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0754 MISTIC DRIVE - Health
754 MISTIC DRIVE, MARST. MILLS A= 079.072 --- ,per C COMMONWEALTH OF MASSACHUSETTS • EXECUTIVE,OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL'PROTECTION ' . . TITLE 5 _ OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PARTA CERTIFICATION Property Address: ��✓'r �iS�!c. Y�a�. :. :, �� il�� Owner's Name: 70.. w e i i ri Xef vi s P.4 Z jR um - O S 6 Owner's Address: 7-1 74 . vt ` Date of Inspection: C,— 3- o `:-,Name of Inspector: (please print) Tohn 9 A�� •Company Name: oh" 174 M0 .-ekh„o S4i-Wjc o _ Mailing Address:Zg1 wa/hu Telephone Number: v9-4121-7779` CERTIFICATION STATEMENT' f 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: I/Passes i. Conditionally Passes .i Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 04L - Date: The system inspector shall su mit 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 off ce of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 1 5 Inspection Form 6/15/2000 page 1 Iv. Page 2 of I 1 71 OFFICIAL INSPECTION FORM 4ii6R'VOI UNTARY ASSESS1ViW1�iTS;,. <.� SUBSURFACE SEWAGE DISPOSAL SYS ItM INSPECTION FORM PART A CERTIFICATION(continuedj. Property Address: 7113' 0iwr - rs Owner: N, 1. f ra IT T� Date of Inspection: Inspection Summary"Check'A,B,C,D or,E'/!ALWAYS compietAn®tSatiioi.i� A. System Passes: �g I"have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: _ !�y , „ i One or more system components as described*i`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. x 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 eAltration of faftia+e is imminent System will pass inspection if the existing tank is replaced with a complying septic tank aiapproved 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: .. �7, t rf� ,-.L f . .. ...! t! Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or.unevea distributian box.S will ion if w' System pass inspect (with approval of Board of Health): broken Pills)amvaplaced11_ c ` c ►; - obstruction is removed t distribution box fs leveled _ or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed . .. ..`1.`�' E" :... ?n.�'I ! u?7w't_s r a I•r T j� T'�� �i -./ ix?n ..`.,. 15i.1 fi F :'r:td` i�;4 � � -I!' i t� # y;- T . ND explain: 2 'Page 3 of 11 OFFICIALiNSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM PART + CERTIFICATION;(continued) Property Address: 7Ys! iYl�sf o �rivf /fir Owner: .7, �. pa 17 7-R _ r� 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 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(lXb)that the system is not functioning in a manner which will protect public health,safety and the environment: r.- t ; _ Cesspool or privy is within 50 feet of a surface water-j - `, Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh su 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 - steace 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 fiord 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 coliforin 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 ire triggered:A copy of the analysis must be attached to this form.. r 3. Other: xr)'ic. s.",�� ,y,..;_.,;+i e Y!-_ l:.x J •,tv.t i. _f•! - '- • ( .. -' . , . e .may,, 1- i ram` 3 Page 4 of 11 ' OFFICIAL INSPECTION,FORM=NQTXMVOLUNTARY ASSESSMENTS t SUBSURFACE SEWAGE'DISPOSitt-3YYSTEM:INSPECMN FOR. , •. PART-A 1_ . CERTIFICATION Property Address: 7 yS' ��� Owner: , Date of Inspection: D. System Failure Criteria applicable to all systems:. You must indicate`y►es"or"no"to each ofthe following for.Ln inspections 11 A.v .��. ..-�f.,.t•� � Y� 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, ' t/ Static liquid level in the distribution box_ above outlet invert due to an overloaded or clogged SAS or cesspool . d Liquid depth in cesspool is less than 6"below invert or available volume is less than%2 day flow v Required pumping more than 4 times in the last year N T 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 .rl r.'nv water supply. .+' ' .'.'a:i' _^ ✓a r to y ;'lv— } f r &/ Any portion of a cesspool or.prvy 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 30 feeCfiom•xpriyate water supply well with no acceptable water quality-analysis.