HomeMy WebLinkAbout0112 MOCKINGBIRD LANE - Health 112 HOCKING BIRD ROAD, M. MILLS
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ,
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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' TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ' = r
;! PART A :s
CERTIFICATION
Property Address: 112 MOCKING BIRD RD MARSTONS MILLS,MA 02648 �
Owner's Name: DON CREEDON t ,1
Owner's Address: 112 MOCKING BIRD RD DENNIS,MA 02638
Date of Inspection:4/2/01 iA '
Name of Inspector: (please print) JOHN GRACI
Company Name: SEPTIC INSPECTIONS RECEIVED ,.4 rf
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 ' f
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Telephone Number: 508-564-6813 FAX 508-564-7270 APR 17 2001 ='f
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CERTIFICATION STATEMENT TOWN OF BARNSTABLE
H ALTH,DEPT.
I certify that I have personally inspected the sewage disposal system at this address and t elow is �tc1 11;
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 k #
inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system:
X Passes 4�+
_ Conditionally Passes
_ Needs Furthe Evaluation by the Local Approving Authority 3,_' I
Fails {z'
Inspector's Signature: Date: 4/2/01 =,1
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The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within s�i
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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
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sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. s s _
Notes and Comments
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFULL LIFE. €'
****This report only describes conditions at the time of Inspection and under the conditions of use at that tittle.Thle
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inspection does not address how the system will perform in the future under the same or different conditions of use.
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Title 5 Incnertinn Fnrm 6/1 5/Mno 411 1
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Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
i
PART A .
i, CERTIFICATION (continued)
Property Address: 112 MOCKINGBIRD RD MARSTONS MILLS,MA 02648
Owner: DON CREEDON
Date of Inspection: 4/2/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15,304 exist.Any failure criteria not evaluated are indicated below. f'1
Comments:
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG
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THE SYSTEM'S USEFULL LIFE. '
B. System Conditionally Passes:
_ One or more system components,as described in the"Conditional Pass"section need to be replaced or repaired.The system, x
upon completion of the replacement.;or repair,as approved by the Board of Health,will pass.
,.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and dyer 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a ;A a.
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of
Health): i.
_ broken pipe(s)are replaced
_ obstruction is removed :-
_ distribution box is leveled or replaced .
ND explain: n/a
n/a The system requiredpumping'more than 4 times a year due to broken or obstructedpipe(s),The s stem will ass
Y 9 , Y Y P
.inspection if(with approval of the`13oard of Health):
_broken pipe(s)are replaced
-obstruction is removed
ND explain: n/a
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Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 112 MOCKING BIRD RD MARSTONS MILLS,MA 02648
Owner: DON CREEDON
Date of Inspection: 4/2/01
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
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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:
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_ 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
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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 n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
rovided that no other failure criteria are triggered.nitrogen and nitrate nitrogen is equal to or less than 5 ppm,p gg ered.A copy a
of the analysis must be attached to this form.
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3. Other:
n/a
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Page 4 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
at
CERTIFICATION(continued)
Property Address: 112 MOCKING BIRD RD MARSTONS MILLS,MA 02648 ,.
Owner: DON CREEDON
Date of Inspection: 4/2/01
D. System Failure Criteria applicable to all systems: .}.
You must indicate"yes"or"no"to 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 ponding,of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
- X Static liquid level in the'distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
- X Liquid depth in cesspool is less than 6"below invert or available volume is less.than '/z day flow
- X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped n1a. ;
- X Any portion of the SAS,cesspool or privy is below high ground water elevation.
- X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
- X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
- X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
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le water quality analysis. This system asses if the well water analysis,performed at a DEP .
no acceptable q ty y ( y p Y t'1
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the syste'm$lails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure. 'S'
E. Large Systems:
To be considered a large system;the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or,"no"to each of the following:
(The following criteria apply to larie systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
within 200 feet of a tributary to a surface drinking water supply
_ X the system�s it ry g P
X 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
es"in Section above the large system has failed,The owner or operator of an large system considered a significant threat
y g Y p Y � Y �
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
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Page 5 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST `
S
Property Address: 112 MOCKING BIRD RD MARSTONS MILLS,MA 02648
Owner: DON CREEDON
Date of Inspection: 4/2/01
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No 'y
X _ Pumping information was provided by the owner,occupant,or Board of Health r ' ,
X Were any of the system components pumped out in the previous two weeks? s
X _ Has the system received normal flows in the previous two week period?
