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HomeMy WebLinkAbout0100 MOUNTAIN ASH ROAD - Health I 100 MOUNTAIN ASH ROAD, MM 1 A:124-039 s //�c�ur�tien� � �p�� �ir✓ 7lJC - P�, ��2Tik'� I Commonwealth of Massachusetts -- - Title 5 Official Inspection Form Not for Voluntary Assessments yY Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification Important: y� 03 When filling out 1. Property Information: forms on the computer,use 100 Mountain Ash Road only the tab key Property Address to move your Today Real Estate cursor-do not use the return Owner's Name key. 1533 Falmouth Road Owner's Address VQ Centerville MA 02632 City/Town State Zip Code Date of Inspection: 12/30/07 Date 2. Inspector: MR. ROBERT A. DRAKE Name of Inspector KCJ ENGINEERING Company Name 66 GREENVILLE DRIVE Company Address .v �a FORESTDALE MA t02644Cityrrown State ip Codes.... 508-477-5048 z Telephone Number co t Certification Statement: I certify that I have personally inspected the sewage disposal system at this addre sand tt theme information reported below is true, accurate and complete as of the time of the ins ection. he irWpection was performed based on my training and experience in the proper function and m intenance 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 of M ® Conditionally Passes P §sy� ROBERT A. tiG ❑ Needs Further Evaluation by the Local Approving Authority DRAKE o clvlLGO GO t No.41642 O Inspector's Signature Date O9 �/S T V- The system inspector shall submit a copy of this inspection report to Authority(Board of Health or DEP)within 30 days of completing this inspection. If the Sys em 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. 100 Mountain Ash Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form A. Certification (cont.) 100 Mountain Ash Road Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Today Real Estate 12/30/07 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 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 components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND)in the❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate Of Compliance indicating that the tank is less than 20 years old is available. ND Explain: 100 Mountain Ash Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form ' M A. Certification (cont.) 100 Mountain Ash Road Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Today Real Estate 12/30/07 Owner's Name Date of Inspection 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 ❑ 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 ❑ obstruction is removed ND Explain: 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 100 Mountain Ash Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 100 Mountain Ash Road Property Address Marstons Mills MA 02648 Citylrown State Zip Code Today Real Estate 12/30/07 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 100 Mountain Ash Road-T51NSP1.DOC.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 100 Mountain Ash Road Property Address Marstons Mills MA 02648 Cityrrown State ZipCode Today Real Estate 12/30/07 Owner's Name Date of Inspection 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 ❑ ® 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Yes No ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 100 Mountain Ash Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y Subsurface Sewage Disposal System Form M A. Certification (cont.) 100 Mountain Ash Road Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Today Real Estate 12/30/07 Owner's Name Date of Inspection 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. 100 Mountain Ash Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6of16 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 100 Mountian Ash Road Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Today Real Estate 12/30/07 Owner's Name Date of Inspection Check if the following have been done. You must indicate"yes"or"no"as to each of the following: YES NO ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 100 Mountain Ash Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7of16 Commonwealth of Massachusetts �.i Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information Mountain Ash Road Property Address Marstons Mills MA 02648 Cityfrown State Zip Code Today Real Estate 12/30/07 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Well 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: A couple of months ago Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 100 Mountain Ash Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments r` Subsurface Sewage Disposal System Form C. System Information (cont.) 100 Mountain Ash Road Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Today Real Estate 12/30/07 Owner's Name Date of Inspection General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: House built in 1981, septic tank, D-Box appear to be original, a 1,000 gallon leaching pit was added to sysytem in 1996. Were sewage odors detected when arriving at the site? ❑ Yes ® No 100 Mountain Ash Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 100 Mountain Ash Road Property Address Marstons Mills MA 02648 Citylrown State Zip Code Today Real Estate 12/30/07 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints,venting, evidence of leakage, etc.): Sewer pipe appears to be in good condition. No signs of leakage. Septic Tank(locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Tank is under existing wooden deck, appears to be structurally sound, Was able to open inlet cover and there was no tee inplace. Inlet cover is within 18"of grade. If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ No certificate) Dimensions: 1,000 GALLON Sludge depth: APPROX. 