[This system passes if theA ell-m ater 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 thepresence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other iaibirie criteria "* ,,are triggered.A.copy of the analysis must be attached to"form.] ND: (Yes/No)The system tails: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 Y Health to determine what will be necessary to conva the failure. - r i _f it J„e• ft �ett'Z1..,^ ('9 .'f� 3Crt; f r .a: .ir ..,. E.ty'Large Systems• m, , ;a z 0 t'::1G' To be considered a•large system the System Must serve a-facility with a design flow..of 10,000 gpd,to 15,000 gpd• _ You must indicate either"yes"or"no"to each of the following: (The following criteria.apply to large systems in addition to the criteria above) yes no the system is-within 400 feet of a surface drinking wad supply 4 the system is within 200 feet of a tri)�t!o a surface drinking water supply y " _ — the system is located in a nitrogen sensitive area(1nterim Wellhead Protection Area—1WPA)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 3'10 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B 'CHECKLIST Property Address: 7V6' Ais A ef, Aiv Owner:c7.t, YP.I Ir 79 Date of Inspection: 9— o Check if the following have been done.You most indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner;occupant,or Board of Health ' r/ Were any of the system components pumped out in the previous two weeks? ✓' Has the system received normal-flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? - r k V Were as built plans of the system obtained and examined?(If they were not available note as N/A) V _ _Was the facility or dwelling inspected for signs of sewage back up? • ✓ — Was the site inspected for signs of break out? Al _. ✓ — 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 JSAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. ` "+ V_ 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)] " 3• .�a.' _ -'7C'ili.;jy`�a:�# ..r`•:�, '_ _��,".'.�..`. °., .;+t ? ..a.. W:�,'I �.k. � lia"L;x }!.. .;.i it J .�" ter'. e- . .J-•"k"Yt .i w..\ _ Y _ ry►` I 5 Page 6 of 1 I :-xj,_PFFICIAL INSPECTION.FORM-1'VOT FOR OIa NTAR ASSESSMENTS . .C.USUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ; .. Property Address: 74T /yis�!v v e �• _ ''. - . Owner. , « Pcv 7 T ._ Date of Inspection: 03—O FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3, ��Number of bedrooms(actual): .. DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms): 370 Number of current residents: A9 Does residence have a garbage grinder(yes or no): �Cs Is laundry on a separate sewage system(yes-or no): .klo..[if yes separate inspection required] .y;; Laundry system inspected'(yes or no): V— - Seasonal use.(yes or no): ge? Water meter readings,if available(last 2 years usage(gpd)): n o 7 Z.10 100 6 = !ev, 9P Sump pump(yes orno): A/ «.., , , :, i.<_•'iw.. a.'.- . .._;j ;.7. ' �� ,.� Last date of occupancy: JA ,0,9 s COIVIMERCIAL/INlDUS t . F`a+�J*1� .W i to -I;,�,t Z.4 '_u r�- F Ah TRIAL Y rType of establishment: .. . . . . , Design flow(based on 310 CUR 15203): y and - - Basis of design flow(seats/personslsq$,etc.): �.., . . ,.• ,.•' -- _ Grease trap present(yes or no): Industrial waste holding tank present(yes or no): r ,, Non-sanitary waste discharged to the Title 5 system(yes or no):— - Water meter readings,if available: East date of occupancy/use: GENERAL INFORMATION'rt, - F ' • ' Pumping.Records E Source of information: Was system pumped as part of the inspection(yes or no): O If yes,volume pumped-_gallons--How.was quantity pumped determined? Reason for.Pumping: d TYPE OF SYSTEM , Septic tank,distribution box,soil absorption syst=,�A _Single cesspool Overflow cesspool . Privy .. .��z-'1.'i a#Sa.c 2 f _aa�?-sta'� �'� ... r�•]-l'fj�"' _Shared system(yes or no)(if yes,attach previous inspection records,if any) _InnovativelAItemative technology.Atta&a copy of the cuz=.operation_and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 11 y tg-r s 1,4411d 6--2 6--.97 TvarAj r'eca:-GIs Were sewage odors detected when arriving at the site(yes or no): /I/o Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACKSEWAGE DISPOSAL SYSTEM INSPECTION FORM r 'PART C: SYSTEM INFORMATION(continued) Property Address. 