_ X Have large volumes of water been introduced to the system recently or as part of this inspection? '.
_ X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwel]igggg inspected for signs of sewage back up? .a
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site?
X _ Were the septic tank']f►mho'les 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?
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X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?
The size,and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15.302(3)(b)]
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Page 6 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _
PART C
SYSTEM INFORMATION
Property Address: 112 MOCKING BIRD RD MARSTONS MILLS,MA 02648
Owner: DON CREEDON
Date of Inspection: 4/2/01 4, r
FLOW CONDITIONS k.
RESIDENTIAL
Number of bedrooms(design):3 "1147 mber of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15203 (for example: 110 gpd x#of bedrooms):330
Number of current residents: 4
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use:(yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO T
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Last date of occupancy: n/a f
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COMMERCIALANDUSTRIAL
Type of establishment: n/a F
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a ;.
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no):NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO z'
Water meter readings,if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a E 3
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GENERAL INFORMATION
Pumping Records i
Source of information: n/a i
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agatlons--'How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool '
_Overflow cesspool
_Privy ;
_Shared system(yes or no)(if yes,attach previous inspection records, if any) r
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from
system owner) 'l:
_Tight tank Attach a copy of the DEP approval T
Other(describe): n/a
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Approximate age of all components,date installed(if known)and source of information: ,r.
1985
Were sewage odors detected when arriving at the site(yes or no): NO
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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: 112 MOCKING BIRD RD MARSTONS MILLS,MA 02648
Owner: DON CREEDON
Date of Inspection: 4/2/01 is
BUILDING SEWER(locate on site plan)
Depth below grade:22"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
THERE IS TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 16"
Material of construction: Xconcrete"metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000-L 8' 6" H 5' 7"W 4' 10""
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle:33"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related ,
to outlet invert,evidence of leakage,etc.):
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND MAINTAINING ;. .
SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene other(explain): n/a c
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
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Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 112 MOCKING BIRD RD MARSTONS MILLS,MA 02648
Owner: DON CREEDON
Date of Inspection: 4/2/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
iiN
Capacity: n/a gallons `
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 9
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 IS STRUCTURALLY SOUND.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or n4 NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
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,Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'SYSTEM INFORMATION(continued)
Property Address: 112 MOCKING BIRD RD MARSTONS MILLS,MA 02648
P Y
Owner: DON CREEDON
Date of Inspection: 4/2/01
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
:s
If SAS not located explain why:
n/a
Type
1000 LEACH PIT leaching pits, number: 2
n/a leaching chambers, number: n/a
n/a leaching galleries, number: nla y
n/a leaching trenches, number, length: nla
n/a leaching fields, number: n/a
n/a overflow cesspool, number: nla
n/a g; innovative/alternative system
Type/name
T :
«, YP of technology:
n/a
Comments(note condition of soil',^sigris of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH PITS APPEARS TO BE FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO ;
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a ;: .
Dimensions: n/a i; ?
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
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Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 112 MOCKING BIRD RD MARSTONS MILLS,MA 02648
Owner: DON CREEDON
Date of Inspection: 4/2/01
'SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
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cage I I of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 112 MOCKING BIRD RD MARSTONS MILLS,MA 02648
Owner: DON CREEDON
Date of Inspection: 4/2/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local,excavators,installers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how g
you established the high round water elevation:
Y g
USGS MAPS AND CHARTS- 12+FEET
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TOWN Of PARNSTABIE ✓
LOCATION
C, (i� t� �C SEWAGE #
cZ(R,C�ft��
VILLAGE : ASSESSOR'S MAP &LOT� 13-
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS51
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or.within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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ra C e
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84 �a
& 34
6c a�
TOWN OF,B STABLE
LOCATION cat r SEWAGE #
VILLAGE--OWLASSESSOR'S MAP & LOT9 Q.
INSTALLER'S NAME&PHONE,NO.