6"+/- Distance from top of sludge to bottom of outlet tee or baffle N/A Scum thickness APPROX. 12" Distance from top of scum to top of outlet tee or baffle APPROX. 4"+/-to invert of inlet pipe. Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? MEASURED IN FIELD 100 Mountain Ash Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 III Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 100 Mountain Ash Road Property Address Marston Mills MA 02648 Cityrrown State Zip Code Today Real Estate 12/30/07 Owner's Name Date of Inspection 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 should be pumped, tees need to be installed and the upstairs bathroom's toilet is leacking should be fixed. Grease Trap(locate on site plan): Depth below grade: N/A 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as,related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 100 Mountain Ash Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form C. System Information (cont.) 100 Mountain Ash Road Property Address Marstons Mills MA 02648 Cityfrown State Zip Code Today Real Estate 12/30/07 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: N/A 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.): Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert At invert of outlet pipe. 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.): D-Dox appears to be working properly. No signs of solid carryover or leakage. Notice running water coming into the d-box. Determined it was from the upstairs bathroom leaking toilet. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 100 Mountain Ash Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form C. System Information (cont.) 100 Mountain Ash Road Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Today Real Estate 12/30/07 Owner's Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2-1,000 gallon ❑ 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.): Leaching pit appears to be working properly, no signs of ponding and vegetation is normal. 100 Mountain Ash Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 100 Mountain Ash Road Property Address Marstons Mills MA 02648 Cityrrown State Zip Code Today real Estate 12/30/07 Owner's Name Date of Inspection 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 Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: N/A Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 100 Mountain Ash Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 100 Mountain Ash Road Property Address Marstons Mills MA 02648 Cityfrown State Zip Code Today Real Estate 12/30/07 Owner's Name Date of Inspection 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. WG`L vr�y y I - i i" i I - L - J J r53 - 2e ' 100 Mountain Ash Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 100 Mountain Ash Road Property Address Marstons Mills MA 02648 City/rown State Zip Code Today Real Estate 12/30/07 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 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: Barnstable GIS Groundwater Maps indicate high groundwater elevation is at approx. = 35' +/-,t GIS Contour Maps indicate that the ground elevation is approximately at elevation 61.0' approx. 25'+/-above the groundwater table. 100 Mountain Ash Road-T51NSP1.DOC.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16of16 Town .of Barnstable �p tHE 1p� Regulatory Services BA ,WABLE Thomas F. Geiler, Director A,Ep39�A Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. I-- — 9 , V THE COMMONWEAL H OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes appliCotton for �Dtzpozal i§pgtem Cottgtructton VCrmtt Application for a Permit to Construct O Repair Grade Abandon O ❑.Complete System ❑Individual Components Location Address or Lot No. /bCj Ino Urv'7,ktyl1 )4 S N Owner's Name,Address;and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel o.�_ k �I CO Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) i�I�iL �7Ecs 1$ JA) SCkri r, 77"L Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date d d r� Application Approved byLZI Date Application Disapproved by: Date for the following reasons Permit No. Date Issued d �� 'Y .w ... "w,�,.�1t..r...rr,:r`.*4^ ..,..r. � ..ro.��.-T�..-Mt. y�,.��a-J(r��"�✓ �i � ��J V t���"� •+`r--^.},•..,-,r*."r'an.�<��7^�-�-tr-',^.,w_ `, _.Y No. � � o � � Fee THE COMMONWEAL H OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippY%catton for �Dtgogal �&pgtem Cottgtruchon Permit Application for a Permit to Construct( ) Repair(!) grade( ' ❑Abandon( ) Complete System ❑Individual Components Up Location Address or Lot No. /(fib )Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No.���` �� Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria Other Fixtures { Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �i�f oL/�C�_ �/=� S 1 A) S ck! s Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation,until a Certificate of Compliance has been issued by this Board of Health. �f Signed r Date Application Approved by tDate Application Disapproved by: Date for the following reasons - J Permit No. Date Issued --------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS �%. BARNSTABLE, MASSACHUSETTS POO Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (1/ Upgraded ( ) Abandoned( )by at bU f © / _ Pas been constructed in accordance with the provisions of Title 5 anddtthee for Disposal System Construction Permit No. dated Installer d'�U� 7 //�.�i Designer #bedroom Approved design flow gpd ` system The issuance of thi ermi shall .of be construed as a guarantee that the ill f ction as . P g I Date Inspector � ———————————may—� — — ————————————————�—————————— No. V�/ � Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE MASSACHUSETTS �f tgpogar *potent Cottgtructton Permit f Permission is hereby granted to Construct ( ), Repair ( ) Upgrade ( ) Abandon ( ) System located at /D�&/1yi&,7a_m_ Ad-1 ED i I! and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction m st be completed within three years of the date of this �: > �^--- j Date Appro d by ` i °f A ; CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory 'T9sr,Ctc Report Prepared For: Report Dated: 1/30/2008 David Holt Today Real Estate Order No.: G0844939 1533 Falmouth Road Centerville, MA 02632 Laboratory ID#: 0844939-01 Description: Water-Drinking Water Sample#: Sampling Location: 100 Mountain Ash Rd.Marstons Mills,MA Collected: 1/29/2008 Collected by: M.DeDecko Received: 11.29/2008 Routine+Ammonia ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Ammonia ND mg/L 0.20 EPA 350.1 M LAP 1/29/2008 Nitrate as Nitrogen 1.9 mg/L 0.10 10 EPA 300.0 LAP 1/29/2008 Copper ND mg/L 0.10 1.3 SM 311113 LAP 1/30/2008 Iron ND mg/L 0.10 0.3 SM 3111B LAP 1/30/2008 Sodium 23 mg/L 1.0 20 SM 311113 LAP 1/30/2008 Total Coliform Absent P/A 0 0 SM9223 AF 1/29/2008 Conductance 170 umohs/cm 2.0 EPA 120.1 DCB 1/29/2008 pH 6.1 pH-units 0 SM 4500 H-B DCB 1/29/2008 Sodium level is above the maximum contaminant level. Those on a low sodium diet may wish to consult a physic' n. Approved B (Lab irector) 2.1 C T7 L' C_n r— C_n f r1 "'� �..'.` "�` .:$_. •:fir o > .�. "C-o.; qz ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 CERTIFICATE OF ANALYSIS Pkge: 1 +J `" Barnstable County Health Laboratory Report Prepared For: Report Dated: 1/30/2008 David Holt Today Real Estate Order No.: G0844939 1533 Falmouth Road Centerville, MA 02632 Laboratory ID#: 0844939-01 Description: Water-Drinking Water Sample#: Sampling Location: 100 Mountain Ash Rd.Marstons Mills,MA Collected: 1/29/2008 Collected by: M.DeDecko Received: 1/29/2008 EPA 524.2- Volatile Organics by GC/MS ITEM RESULT UNITS RL MCL Method 4 Analyst Tested Note Dichlorodifluoromethane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 Chloromethane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 Vinyl chloride ND ug/L 0.50 2.0 EPA 524.2 yn 1/29/2008 Bromomethane ND ug/L, 0.50 EPA 524.2 yn 1/29/2008 1,1,1,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 1,1,1-Trichloroethane ND ug/L 0.50 200 EPA 524.2 yn 1/29/2008 1,1,2,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 1,1,2-Tri chi oroethane ND ug/L 0.50 5.0 EPA 524.2 yn 1/29/2008 1,1-Dichloroethane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 1,1-Dichloroethene ND ug/L, 0.50 7.0 EPA 524.2 yn 1/29/2008 l,l-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 1,2,3-Trichlorobenzene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 1,2,3-Trichloropropane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 1,2,4-Trichlorobenzene ND ug/L 0.50 70 EPA 524.2 yn 1/29/2008 1,2,4-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 1,2-Dibromo-3-chloropropane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 1,2-Dibromoethane(EDB) ND ug/L 0.50 EPA 524.2 yn 1/29/2008 1,2-Dichlorobenzene ND ug/L 0.50 600 EPA 524.2 yn 1/29/2008 1,2-Dichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 1,29/2008 1,2-Dichloropropane ND ug/L 0.50 EPA 524.2 yn /29/2008 1,3,5-Trimethylbenzene ND ug/L. 0.50 EPA 524.2 yn 1/29/2008 1,3-Dichlorobenzene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 1,'3-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 1,4-Dichlorobenzene ND ug/L 0.50 5.0 EPA 524.2 yn 1/29/2008 2,2-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 1/29/2008- 2-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 4-Chlorotoluene ND ug/L, 0.50 EPA 524.2 yn 1/29/2008 Benzene ND ug/L. 0.50 5.0 EPA 524.2 yn 1/29/2008 Bromobenzene ND ug/L 0.50 - EPA 524.2 yn 1/29/2008 Bromochloromethane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 Bromodichloromethane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 