7�J,S" SG pyre t Owner. �. Date of Inspection: BUILDING SEWER(locate on site plan) .. 4 Depth below grade: Materials of construction: cast iron 40 P other(explain): , Distance from private water supply well o ction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:—(locate on site plan) Depth below grade: Material of construction: concret _metal_fiberglass other(explain) If tank is meta_1 list aged_ Is age confirmed by a Certificate of Compliance(yes or rio)-•_(attach a copy of . _ certificate) Dimensions: jr X 'r Sludge depth: IJo-e Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Alvn.e Distance from top of"scum to top of outlet tee or,baffle: Distance from bottom of scum to bottom of outlet tee or baffle: .— How were dimensions determined: -A441s61nei'9 Red Comments(on pumping recommendations,inlet aadoutlet tee or baffle condition,structural integrity',liquid levels as related to outlet invert,evidence of.le�kage,etc.): Tank C dh�6l1 I1 P C,eAr ►cia/btis4 /r 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of l l - e�•1 .++°� ,}Iki'U- Y.•` �Lr�... !w �' r �+) ° `�-�C',.-��'"r' C ;x �,�. �- - t � .-.,.... 3 r-OFFICIAi:INSPECTION FORM. N . VOLUNTOX ASSESSMENTS SUBSURFACE SEWAGE DISPgSAt,- IrMftCTION`FORM:- : .. -'FARE' SYSTEM INFORMAITON"tinued) Property Address: 7Yf AGh Owner: T Date of Inspection: 9 V•'-C)7 TIGHT or HOLDING TANK: (tank must be pumped at time of im site plan) Depth below grade:_ - •rP. ,i �r�. 4L Material of construction: - concrete _ metal .!,' fiberglass~r Dolyethylene T 16ther(ezplain): ' Dimensions: _ .. Capacity: ¢allons� Design Flow: ¢allons/day Alarm present(yes or no): `. '' _ a a _ ` '+f r_ ' j. Alarm level:' Alarm in working order(yes or no):• Date of last pumping: ' _ Comments(condition of alarm and' 16at switches;etc.):_._ x) DISTRIBUTION BOX: (if present must be openedxlocate on site plan),-- Depth of liquid level above outlet invert: ® 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.): pr- /�ca_ �s .ttVel e.�d` -fat,SO4i ory` 4rVM�I;�: �H i•, 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 ofpamps and appurtenances,etc.):. . r Page 9 of l l OFFICIAL.INSPEMON FORM—NOT.FOR VOLUNTARYASSESSMENTS SUBSURFACE_SEWAGE.DISPOSAL SYSTEM INSPECTION FORM : PART C. SYSTEM INFORMATION(continued) Property Address: a s ohs i Owner. j Date of Inspection: 9— ,3-0 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) if SAS not located explain why:. TV leaching pits,number' 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.): 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: F Materials of construction: Indication of groundwater inflow(yes or no): - Continents(note condition of soil,signs of hydraulic failure,level of pondm&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.): 9 Page 10 of 11 OFFICIALINSPECTION DORM.=NO Volk VOL� IN'I')mY;�SShlLNTS :SUBSURFACE SEWAGE DISPQSA'SYS'FE1VI INSPECTION FORM ' PART:C 'I` SYSTEMFAMR?aATION(co ut u •ems .. Properq Addreu: 7yjr ' Nis7i°c Ari ",,e owner. \7 Date oflnspecdon:_ 9— —10�. r.l:~ •• 15'•,�(i�: tt . .)•t {Z ►t•�i( • � 11` .. '.A•- .. J.,�f:[. ,�'� �_ � a.. ••i..� .•�••�°� S � J �.. a:. _'.w; 1r .l- i e's�. SKETCS OF SEWAGE DISPOSAL SYSTEMr Provide a sketch of the sewage disposal system inclgding ties•to at least two permanent refatiaca laudmarks'or.R" benchmarks.I.ocate'all wells within 100 feet.L. whempubUc water MMIY enters the building•.... . _ I c Wa •�/� Ctrs �r4�yv �YOf, - nd� GNP /y7j ...-.•....,_.. «.wr. ..w._w __w_._ _!�v a. .1 n •Its,; .�,�••�-! �.�-;�� �•i.s�c��,•�•_,.,., .1::'fiLt °�-�+ +•_si }�:l►.._ i�ra_ � ,�,': � _ .0 f, ,t- , O� O -2 Toeewfr .•yam ..,_+.. 6.l. '1 [ 3rwvtr o � I b $":rip ao�d�, ' :�.v'�';�f:.�J•. :'�I.�.°�r.L• :7�a�31yJ,^1, J,'j�'1c7.�r4�s��it,'i. , t�:;yr��s,w '!>.:2�'�1 T^.��'1: •.E �aE:Y. :.3�;"'r t ,ti ,Frr;r• Page 11 of 11 - OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS r .