; 0 C. I. OR PVC TEES �' 8�•Z� BSMT. FLR. GALLON e •o D. }, T . ''BL/T.T'ON BOX o' `INSTALL ON LEVEL BASE ' 3 ._7„ S T CONCF��E TE" y 3/4 " TO 1-1/2" 6 ��, o o,•o.. .o..o: D;•: o •. C: o. ! ECA S T p o::o'.•°'•'p•.•0:'0 t? ® ®/�"� n ? WASHED o :4 CRUSHED a '¢ p• CONCR�E�� e: S TGNE .p. aG.°. ..°:o::: .o,o. . . :a-.Q:• •o:: .. .o'.•6 •'o.'• b'o..o: i ,b.-;o,.o, b:.ti:'o e.o.o.a•.°:o.°:•:n':'o.'-.e•°:'.o:o o•:o•n•.• :e:.:°..•o•b..o_: �• �ri T �•- •� off, � :o /l/ /-iE N/� . °.. O o. SEPTIC TA INK .. INSTALL ON LEVEL BASE + °':° ° ° °:.e•. °. ;. ,e.'n•o.°•'.°'o NO TE• EXCA VA TE TO EL EV V. 7 6 ' - OR a, a: ' . a •, E-L 2.4 L OWER TO REMOVE' ALL .IMPERVIOUS — - — - MA TERIAL BENEA TH THE L EA CHING AREA 2 0 2 0 •. :; REPLACE EXCA VA TF_O MBA TERIAL WITH _ vT 6 0 EA C A R AND CLE L YFEES 10 ._0.,, I '=FECTI VE METER ? . r L N ' ?, L ND T 'S LEACHING PIT 1. ALL ELEVA TIONS SHOMN ARE BASED ON FIELD SURVEY INSTALL ON LEVEL BASE } �,o gu 9Q 2• ALL PIPES IN THE �YSTEM_MIIST .BE CAST TROY OR SCHEDbL E 'a. "" 4!J P, DBSL i T.� ,�rV PIT s 89,18'dQ of 3. THE BOARD OF HEA L TH MUS T BE NO TTF IED _ 300.00 j _ � ' 94 WHEN CONSTRUCTION IS COMP!ETE PR_?'OR P-5571 8Z \ I --__ / TO BA CKFIL L ING PEOCOL A TION F44 TF.- I `` f 2 ,^SIN.I-TV. 4. ANY CHANGES .IN THIS PLAN- MUST BE APPROVED I 3O B Y THE BOARD OF HEA L TH AND CAPE C ISL AN.OS d+'I TNES:�EG' BY* :' SURVEYING CO. , INC. T. Mc EAN - 8� - WATEC- `•?�WV W 5. MATERIALS AND INSTALLATION SHALL BE IN K �' �► Ir , COMPL IA NICE WI TH T!lE S TA TE" SA NI TAR Y .—BA —BRD. OF HEA L TH DESIGN DA T ~ - - DA .!E.' s�UNE,17 1986 ti I CODE TITLE V AND LOCAL APPLICABLE I1250 GALLON Q I PFECAST CONCRETE o ;� O RULES AND REGULATIONS o chi SEPTIC TANK Q 6. NORTH ARROW IS .FROM RECORD PLANS AND 0 •, - "� (. 3 NUMBER OF BEDROOMS '5041 `� V �O GA 98A GE' DISPOSAL NO 1 � �/ � � �C�� � ti IS NOT TO BE USED R SOLAR PURPOSES 7. FLOOD HAZARD ZONE C TOPSOIL 6` DA IL Y FL O N •SUBSOIL � f • N� � v \ B. WA TER SUPPLY TOWN WA TER 24 SEP T I G TANK PEG 'D LOT 35 I N s _� SEPTIC TANK PROVIDED 1250 GAL . zz i I 7 4 . �� LEACHING GHING RE/�UIR D 440 5 D E 0 0 S. F. S. F. EQA CONCRETE 8Z N \ L GBH G PIT MEDIUM ` 300. 00 SAND « SIDEI�ALL AREA 225 S. F. N B9'18'40 1✓ � ' J4 2255. F. X 2. 5 6/5. F. - 562GPO 84 9O yz 92 �2 BOTTOM AREA - 157S. F. LEGEND 1575. F. X 1�0 G/S. F. 157GPD L EA CHING PRO VIDEO 719 GPD ._ --o PROPOSED ELEVA TION " NO GROUNDWA TER 144 �L -(�. —90-- EXISTING CONTOUR SINGLE FA MIL Y R } OBSER VA TION PIT ESIDENCE � i ❑ DISTRIBUTION BOX �P�K 0F Mgssq�y �o RiCFlbRp G PROPOSED SEIM GE DISPOSA L *YS TE1 JAM s CD © •L EA CHING Pl T RERTUND N PREPA RED FOP F 0 0 P NK' OFFS CISTER���.,�'F. -SEPTIC TA s i U �. � NA►. CA MME T T CONS Ti9UC TION l R P) RESERVE ._. � -A" ofMq�s L D T 35 MIS TIC DPI VE •i q i DAVID BA RNS TA BL E — MA PS TONS MIL L S — MA SS . PIPE INVERT ELEVATION CHARLES yN SANICKI PLOT PLAN 9 28085 o y DA TE:'GCT. 5O 1'58� FG�ST��q' CAPE cG ISLANDS SURVEYING, I.NC. �Q , �-�° SCALE AS NOTED P. 0. ©0X 334 SCALE: 1 "�40' I 21 � �`�,0R`� r � TEA TIC KE T � �i�.+ '..`P'Ci�.. A C.i T H.�?E _ ,y.•'r-' C,•.,P• , �. a� ..-_._ __.__—_. � ____ _ -. --,w...,+ter..n,.++n+wr,rtaws.n-wr..e...w-•-.-.n... I it