Bromoform ND ug/L 0.50 EPA 524.2 yn 1/29/2008 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level -Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 CERTIFICATE OF ANALYSIS Page: 2 " Barnstable County Health Laboratory ssaC �/ Report Prepared For: Report Dated: 1/30/2008 5 David Holt Today Real Estate Order No.: G0844939 1533 Falmouth Road Centerville, MA 02632 Laboratory ID#: 0844939-01 Description: Water-Drinking Water Sample#: Sampling Location: 100 Mountain Ash Rd.Marstons Mills,MA Collected: 1/29/2008 Collected by: M.DeDecko Received: 1/29/2008 EPA 524.2 - Volatile Organics by GC/MS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Carbon tetrachloride ND ug/L 0.50 5.0 EPA 524.2 yn 1/29/2008 Chlorobenzene ND ug/L 0.50 100 EPA 524.2 yn 1/29/2008 Chloroethane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 Chloroform ND ug/L 0.50 80 EPA 524.2 yn 1/29/2008 cis-1,2-Dichloroethene ND ug/L. 0.50 70 EPA 524.2 yn 1/29/2008 cis-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 Dibromochloromethane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 Dibromomethane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 Ethylbenzene ND ug/L, 0.50 700 EPA 524.2 yn 1/29/2008 Hexachlorobutadiene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 IsopropyIbenzene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 Methylene chloride ND ug/L 0.50 5:0 EPA 524.2 yn 1/29/2008 Methyl-tert-butyl ether ND ug/L, 0.50 EPA 524.2 yn 1/29/2008 Naphthalene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 n-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 n-Propylbenzene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 p-Isopropyltoluene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 sec-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 Styrene ND ug/L 0.50 100 EPA 524.2 yn 1/29/2008 tert-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 Tetrachloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 1/29/2008 Toluene ND ug/L 0.50 1000 EPA 524.2 yn 1/29/2008 Total xylenes ND ug/L 0.50 10000 EPA 524.2 yn 1/29/2008 trans-1,2-Dichloroethene ND ug/L 0.50 100 EPA 524.2 yn 1/29/2008 trans-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 Trichloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 1/29/2008 Trichlorofluoromethane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 Sodium level is above the maximum contaminant level. Those on a low sodium diet may wish to consult a physician. Approved By: --- - --- / (La irector)i J ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 s`� 0-'./ 0/2008 WED 16: 07 FAX 5083627103 Barnstable CTY HealthLab --- Barnstable Health 2003,'003 x; J CERTIFICATE OF ANALYSIS Pa Barnstable County Health Laboratory Report Prepared For: Report Dated: 1/30/2009 A � David Holt Today Real Estate Order No.- G,0844939 1533 Falmouth Road (90 Centerville, MA 02632 pa*4 j,abnr;tors ID#: 0844939-01 Description: Water-Drinking Water l Sample#: Sampling Location: 100 Mountain Ash Rd.Marstons Mills,MA Collected: 1/29/2008 k Collected by: M.DeDecko Received: 1/29/20(,II TPI.f 524.2- Volatile Organics by GUMS ITEIM RESULT UNITS RL MCL MethotI f ',n est Tested Not, 1 1 Carbon tetrachloride ND ug/L 0.50 5.0 EPA 524.2 In 1/29/2008 Chiarobenzene ND ug/L 0.50 100 EPA 524.2 yn 1/29/2008 L 0.50 EPA 524.2 vn 1/29/2008 u Chloroethane ND t� - Chloroform ND ug/L 0.50 80 EPA 524.2 yn 1/29/2008 K cis-i,2-Dichloroethene ND ug/L 0.50 70 EPA 524.2 yn 1/29/2008 f cis-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 Dibrmnochloromethane ND ug/L 0.50 EPA 524.2 ;m 1/29/2008 Dibromomethane ND ug/L 0.50 EPA 524.2 m 1/29/2008 Eth;ylbenzene ND ug/L 0.50 700 EPA 524.2 yn 1/29/2008 E Elex:achlorobutadiene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 [sopropylbenzene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 Nfei:hylene chloride ND ug/L 0.50 5.0 EPA 524.1 yn IJ29/2008 VIe�hyi-tert-butyl ether ND ug/L 0.50 EPA 524.2 yn 1/29/2008 1 Nlap1•tthalene ND ug/L 0.50 EPA 524.1 ;,n 1/29/2008 n-B-utylbenzene ND ug/L 0.50 EPA 524.'! n 1/29/2008 i a-Propylbenzene ND ug/L 0.50 EPA 524.:! /n 1/29/2008 1-1sop'-ropyltoluene ND ugIL 0.50 EPA 524.2 yn 1/29/2008 u 0.50 EPA 524.2 yn 1/29/2008 Sec-Butyl benzene ND g�- }I Styrene ND ug/L 0.50 100 EPA 524.:? yn 1/29/2008 tert-r3utylbenzene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 I j I etrachioroethene ND ug/L 0.50 5.0 EPA 524.? ;rn 1/29/2008 i Toluene ND ug/L 0.50 1000 EPA 524.:! n 1/29/2008 ) Total x.:ylenes ND ug/L 0.50 10000 EPA 524.:: yn 1/29/2008 fians••1,2-Dichloroethene ND ug/L 0.50 100 EPA 524.2 yn 1/29/2008 i trans.. ,3-Dichloro ro ene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 _ P P r' > u 0.50 5.0 EPA 524... n 1/29/2008 c ethen y C.1 .hlclo e ND ?