• -SUBSPRFACE S*WAGE DISPO.SAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: P4 Date of Inspection: 9—3>y$ SITE EXAM lope - Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked,date of design plan reviewed: Observed site(abutting property/observation hole.within 150 feet of SAS) v Checked with local Board of Health-explain: Checked with local excavators,installers-•(attach documentation) �! Accessed USGS database-explain: Meson a f You must describe how you established the high ground water elevation: , ;84e l `s 7 2' rvat N �l �'s '7a.3 "w" APO; 's"T I Pat ti Jay� �3 V 8�� - iS t�J�'JroDt, fS� a hvv.� ti��• �YaH� w���r, �� ' ll • ✓' r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION Y 4 � O v e� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 754 Mystic Drive Marstons Mills MA 02648 Owner's Name: Gary Glatki Owner's Address: Same Date of Inspection: June 7,2007 Job#07-123 Name of Inspector: PATRICKM. O'CONNELL4. Company Name: SEPTIC INSPECTION SERVICES CO. CFIr Mailing Address: 1189 CAMMETT ROAD' MARSTONS MILLS MA 02648 'j _ Telephone Number: 508-428-1779 CID CERTIFICATION STATEMENT -p- ,--, 1 certify that I have personally inspected the sewage disposal system at this address and that the informatio reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based n my training and experience. in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Appr ing Authority _ Fails Inspector's Signature: Date: 6/7/07 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. Notes and Comments: Both leaching ppits have 2-3"of standing water,tank was pumped following ;inspection. ****This report only describes co' ditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I i Page 2 of 11 I r OFFICIAL INSPEC ION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE EWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 754 Mystic Drive,Marstons Mills Owner: Gary Glatki Date of Inspection: June 7,2007 Inspection Summary: Check A, ,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes One or more system compo ents as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon c(m ion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined ( ;N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a corr plying septic tank as approved by the Board of Health. *A metal septic tank will pass insp ction if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank.is less than 0 years old is available. ND explain: I n Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced bstruction is removed ND explain: I • i I :i Page 3 of 1 I i OFFICIAL INSPEC�TION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE .YIEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:754 Mystic Dive, Marstons Mills Owner: Gary Glathi Date of Inspection: June 7,2007� 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, siI fery or the environment. 1. System will pass unless Bdard 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 w thin 50 feet of a surface water _ Cesspool or privy is w thin 50 feet of a bordering vegetated wetland or a salt marsh I i I i 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 septi�tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or trib 1 tary to a surface water supply. i _ The system has a septi�tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septiµ�tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septi4 tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well** Method used to determine distance **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organiq 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. I i i I 3. Other: I i I I I i i r I I i I Page 4 of 11 4: OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 754 Mystic Drive, Marstons Mills i Owner: Gary Glatki Date of Inspection: June 7,2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"t each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ _X_ Discharge or pondingbf 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_day flow _X_ Required pumping mo�e than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X Any portion of the SA$,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 cessp�ol or privy is within 