SEPTIC TANK CAPACITY
LEACHING FACIL=: (type)_ (size)_ 4.1
NO.OF BEDROOMS
BUILDER OR OWNER S �
PERMTTDATE: [ / COMPLIANCE-DATE: /l
- Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist �,
on site or within 200 feet of leaching facility) 14 Feet
Edge of Wetland and Leaching Facility(If any,wetlands exist '"'
within 300 feet of I aching acil 'Feet
Furnished by
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No. 4 _ Fee 7 C�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for ;Di. ppwml *pgtem Co 5truction Permit
Application is hereby made for a Permit to Construct( )or Repair( E an On-site Sewage Disposal System at:
Location Address or Lot No. Ow is Name,Address and Tel.No.
Assessor's Map/Parcel � aw �
Installer's Name,Address,and Tel.No. _ l Designer's Name,Address and Tel.No.
Ca
Type of Building:
Dwelling No.of Bedrooms _ Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Al erations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is b this Bo d of ealth.
P Y
Signed aa
Date
Application Approved by Date 9 — 1
Application Disapproved for the following reasons
Permit No. 9 6 3 Date Issued 7-3
No. tl f x a»' Fee
,THE COMMONWEALTH OF MASSACHUSETTS it
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
ZIpprication for Mf 6pogal bpgtem Co gtruction Permit
s
Application is hereby made for a Permit to Construct( )or Repair.( an On site Sewage Disposal System at:
Location Address or Lot No. Otwnneerr's,NCame,Address and Tel.No.
CAA
Assessor'sMap/Parcel ~w
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
f Ju Plc,,, cd 1
Type of Building:
Dwelling No:of Bedrooms Garbage.Grinder A �
Other Type of B;nilding - No. of Persons Showers( ) Cafeteria( )
Other Fixtures '•"' -
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of-sheets Revision Date
Title
* Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Add i [ o z1.^ (,�c 2 ps
_
Date last inspected:
i
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is by this Bo§rd of ea
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. 94 r 3-ir 2 Date Issued 7 S
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced Von
i by !--- Installer rr f.?r rcj s+
at �"� M i has been constructed in accordance
with the provisions of Tidt 5 and the for D_isposal System Construction Permit—No. 9 G ` 3 1:-;) dated 2—?/—S'bf
Date I Inspector
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE 1r' T THE SYS-
TEM WILL FUNCTION SATISFACTORY.
————/———————————————————————————————--/——
No. (� .�..5 Fee `'� U
N THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION BARNSTABLES MASSACHUSETTS
ltgaar *pgtem Construction Permit
Permission is hereby grant 4to r1 ^ L( . M ASK r
to construct( )repair( an On-site Sewage System located at No.# _ b ir
street
and as described in the above Application for Disposal System Construction Permit. Y,16 " s�7 7 3/ -`2G
No. Date
The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below. /n'
Date: `7 / — �/l Approved by
Board of Health
j
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
I, �°' ►� , hereby certify that the application for disposal works
construction permit signed by me dated c� I tU , concerning the
property located at ` M meets all of the
M
following criteria:
t
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
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SIGNED:— DATE: . Y
LICENSED rPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
,: � ��► � � / Lei
01 At
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ELDREDGE �° \ , i ��� a
a. No. 19367 0 /
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LE EN PLAN
PLOT
S SPOT ELEVATION O,10 C -CERTIFIED
IIlTIN ��_ /NG3/R� L,INE
I �(ISTIN9 CONTOUR --- 0 --- - �;-- /0& Mo&C
°FII�IgNEO SPOT ELEVATION
a3
:,flljl9NED CONTOUR existing unders;�'ound sewerage* IN
NOTE The location of any plan is a rox- .\ L, e
wells, 'or other Ut111t1eSfTomwTeCOrds on 1and/Or verbal �, a�� ���1J �+�J � ~
i ,imate only as determined responsible for the DATE 8-�a"g S
e contractor is'_. 'information. .'Ih locations in the field. SCALE� v
M1`verif ication of the existing
_!