� T:richlorofluoromethane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 _ S'odhan level is above the maximum contaminant level Those on a low sodium diet may wish to consult a �;1 si„cci,. r Approved By irector)i f ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 I 0:_/30/2008 WED 16: 07 FAX 5083627103 Barnstable CTY HealthLab Barnstable Health 0002,'o03 CERTIFICATE OF ANALYSIS') Page: .1 Barnstable County health Laboratory Report Prepared For: Report Dated: 1/30/2008 David Holt Today Real Estate Order No.. G0'8441939 1533 Falmouth Road Centerville, MA 02632 11 aboratory ID#: 0844939-01 Description: Water-Drinking Water Sample#: Sampling Location: 100 Mountain Ash Rd.Marstons Mills,MA Collected: 1/29/2008 R. Collected by: M.DeDecko Received: 1/29/200:1 r r 11 f 524.2- Volatile Organics by GUMS _ITEM RESULT UNITS RL MCL Method# 'un.3lvst Tested _K.,1 I)ichlorodifluoromethane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 Chloromethane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 4 Vinyl chloride ND ug/L oso z.o EPA 524.2 yn 1/29/2008 Bromomethane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 1,I,1,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 3 1,1,1-Trichloroethane ND ug/L 0.50 200 EPA 524.2 yn 1/29/2008 3 g 1,1,2,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 1,1,2-Trichloroethane ND u2/L, 0.50 5.0 EPA 524.2 yn 1/29/2008 F 1,1••Dichloroethane ND ug/L 0.50 EPA 524.2 yn 3/29/2009 { 1,1 Dichloroethene ND ug/L 0.50 7.0 EPA 524.2 yn 1/29/2008 I,1-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 I 1,2,3-Trichlorobenzene ND ug/L oso EPA 524.2 yn 1/29/2008 1,2,3-Tri chloropropane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 j } 1,2,4-�rrichlorobenzene ND ug/L 0.50 70 EPA 524.2 In 1/29/2008 ( 1,2,4-Trimethylbenzene ND ug/L 0.50 EPA 524.2 in 1/29/2008 `i 1,2-Dibromo-3-chloropropane ND ug/L 0.50 EPA 524.2 yn I/29/2008 j } 1,2-Dibromoethane(EDB) ND ug/L 0.50 EPA 524.2 yn 1/29/2008 1,2-•Dichlorobenzene ND ug/L 0.50 600 EPA 524.2 yn 1/29/2008 1,2-Dichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 1/29/2008 1,2-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 I i 1,3, =Trimethylbenzene ND ugfL 0.50 EPA 524.2 ;,,n 1/29/2008 1,3-Dichlorobenzene ND ug/L 0.50 EPA 524.2 ;n 1/29/2008 0-Dichloropropane ND ug/L 0.50 EPA 524.: ;in 1/29/2008 1,4-:1)ich1orobenzene ND ug/L 0.50 5.0 EPA 524.2 yn 1/29/2008 2,2=:C►i;.hloropropane ND ug/L 0.50 EPA 524.2 yn 1/29/2008 ; 1-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 1/29/2008 4-C.h.lorotoluene ND uea 0.50 EPA 524.2 /n 1/29/2008 Benzene ND ug/L 0.50 5.0 EPA 524.2 vn 1/29/2008 Bro-r:obenzene ND ug/L 0.50 EPA 524.2 n 1/29/2008 13royn.ochloromethane ND ug/L 0.50 EPA 524.2 m 1/29/2008 BroModichloromethane ND ug/L 0.50 EPA 524.2 ya 1/29/2008 Brornoform ND ug/L 0.50 EPA 524.2 yn 1/29/2008 f ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 - 0--/3C/2008 WED 16: 06 FAX 5083627103 Barnstable ('9')? HealthLab --- Barnstable: 200111w03 b '94 CE AA' R I -" F ANAL YSIS' _ RTIFICATE. 0 Barnstable County Health Laboratory Report Prepared For: Report Datedi 1/30/2008 David Holt Today Real Estate Order No.-.: (,"11,418-4, 1)3) 1533 Falmouth Road Centerville, MA 02632 .................. Laboratory ID#: 0844939-01 Description: Drinking Water Sample N: Sampling Location: ]C;,)Mountain Ash Rd.Marstons Mills,MA Collected: 1/294 003 Collected by: M.DeDecko Received: 1/29/7003 T 0 wine+Ammonia ITE111 RESULT UNIT' RL MCL Method k i aly.0 Tested N-A4 Ammonia ND mg/L 0.20 EPA 350.,.t, AP 1/29/2008 Nitrat,-2 as Nitrogen 1.9 mg(L 0.10 10 EPA 30( 1-0 1/29/2008 Coj:)I?c.r ND mg/L 0.10 1.3 SM 3111,13 ).Ap 1130/2008 Iron ND mg/L 0.10 0.3 SM 311 IB LAP 1/30/2008 SOCI.;UITI 23 mg/L 1.0 20 SM 31118 I AP 1/30/2008 Total C—oliforni Absent P/A 0 0 SM9223 AF 1/29/2008 Conductance 170 umohs/cra 10 EPA 12C.i I i:7B 1/29/2008 pH 6.1 pH-unift 0 SM 4500114� 1:CB 1/29/2008 .;odium level is above the maximum contaminant level Those on a h)w sodium diet may wish to consult i.,r"Ity-14"wn. Approved Br_--_ i (.Lab hector) ND 7 None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 V TOWN N OF BA RNSTABLE LOCATION IbO �np�n�jcy�� Q�� SEWAGE # VILLAGE p ZSiS (M I rIS ASSESSOR'S MAP 6r LOT INSTALLER'S NAME & PHONE N � Snvl n i r SEPTIC TANK CAPACITY L0 y LEACHING FACILITY:(type) o� _�c.�`� (slze) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER RU?T,nRR, OR OWNPR DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: I d yy 3� NELI) �_f3 Fee 0.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS TippItCation for Migogar *pgtem Com5trurtton Verna Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. Fred Derham 100 Mountain Ash Road 100 Mountain Ash Road Marstons Mills,Mass. Installer's Name,Address,and Tel.No. 508-775-3338 Designer's Name,Address and Tel.No. 508-775-3338 .P.Macomber Jr. Box 66 J•P•Macomber Jr. Box 66 Centerville,Mass . 02632 Type of Building: Dwelling xx No.of Bedrooms 3 Garbage Grinder f`0) Other Type of Building RES No. of Persons 4 Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 0 gallons per day. Calculated daily flow 3 x 110=3 3 0 gallons. Plan Date 4/11 /96 Number of sheets 2 Revision Date Title Description of Soil Sand & gravel Nature of Repairs or Alterations(Answer when applicable) Addi n g 1_1 n n n sra l l n n l a a r-h i n g nT i t t o an Pxi 4'f� Tank lynx and pit 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 t to place the system in operation until a Certifi- cate of Compliance has been issu by this B d Signed Date 4 /T1 1 /9 6 Application Approved by ,% Application Disapproved for the following reasons Permit No. & 13 Date Issued q ------------------------ 1 z ,. _. t M /3S •' ; Fee 0. 