50 feet of a private water supply well. _ _X_ Any portion of a cessp�ol or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acbeptable water quality analysis. (This system passes if the well water analysis, performed at a DEP ertified laboratory, for coliform bacteria and volatile organic compounds indicates that the wel is free from pollution from that facility and the presence of ammonia nitrogen and nitrate ;itrogen 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 forma No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMRI 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. I E. Large Systems: To be considered a large system t!he system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"ho"to each of the following: (The following criteria.apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in ainitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public waterisupply we I If you have answered"yes"to any 4uestion in Section E the system is considered a significant threat,or answered "yes"in Section D above the large tystem has failed.The owner or operator of any large system considered a significant threat under Section E o�failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should cbntact the appropriate regional office of the Department. ✓' Page 5 of 11 i OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 754 Mystic Dive, Marstons Mills i Owner: Gary Glatki Date of Inspection: June 7,2007' Check if the following have been dbne. 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 jcomponents pumped out in the previous two weeks'? _X_ _ Has the system receivetl normal flows in the previous two week period '? I _ _X_ Have large volumes of i hater been introduced to the system recently or as part of this inspection? i _X_ _ Were as built plans of tke system obtained and examined?(If they were not available note as N/A) i _X_ _ Was the faci►ity or dweNling inspected for signs of sewage back up _X_ _ Was the site inspected for signs of hreak out _X_ _ Were all system components, excluding the SAS, located on site _X_ _ Were the septic tank mjnholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees,mat�erial of construction, dimensions,depth of liquid,depth of sludge and depth of scum? I _X _ Was the facility owner(land occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems :' I The size and location of tote Soil Absorption System (SAS)on the site has been determined based on: Yes no _X_ _ Existing information.Fbr example. a plan at the Board of Health. . X _ Determined in the field j(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)) i Page 6 of I 1 ; OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 7.54 Mystic Dfive, Marstons Mills Owner: Gary Glatki Date of Inspection: June 7,2007 FLOW CONDITIONS RESIDENTIAL - Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 1.15.203 (for example: I I6gpd x#of bedrooms):440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required) Laundry system inspected(yes or rio): Seasonal use: (yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Readings inaccurate due to irrigation system. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL, Type of establishment: Design flow(based on 310 CMR 15.203): ___ gpd Basis of design flow(seats/personsYsgft,etc.): ._ Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available:; Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Tank had never been pumped. Source of information: Owner Was system pumped as part of the inspection (yes or no): No If yes,volume pumped: galldns -- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box, sbiI 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) i _Tight tank _Attach a copy of the DEI' approval Other(describe): Approximate age of all components, date installed (if known)and source of information: Compliance date: 2/27/91 Were sewage odors detected when arriving at the site(yes or no) No j Page 7 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C :SYSTEM INFORMATION(continued) Property Address: 7.54 Mystic Drive, Marstons Mills Owner: Gary Glatki Date of Inspection: dune 7,2007 BUILDING SEWER: XX (loc�te on site plan) Depth below grade. 