�
I
I CERTIFY TTHE
SOL
ON PLAN
CL � i OWNkDREDGE ENG/NN JOB NO• � BUILDING ING LAWS
REO ' ERED CONFORMS TO THE ZON
4STERE MA59• VCIYIi L OF BA NST ,Yj
By
*` T12 MAIN STREET CH. 2, EG. LAND SURVEYO
,..
i. , : ;•.:,. HYANN I Si MASS. SHEET-L OF DA E
ry .: —
20 FT. MIN. /VO'TE /F E/TNER TI/E S'EPT/C TANK OR
ZACHiivG PIT A V,6 MORE 7-HA"01 /2"BELOYV
/O -r. M IN _rRA OF, � 24"�/A�E TER COiyCR E TE CO vE,P
SNALL BE BaOvGNT 7-0 GR.4 O.E.��'+N EXT�PA
CONCRETE 4'PVC PIPL MEAVY CAST /lPO/Y Got�ER .4LL OE USE' e
MIN. P/7' /F//V OR/VEyVA Y
COVERS /e"PF,Q FT.
. C'O/VC,eFTE
2 • MAN. CU VE'R
A :a. _ /• ��_ ( G qOE GLEAN SANG
'914GXF/ L.�.
•� [//D LEVEL / - . -L: 'f.•t_ : - - - _ ���
11Q _ 2 LAYER
4'C/tST o • OF 1�3
/RONPIPE /OUO •� � •
MlN.v/TGN GAL. • • • • • • • , • o • i'YASHFO S727NE
D/ST. • • • . • • • • ,� • •
.y ►/4"PAR fr SEPT/C TANK • s
g • • . • % , .
Q ; � I • ► •EFFECT/✓E • r .
• ° • • DEPTi1 • • • ' WA5,YED STa�YE
v • • s • •• 1 1 p o e
`j !�s� x ZS - 47 n •�•� • • • • • • • • • o p • PRECAST SEEPAGE
7Ff x l.0 = • �• • • P/T OR EpU/V-
!Ni/e,4VT CLEYAT/oNs SIT ct*r'��/-ry S��-B G/�G�t�fFy a �. • • • • . • • es o EL `j3,S
y/NYERT AT DU/LD/NG /b! o FT /o FT 0/AI+I• C SEE Tf49ULAT10N�
/NLET SEPTIC T.4/VK /'o.SFr
OUTLET SEPTIC TANK Oaf FT.
��� O GROuNO yV�iTER TA9LE
/NLET OISTR/8l/T/ON BOX FT. SECTION oF'
OdTLETD/STI�lBL/7/ON BOX�B FT .SELVAGE E7/SPOSA L SYSTEM
hV ET LEAC/+rING "17- 9 9.S FT. 'TABllLA?!ON
- LEACH/Nrs �/T DIMENS/ON A
scAL.E _ %s" / -O D/�►/ENS/aN 8 _FT.
DES/GN CR/TER/a
MIW-
NUMBER OF BEDROOMS
3 D/MFNS/ON C _FT.
GARBAGE D/SRO.SII.L UN/T' ,vO n/E SOIL LOG SD/L TEST t
TOTAL E37IM.4>-EO FLOW 3 3 O GAL.1DAY SO/L TEST A/ SO/L 7ES7-#2
NUMBER OF LE,4CfII,vG P/TS f`ELG•Y. /��0 �` ELEY, PATE OF SO/L TEST
S/OE LEACHING PER PIT /�� S!•i PT. RESUI..TS *VITNESSED dY`/�E ✓R Gpi3 /
90TTOM LL,.ICN/NG PER P/T 7`S $Q. �T D - 1 Z PtRCOLAT/ON RATE At/ LEA M/N�IINGN
AE,IC0I-A-r/ON RATE 2 7-14,o+NMI N.1/NCH
TOTAL LEACH/NG .4RBA '6 SQ. FT. �'% _ S.4n/D /7 Z,p
'q SERVE GEACNIN6 AREA �-6 6 SQ. FT.
So ILTC,-S r / 7-3 Z-S—
`� OF ` LOT /0 G /L/ocklA/G[312D !�9 �
Ut 44
��`
9s'c o� RUBBRTa.
;
A.
` ELDR DG
H
� MORSE �! � � :.. -- � ••` �� t., _ ELD 0 EEJVr_ / X GO,/J1/f o r .. _ /f�s'ST_ :' /lIYHNN/S,r MAss:.i
if
No. --?-2 FRia.....� -- .