00 �. THE COMMONWEALTH OF MASSACHUSETTS PUBLICHEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppl.icattan for Mi$pOgal *p$tem Con! truction Permit Application is hereby made for Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. Fred Derham 100 Mountain Ash Road 100 Mountain', Ash Road Marstons Mills,Mass. Installer's Name,Address,and Tel.No. 5 08-77 5-3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8--77 5-3 33 8 J:P.Macomber Jr. Box 66 J•P•Macombor Jr. Box 66 Centerville,Mass. 02632 02832 Type of Building: Dwelling xX No.of Bedrooms 3 Garbage Grinder 0 ) -Other Type of Building RES No. of Persons 4 Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallonsperday. Calculated daily flow 3x1.10=330 gallons. Plan Date 4/1 1 /96 Number of sheets 2 Revision Date Title Description of Soil Sand & gravel .. -Nature of Repairs or Alterations(An w r when applicable ) Adding 1 1 n 0 n rra l 1 o n 1 P a c+h i n k -n i t t p s an Maxi sting Tank hox and niter j Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and n t to place the system in operation until a Certifi- 2 11cate of Compliance has been issu by this B d o kh. Ir 1 Signed Date L:/11/96 Application Approved by Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate Of (Compliance ' THIS IS TO CERTIFY,that the -n-site aSeage is s 4'System ins led )or reps -eti/ieplaced(XX)on by " q� Derh m as t' s. Z has been constructed w d with the provisions of Title 5 a '�d t e°'for Disposal System Construction Permit No. G "13�t dated `� Z-1 .V Use of this system is conditioned on compliance with t e provisions set forth below- l t' — -- No. �-3--f � Fee$ 40.00 '----- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mtopogaf *p.5tem COtte;trurtton Permit Permission is hereby granted to J.P.Macomber Jr. to construct( )repair;�X )an On-site Sewage System located at 100 Mountain Ash Road Marstons Mi_lls ,Mass . and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.. All construction must a completed within two years of the date below. Date: `� '�/ /Approved by r, y CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) a I, J P.Macomber Jr , hereby certify that the application for disposal works coristruction permit signed by me dated ti(1__/ h , concerning the 4 property located at 100 Mountain Ash Road Marstons Millsmeets all of the following criteria: • 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 "4 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. SIGtNZEPTIC " DATE: "7'`42 LIC 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). ` SEWAGE PERMIT M:O L 0 C A,.T ION rA VILLAGE INS> ::.A, LIER'S NAME i ADDRESS R U1` ER OR OWNER DATE . : PERMIT ISSUED - j DAT. COMPLIANCE ISSUED 1_64�e K a' Z'�' 3� �Ord C ry — —— — — —- — —_J• �s. IZP • s- a Via., 607 n A .. 19, � Q ` 9�. $ \� r - -•, .. any, a t , `r-� ��'�,'4r•` y ' b � " a���4 LT.?s' l..,Jy y'�•'�r a a j'4 • •,� ,.,x , y � - \ x ._ — _�, .y .. .. ` ! • . .. �q�s ��a t�fis�"ajr. G"L�;T'f're+.t��y 4 '4r�.r� . h AN to 3 2 ; N fle01 Ob lk LOCATIO2N �(� S' EWAG �I PERMIT NO. Cr V'IL,LAGE f�v lq�-A I N S T A LLER'S NAME i ADDRESS 3 U I L 0 E R OR OWNER 0ATE PERMIT ISSUED DATE COMPLIANCE ,ISSUED 04I7 1, j/ 1 G1 I f Q lc s' j b bo 1 :3 40 z, 1 . ys ` THE COMMONWEALTH OF MASSACKUSETTS BOAR® OF HEALTH Town Barnstable ...............I._... ....................O F...........................---........------------...----------------------.............. ,NliplirFatiou for Bi,gpngai Morkii Towitrnrtion Prrutit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: / 60 Mounyain Ash Road Lot 20 ................-............................................. --------------------------------- -----------------------------•---------------•----------------•------------:-..--•------•--------- A Location; dres or Lot No. ..... A444e - -- --- ----------•-------•---------------•- -•---•-•-•----------•-•-------------- -------•-------------------------------------------- Owner Address a ... -................................................ nstaller Address 27,069 Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms..................3------------------------Expansion Attic ( ) Garbage Grinder fio) aOther—Type of Building ____•_-_------_-_•-_--____- No. of persons...------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------------------------- Design Flow.........................._.........._._....gallons per person per day. Total daily flow--_-___--33_0---------------------------gallons. W r rt WSeptic Tank—Liquid capacity Pg gallons Length_$___6_iv_____ Width..4..t.1Q__ Diameter---------------- Depth_4?.011 x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. � Seepage Pit No______________________ Diameter.....l�._....... Depth below inlet.......... ...... Total leaching area__26:7--------sq. ft. Z Other Distribution box ( X) Dosing tank ( ) aPercolation Test Results Performed byC3pe--_COd--SuX'V v...CQmultant,�Date_.