2 Materials of construction:_cast iron _X-40 PVC_other(explain): Distance from private water supply;well or suction line: Comments(on condition of joints, 'venting evidence of leakage,etc.): i i SEPTIC TANK: XX (locate on site plan) Depth below grade: 2' Material of construction:_X_concrete metal _ fiberglass_polyethylene _other(explain)_ If tank is metal list age::_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10.5'long x 5.8' wide— 1500 gal. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined:; STICI< WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidenceof leakage, etc.): Tees are intact and liquid level was found at bottom of outlet invert.Tank was pumped after inspection was completed. I GREASE TRAP: No (locate on site plan) Depth below grade: Material of construction:_concrei,te_metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leaka(le, etc.): ^5 Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property`Address: 754 Mystic Drive, Marstons Mills Owner: Gary Glatlki Date of Inspection: June 7,2007 TIGHT or HOLDING TANK: No (tanl< must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete_ metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in workingorder(yes or no : _ ) Date of last pumping: Comments(condition of alarm and float switches. etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): No solids or hieh stains present. R . PUMP CHAMBER: No (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.): Page 9 of 11 OFFICIAL, INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE. DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 754 Mystic Drive, Marstons Mills Owner: Gary Glatki Date of Inspection: June 7,2007 SOIL ABSORPTION SYSTEM:(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: Two 50 pits. _leaching chambers, number: _leaching galleries,number: _leaching trenches,number, length: leaching fields, number,dimensions: _overflow cesspool,number: _innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Both leachinE nits have 2-3" ot'standine water with no hieh stains CESSPOOLS: No (cesspool must be pumpccl as part of inspection) (locate on site plan) Number and configuration,: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Page 10 of 11 t OFFICIAI. INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 754 Mystic Drive, Marstons Mills Owner: Gary Glatki Date of Inspection: June 7,2007 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. 1_,ocate where public water supply enters the building. Mystic Drive Water Service 752? 49 2 46 39 49 8 tS= • Page 11 of 1 I r� OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 754 Mystic Drive, Marstons Mills Owner: Gary Glatki Date of Inspection: June 7,2007 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 20 feet Please indicate(check)all methods used to determine the high ground water elevation: _Obtained from system design plans on record- If checked, date of design plan reviewed: _X_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) _X_Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.35 and topo map shows property at el.70.No water was observed upon installation. tr. TOWN OF BARNSTABLE LG'CATION ��� 1 $�'�`��(�- SEWAGE# P VILLAGE j l ASSESSOR'S MAP&PARCEL NAME&PHONE N). 'ri c_lc VCm✓�V/ L)a& n-)' SEPTIC TANK CAPACITY ISO 0 LEACHING FACILITY. (type) a p i'l- (size) Sne NO.OF BEDROOMS L OWNER ac. -1 IcA 1C4'_ PERMIT DATE: COMfttft1TM DATE:To,-k. 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 I�_ i ater ENIC2 i . f 49 46 39 d + 49 k r 8 ! 1 4f �� TOWN OF BARNSTABLE 1 LOCATION bet ye, SEWAGE # 366 VILLAGE /T7`'��� /�-t^^ S ASSESSOR'S MAP & INSTALLER'S NAME&PHONE NO. J/.� o SEPTIC TANK CAPACITY LEACHING FACILITY: (type) / T (size) 1000 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: .��T - t `�c' COMPLIANCE DATE: —D-7 ?7 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 q, on site or within 200 feet of leaching facility) /il Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi ��aclIi//lity) Feet Furnished by (LAO N N u. Ow -r No....... _���� /FR' ...