THE COMMONWEALTH OF MASSACHUSETTS
� BOAR® of HEALTH
TI ........... . YIS1..........OF................b.tX r .....---
Appliration for Bispwi al Works Tonstrar Lion ramit
Application is hereby, ade for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst at:
.. .........................................Lrr....... ............................
Location-Address or Lot No.
.....?T ,?_.'.. [.ray--------------------------------------------- --_____-------•---•------------____-_---__-------__
Owner Addres
Installer Address
d Type of Building Size Lot............................Sq. fee
U Dwelling—No. of Bedrooms.___.__ __ _Expansion Attic Garbage Grinder
aOther—Type of Building ____N ______________ No, of persons............................ Showers ( ) Cafeteria ( )
Otherfixtures ---------------------------------•-------------...---•-------•--•--•••--------•-----••------••----------•----------..__...-----•--•-•-••---•--------
W Design Flow____._:_.__65.........................gallons per person per day. Total daily flow_._.._._._330.__.____.._.__.__._____gallons.
WSeptic Tank—Liquid capac- y� ___gallons Length__f:_l�e.____ Width_'/-�a'-_ Diameter________________ Depth__1.__ ef-
Disposal Trench--No. .._.. _______ Width_o______________... Total Length.................... Total leaching area_________._�...._sq. ft.
Seepage Pit No...../------------- Diameter......!__......... Depth below inlet-4_._6__.___. Total leaching area.� ____.....sq. tt.
Z Other Distribution box (✓� Dosing tank ( ) IS",1�l
Percolation Test Results Performed b -_ _
Y lir -- •---- ----_... Date--- �water
•-•-.l. 3
-
Test Pit No. 1_4- _______minutes per inch Depth of Test Pit-----1a�...... Depth to groundt_._..__.
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
W ............................................•_.....................................
Description of Soil............ ---------- --------------------•---------------------
V -----•----•-------••-----•---•-----------------•----------------------------------...--••--•-•--=-••-r------•------------•----------.--•--•-------- .................................................
W
x ----------------------------------•---------•---•---------•-----•---•-•-----•--•-•--•-----------•••----•----•-------•-------••------------••------------------•---------•-•---•-----------......_...._.
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
.-- - •--••••-------•-------••--•--------•--•--••----------------•-•-••---••------
Agreement:
he undersigned agrees to install the'aforedescribed Individual Sewage Disposal System in accordance with
*tpplitcation
ons o i TLE 5 f the State Sanitary Code— The undersigned further agrees not to place the system in
atu a ifi of Compliance has been issued b the bid of health.
Signed __-------_•-•--•-------•------------
__
Date
n Approved BY---e - --------------- �1 -----` �
Date
Disapproved for the following reasons-----------------------------------------------------------------------------------•-•---------._...._..--•------
-- ----------------------•---••------.....--•--------.....---------------------...-•-------...-------------------------------•----- -•------•-----------•-•--------•-------•---..................
- Date
PermitNo.---- ..........................� Issued........................................................
Date
No. ...... Fxs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........OF............. -.----------------..---.-..-----
Appliration for liiipnsal Works T.nnntrnrtinn Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sys em at:
............. ......------....--------.....----.......zt`",:-------1_°L-----.........------.......--
Location-Address or Lot No.
al.!..._61al-7-11................................................ ................----•-......-------•--------••-----...-----•--•--•---•------------•........_..-•--
�„ Owner Address
.
?:.....1� 2 ..... ..... C; ..W ►.. , ....�111 1r ...
....-•_..
Installer A ress
Type of Building, Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms___.._ _. .................Expansion Attic Garbage Grinder
a yp g ...._. No. of;persons..............
......................... Showers ( ) — Cafeteria )
Other—T e of Building N�?________________
�; t
Other fixtures ................................................... --
W Design Flow...........�..`-�!�........................... per person per day. Total daily flow__-____-.j3&---_-.-----__----•_gallons.