__.....3/1.14,./.8.0............ Test Pit No. l..... -___--___minutes per inch Depth of Test Pit------12.__------- Depth to ground water....nona_____---- (i, Test Pit No. 2................minutes per inch Depth of Test Pit_..__-__•-_________- Depth to ground water........................ --------•--------------------------------------- ----------•-------•--------------------------------......................................................... 0 Description of S oil.0.0-0.5 wood--l9am......Q..5=1__5---aub_s-ail......1_54—._5---gr-av81•, .......................................................... med_,___w_h__it e--.sand-_----------------•-----------------------...----------------------�' �jx_o� G . � ass W ------•-•-•--•---•----------_ ----••-...-----•-•-•-------------------------•---•-•----•-----------•------------------------------------------------------•----------------;%"tj.......------------ RORERT c U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------..... . .. ........... ---•------•-•-•-•---•---•--•----------•---------•-•--------•--------•-•-----•-----------•--•.........................�<........ i`}'c7=t� Agreement: �A No.2374 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System inac�e'iCla, T -� 5 of the State Sanitary Code— The undersigned further agrees not to lace tth 's� the provisions of A. t y g g p g . operation until a Certificate of Compliance has been issued by the board of health. `` r Sid------- ••- - - -•-----•---•---------------------------------------------- -----------------------•-----•-- Dt Application Approved By..-.,. .-----... lull ------•----------- �-� � - .............. Date Application Disapproved for the following reasons:.....................- - ----------•---•----•--•----................................................... ....-----••-•--•-•-----------------------•---------•----------------•-----------•-----.........---------------------------------------------•--------------------------•------------------.------------- �' i Date PermitNo......................................................... Issued....................................................... Date r N t:o��).... ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town OF......Barnstable , ............... ­­_­............... ............ ...................................................................... Appliratiou for Dhipwial ]Vvrkii TonlArkruon Vrrmit Sys 1pplication is hereby made for a Permit to Construct (X ) or Repair an Individual Sewage Disposal at: f .1,M,oiin*ain Ash Road Lot 20 ............ ...........­ ---------------------------------- .................................................................................................. or Lot No. ,.. ...............L­9-c-a-tio-.n--.� ��t;e�7sj .................................. .....................................................I............................................ wne Address ........ ... .......................................... ....... .......................................................................................... ristatier .1, Address Type of BuildingSize Lot__________27j.069......Sq. feet .....I......... Dwelling—„No. o Bedrooms________________3________________________Expansion Attic Garbage Grinder tLo Other-/-Type of Buildilig ............................ No. of persons._.______.__________________ Showers Cafeteria Other fixtures ." -------------------------------------------*---------------------------------------------------------------------------------------------------Design Flow....................55..................gallons per person per day. Total daily flow---------330...........................gallons. Septic Tank—Liquid capacity,11000gallons Length..S'.6t'.-. Width.-4.'-lQ'- Diameter________________ Depth..4!D.!!... Disposal Trench—No_.................... Width____.___________.__. Total Length_______._________.._ Total leaching area....................sq. f t. Seepage Pit No....:-I............ Diameter.....10!....... Depth below inlet.........46.1...... Total leaching area..267.......sq. f t. Z Other Distribution box Dosing tank aPercolation Test Results Performed by.Gape---Cod..Survey_►...Gonsultant Mate.........3/11+/.80........... Test Pit No. I......2--------minutes per inch Depth of Test Pit------12-1------- Depth to groundwater----none--------- Test Pit No. 2................minutes per inch Depth of Test Pit;_-_________________ Depth to ground water._.__-_____________-___- .............................................................................*......*---------------------------------------*,-**............................ LQ.0 Description of Soi ..Q.!nQ.o..5...WOOd...loam,.Q...5-1.5... ...gravel,.................... ...................................8_4�1.2.._O..wda....xhite...sarAe..................................................................... U -------- UF W ...................................... ---------------------------------------------------------------------------------------------------------------------:t............