---/� '7 b.0 THE COMMONWEALTH OF MASSACHUSETTS 3 BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Di-tipuual Vorkii Towitrurtiuit rratit Application is hereby made for a Permit to Construct ( V1/0r Repair ( ) an Individual Sewage Disposal Svstem at: ...:7. .:... ........................... ... . ....•-.-- - � ........ % ........................................................ X�i- ddres t No. ( ... y� Address ......•....... ...........................•.. .-• .... fd ti/ + C2./-VP........-i/ . �------......-•--•--•-•.. Installer Address Type of Building Size Lot-----`--.r.L4�f....Sq. feet ' U Dwelling No. of Bedrooms _ Expansion Attic�+ g— •--- --------------- -- P" ( ) Garbage Grinder ( ) aOther—Type of Building o. of persons---------------------------- Showers ( ) — Cafeteria ( ) � Other fixtures -------------------------------------------------------........... / W g g P P P Y Y .Y'Y ----------------• ---gallons. Design Flow_____________________________________ __gallons per person per day. Total Bail flow..__._.._ _ R: Septic Tank—Liquid capacity/ gallons Length---------------- Width---------------- Diameter................ Depth---------------- W x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._-_-..-_.. _--I.... Diameter-------------------- Depth below inlet..................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank `�' Percolation Test Results Performed b /S ` 11—1-7 9 WY----- ---- Date. .................................. Test Pit No. 1. -_._minutes per inch Depth of Test Pit-------------------- Depth to ground water.....i-A�� (L. Test Pit No. 2'................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ---• - •---.......-•---•---•--•-----••-•-----•---•---•-•-••------.•-------------------------•----•------•-......--..._.......•--- Description of Soil...... .: . ._ U ---------------------------------------------------------------------------•------------•--•--------------------------------------------------- W 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Con}}zliara s en issued by th oard of health. Signed -- .......... ............... ..... ........ --. 7 Application Approved By -- ---- e -t�....--- ------------- Application1 ..p,�.... �e Disapproved for the following reasons: .... . ......................................_....._ --_._....--::.:-..-- ..................... --------------------------------------------------I.............. . ......--------------------- -------------------..----------------- �j ((�� Dace Permit No. / Jr------- ----------------- Issued ------------- '../:���-...-........... Dare No:..._._ ...t_ :��� � - t ........ ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE .!; ,��,�lirttti��t,�fur �i��n�tt� larks C�a��t�tr�r�tutt �rrutit Application is hereby made for a Permit to Construct ( lam)/r Repair ( ) an Individual Sewage Disposal System at: f�ocan- dress / l ---•---------o-.-----------------------------•-----__----- O•"• : -......... Address- I Installer Address L UType of Building u Size Lot_.._��t_C ._._Sq. feet ., Dwelling— No. of Bedrooms. .__.__.C .__ ______________Expansion Attic ( ) Garbage Grinder ( ) 3 a Other—Type of Building ___:P�u_ -No. of persons________________________... Showers ( ) — Cafeteria ( ) dOther fixtures --------------- ---------------------------------------------------------------------- ----_-------�---/-- // W Design Flow........_--------------------------- _____'gallons per person per day. Total daily flow........_1_ [ ........................gallons. WSeptic Tank—Liquid capacity/ a�gallons Length________________ Width-----.--------.. Diameter---------------- Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length_------------------ Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter-------------------- Depth below inlet.............i...... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank (�G ----------------•-�------- Date____ //----/•7_� 9 - aPercolation Test Results Performed b ._____-._-..-�_.� r ,a Test Pit No. 1.. .`_____. minutes per inch Depth of Test Pit____________________ Depth to ground water..... )V' /r�6r.. Gz, Test Pit o. 2________________nllnutes per Inch Depth of Test Pit______.._______.