WSeptic Tank—Liquid ca.pa it}.000....gallons Length fit:..G....._ Widtht/_0.':.__ Diameter................ Depth.��:e`..
x Disposal Trench—No. A........... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No....!_____________ Diameter.._../a........... Depth below inlet T p•tal 1 Ching ______s . f .
ej
Z Other Distribution box Dosir `t f(k I(�i' � ' r �"2 /S/tob/
aPercolation Test I estil�. Performed by.._:,'_""---.... ------••-------=-- ...... Date
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Pa
Description of Soil ::.! G_C�rU�i_�
--------------•-• --------•---••-----•---••-•--•---------•-•-- ----•--•-•-•---.....•-•-•-. -----...-•••-----••-••••.----•---•••••---•-•....••--...--------------..
- - --------------------------------------------------•----------------------------------------------------•-----------------------------------------------------
V ``< ` Nature of Repairs or Alterations—Answer when applicable................................................................................................
---------------------•--------------•----•--•-------•---•--••----------------...--------•--------....----------------------------•-------------------...._._..--•--.._........-•-..........-•••--
eement:
`lThe_ u r ' d ees to install the aforedescribed Individual Sewage Disposal System in accordance with
h ovis Im 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
Cate of Compliance has been_ig ue ,.b the board of health.
Signed ._.... -----•-------------- •---•- --:----.-•••---
,.-�-�; ,may --------------------------
Application Approved BY ........ --- _..-CC -------------------- -- ..------ D t ..
< Date
Application Disapproved for the following reasons--------------------------------------------------------•--------------------•----------•--...•-•-•---........-•-
.....••---•------------------------------• •--•---•-...�.�•----•---........- •----••••---------•----••.....................---•--Date•--•••••--•---
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(Inrtifiratr of Tuntpltnnrr
THIS IS Ta"C That t1:,--I,ndividual Sewage Disposal System constructed ('X) or Repaired ( )
by--•--•---___--•--_. -------------------•---•-----'-....__....._---- ---------------------------------__--__-_-_----------•----._-----------•-•--__-__.._________---
ff k-- I -taller� �4
at........................"` — F 10...-.. 1� � .�a••�--•---•---------------••---•---•---•-•-•------------•--•-----
has been installed in accordance with the routs ITLY _ f T e Sanitary C Ses r in the
application for Disposal Works Construction Permit No.......
__- •._". datedy..__
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR ED AS A GU TEE T AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...............__._-._. g .._••-•-•••. •-_. Inspector................... �•• . . •---- - • ........
-•--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No. ........ ...�) ......... j. l!'.1...................OF......... ...... .,
...... FEE.........................
Dinpnna�l nrkii 0..11nntrttrt n rrntit
Permission is t�reby granted.__..._..T�49......... .........w�.
- ------------------•..----.....................................................
to Construct ( or Repair ) an Individual Sewage Disposal Syst 'n
at No... 1Qoci� ll% L?.... �, `J "11 -� •
Street /
as shown on the application for Disposal Works Constructiom P a"�I� -.--__ 'D .............................
_......t....:. ......._....
r'
12� Board of Health
DATE --••-- •••--
FORM 1255 A. M. SULKIN, INC., BOSTON
LOCATION O► 3 0-3 6 SEWAGE PERMIT NO
VILLAGE
INSTALLER'S NAME&ADDRESS
a
BUIgbER OR OWNER
DATE PERMIT ISSUED
` la
DATE COMPLIANCE ISSUED ���
36 r 3�
pps
ROBERT �,
aLpREDGE
No. 19367
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xm4ws , :, LE 'EN
-SPOT ELEVATION OxO
'
der CERTIFIED PLOT PLAN
��1�ISTIAO®::- CONTOUR --- ® ___
{ !lgNED SPOT ELEVATION Z loco Mom/wG3oe 4_*Ive
'PINISNEW, CONTOUR - 0
rqO '� 'The aocaiion of any existing underground sewerage;
IN
w.�lls, or"other utilities shown on this .plan is approx- aa
0
. 4e 1A��:�.�a
ate{only as. determined from records and/or verbal
information The contractor is responsible. for" the dam
w desif cati on :ofythe. existing locations in the field. SCALES / "=30 DATE., 9-12 `
� WEDOE ENGINEERING CO /N gyp",
CLIENT. L�&Q2 I CERTIFY THAT THE PROPOSED
'S
< EOISTERE RFOISTERED SOS N0. /O BUILDING SHOWN ON THIS PL AN
y' LAND 14 CONFORMS TO THE ZONING LAWS
f
R { ®R..®Y' .�. ._.� OF BARNSTABL E , MASS.
?I MAIN -STREET ; CK BY'3 :H .
SHEET—L OF 3
YORYANNIS MASS �
r�x r
2 FT. MIN • /1fOTE' /F E/TNER TNE.SEPTJC. TANK OR »_
G `_EACN/wG P/T .4RE 1%,JORP Ts•/A.v /2"4SE40J&V
M _rRA OEM 24`OM ICJ E T,ER CONC'R E 7 CO tiER by
S,Nf44L &E BROUGHT TO 4S)TAo.E.64,v EXTRA 1.
CG/VCRPTB MAN c PiP NEAV y CA S T /ROJY C o L L- L3E US EO ~
L 104 CONER.S �B"pEiQ /N O IT/VIFWA y
A G •2' MiN. Co/VCRE TE
a- ��_ 4DE CCU VER CLEAN SANO
�. - . ,.• .^�-� . BACKS/LL i
VQU/D LEVEL
4 ; 4"'CAST 2 LAYER
IRON PIPE
MIAl.PrrCll GAL.' e • • • . . . . • • e •4 RYA SHEO 570.,YE
SePT/C TANK D/ST. • e ! • . . . . . • , , e At . , t'
BDX a • • B • . • • • � .•D • .
:: v • •� ! • •EFFECT/VE ` • •, 3140
- �2� i.
=�:_ • o • • • DEPTH • • • � • v.o lV.4SHEO'STaNE� � :k
a - • o • • • • • •• •
l.o = 79 ` lop• . •. it • • • o p PRE445T SEEPAGE
YNd/�1�7 ALB✓AT/oNS OJT Ct+l'-+c1T. S�6' ���4Gw�4y a �a • • • • • . • • e a • P/T ORdw
/NYERT AT B[//LDl/VG l /. FT 6 t-T. D/AM.
/ T /UO,;S T /o FT. VlAdw- C SEE TA.504A /ON>
INLET .SEPT C .4NK_ F . .
OCl.TLET SEhT,,c -rANiC 1.00,3FT
INLET 40/STR/8l/TJON BOX to o•y FT GROUND Wil TE/r TABL E
-TECT'!Q/V O/c- .
00774L DJST B[JTY0111 BOX 998 FT
//VCET J'rACgjVa F*rT ✓ - 'Cr .SENIAGE O/SPoS'r4 I- .Si�ST'�/�9
'TAB41L�RT!G/V,
s DIMEIV510M i$
_ �4 p =. ./= 0�
-DES/6M CRI'TER/fit SCALE 0L f.E1 _FT.
NUMBER Of BED/�o 0/+9S 3 DJaJENS/ON. C- F 7: m1f✓ .. ,.
GARg,aG.E DrsPo Ac u�rJr Jvo.✓�.., SQ/L L®G So/1. TESL"
TOTAL E3`Tl1.1ATEG FLOytr_ 3 3 F, G.�SL.�DAY. SO/L TEST A/ SOIL 7ES7-*2 .
NUMBER Off' LLsACXlNG PITS_ / �ELe�Y. �of_� �L�Y. OATS OF SOIL TEST �! �/g 3
SJOE 4EACHIA/6 PER.P/7- ' /�"�.._Sq FT. RESULTS /s//TNESSED 8YJ�E ✓ACo8
9oTTOM L r9CHJNG PER.P/T_7� $Q. FT. v Z PtlV C®L/�T/ON RATE Af/ L�� !y/N�I NCH
TOTAL LEACH/NG A.R ?�6 SQ,' .FT. ` j n?C-ice%tJ! l� hCOLAT/aN R.4T.E 1k2 T' /��/hI/N�INCH
ARSERYE LEACNJNG ARE/►_ eo SQ. FT. Z,0.
\CH OF V 0F LO OG ./LlOckiNGC3/2D ME. f
4ss TA
F�
l B RT G
A \
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