___. Depth to ground water-.._.__-_..____.__.._... DDescription of Soil----- Z.�---------------•---------._...-----.---------------------------------------------------------------.....----------- V ....•--.....•-•-•------•-••------------•------...•--••••--•----••'-•-•------•-••----•••----•-•-•--•------------••-•---••-••--•---••-•---•----- 1-1 UW .............................-..........................................................................................--------....--------------------------------------------- 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 TITLE 5,of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliaa-I s .en issued by th board of health. Signeds-./...... . ......... .- ------------ -------._:...-------- . /Z.7..... .. Dace ApplicationApproved By ........... .-.. .e,.�„- - ......._..........................._....................... .. .......... .. ..-.1 e ..�1'` .... Application Disapproved for the following reasons: ................._.... ...----------------------------------------------.............------.......---------.._.....--------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------- .................. . .. Dace:. -- Permit No. . r ..��---6 Issued ............. .. ...- ----------------- Date .---- --------ws.><_...�_—._.--- ti----- ------min—Qo,.�. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cer#tf rate of Compliance H S IS T CERTIFY That the div'dua wage Disposal System constructed ( (/or Repaired ( ) by . .. - '.- _ ...... .. '.f.1. _......- - - ......... at -----------------------------_.-7-`�...._... - ..... .............. ... ....� ... - - ...... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..------ -....�.�.�---- dated _..-3. -__)_0-....-----_5 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE _z....77�^q. ............. - _..........:..._.... Inspector .... _.........._.._... - -------------- ----_------------------------- I -_--------- --------------t----_ - --------- ----------- _ -----_,---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.-_•-•-•__�___-..��G FEE........ /)r>..... Miji ial Works- Tvniitrttdiv r mi Permission isthereby granted---•- ----------L 0i . _y__2..... .tJ•0............................... to Construct (`�) or Repair ( ) an Individual-Sewage Disposal.System L � Street ear as shown on the application for Disposal Works Construct t' n Per it No._l.-Z..: Dat;�dn� ________,___..-- ..a- Bo2i Jof Health DATE. -�------•--...-- FORM 38308 HOBBS✓k WARREN,IN/C..PUBLISHERS F 7cSy TOWN OF BARNSTABLE ti LOCATION Z24, jEUE PO U&,' SEWAGE # s . VILLAGE— ASSESSOR'S MAP && D INSTALLERS NAME&PHONE NO: SEPTIC TANK CAPACITY LEACHING FACILITY: (type) i T. (size) '/O0d NO:OF BEDROOMS_ _ BUILDER OR OWNER PERMUDATE: COMPLIANCE DATE: Se pazation 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 leachi facility) Feet Furnished by 1Y7� 41V ' Z9 y9 o L y 36 - © 3 S"" q. �� 7 I P ►� T J Li l� J pw�gc., "P rr- i L r 74 Ax �T c-,f ►U vu Tf i I v�►���i� G(Zrcp(p 4OPP&Cj ���v=� �! Ppe lug •�+ f 4"p,PB IW. GAt.• 7Z,3 .r 1. • luV. `J TANK to .• - - GHQ v�Z �Q.. �►.5 . , � uV. tW. .. GAL.... . GRA U13, PITS1J o-�-� : A� S�iTL�cTU PIE'5 w 56 PA&fze r�� c� a' 5 WAVAED n,f.L...bL T' P�gYI^Ot..4,1 . } STo►-tE G PITEF NO. 29133 � U c ScA.L!✓- ��S�OAfAL E���� Igo �N Rom- Hiwe ./�tW Design Data Single Family - 4 bedroom No disposal, Daily Flow = 4x110--440 GPD. Septic tank = 440xl.5=660 gal. Use 1500 gallon septic tank. Disposal - Use 2-600 gallon leach pits w/1' of stone. Bottoms = 100 sf @ 1 G/sf = 100 G/D. �� v Sides = 176 @ 2.5 G/sf = 440". _TN AJ Total Design = 540 Total Required = 440 SN of /:;/,0 7 AA./ I certify the proposed dwelling �,�V, conforms to the sideline and setback WILL M s ��Cl��S !�L A�� requirements of the Town of Barnstable C. �., �/ '_ ` and is, not located in the floodplain. r No.. 1933a41 Professional:..Land Survey r Date SCR' iW :: L Q 7- 7- /�c,,,oW /max. 0 53 CLG—��S-i?GyU s �jdkT�.f Al yE", /Nc.' SAS aN i o+��cJ o�' �" !=��s;�Gti�}�c.. CA$JD s t��yo1_1q 46rA 2115 e5, .T.5, M A-A3 Inv l c__ Ui C��C";45