�!......... . Nature of Repairs or Alterations—Answer when applicable....................................................................... U 08 T cyc ---------- ............*------------------------I.......................................................................... ------------------------------------------------ ------------F..... Agreemeht: DAYLOR - R1 Th(�r undersigned agrees to install the aforedescribed Individual Sewage Disposal System in a- e. 1 the pro,, 0 "ions of'ITLE- 5 of the State Sanitary Code—The undersigned further agrees not to place 'Pis operation until a Certificate of Compliance has been issued by the board of health. S' . A ...................................................................... ................................. 7.0 Date .... . .. - - - -------Application Approved By,—. O��Q - ----- ----------- -- -4;c-,/............. Date Application Disapproved for the following reasons:.................... ................................................................................... ....................................................................................................................................... ............................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF............. .............................................. 0, Ae W-urdlifirab of Tji IS IS TO G TIF That the Individual Sewage Disposal System constructed or Repaired by... ....------- CC............ ....... . ............... . .......... ........ J­ ----------------------------------- ............. ---- ------- t ta ............... -- hasf*p.... .. 4..... .. .... .Lf --------------- .................... ----... ...�V at- ........ _Mqcordance with the provisions of - f The State Sanitar Co e a been installedii accordance �F � d scribed in the ............. date application for Disposal Works Construction Permit 'I .......4q............. ------------------------------------------- t THE ISSUANCE OF THIS CERTIFICATE SMALL`NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. .............................................................m.............. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF,,-)HEALTH _g_ ........... ...................................... FEa-7.................. N.6__�..... ........... Map I Wrkii 01.41notrudialt prrutit Permission is hereby granted_..___ �(�,C --- A--------------------------------------------- ..................... is . ................14 _Pv to Con ct� Repair an •jn�hy I Sewa / osal SA at No..--. ...... 2-d 4?t Street as shown on the ;Ration for Disposal Works Construction Permit No-' ....... Dated_.________...____._._.._..__..._______.___ ........................ -------------------------- Boa a of iie.ji DATE..........Y7. .7 ............................................1, FORM 1255 HOBBS & WARREN, INC., PUBLISHERS No. - ---------- ------- Fee--- ------------ ---- BOARD OF HEALTH TOWN . OF BARNSTABLE 2(pplication-*rVell Con0ructionpermit Application is hereby made for a permit to Construct ( ), Alter ( ) 0 Rep it (Vlan individual Well at: Location — Address Assessors Map and Parcel Fe u✓ '--------------------------------- Owner G_SAddress ®D ------------------------------ l�/• N1+ s rows M �� I--- Installer — Driller Address Type of Building Dwelling----------------------------------------------------------- Other - Type of Building ---------- No. of Persons----------------------------_—__—________ Type of Well Capacity---- - - --—----- --— Purpose of Well--QQ n{e$7`.L----------—------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificat of Compliance has been issued by the Board of Health. Signe ���t/5t Q date------- M Application Approved By �� - - -------- date Application Disapproved for the following rea s:------=------------------------------------------ ----------------- date rA l —�— Permit No. -�/-!l �--� ---------- Issued-----�- --------------------------- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of Compliance THIS IS TO WFIFY, That tthe Individual Well Constructed ( ) Altered ( ), or RepairedbY------- . C�Ln�rvo -------- --------------------------------------------- - ----------- ----- n I �!,/p�Install)eJ,V/�� at- /00 /1A ot.a.�c., CtS D. IC e� 1 1 1 �, J I 1 ----- - - --- --- ---has been installed in accordance with the provisions of the Town of Barnstable Board)of H,e�allt Private Well Protection Regulation as described in the application for Well Construction Permit No. - -Dated-- ------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------ —- -- Inspector-- ----- - - ---—----—- -....--�,...-x�.tl•-r.s••vx..as+»•4w ..r-.-.��--"'---". ;""'--....+-v+z..�.-��v.,W,rpr,rr•n+w'r:.vt�.i»+r 1. ,.w•.+c,_:.,.wr,�ar ..r?'pti^Iar•`i....'ck:V`.:�,v'v"'t.'o'.*`. ,. ,T- ... ., v.. r... t j J g _ NO. -------- --------. Fee- - ---- ----- --- _ - s 'BOARD OF HEALTH TOWN OF BARNSTABLE Application-*rVelt Congtruct onVertttit Application is hereby made fora permit to Construct ( ), Alter (. ),'o`�,Re it (Vlan individual Well at: `,;Location Address p Assessors Map and Parcel . f� __ Du_�Gam , --��- s rb rs Owner Address D _Sou �( - - - - - • - � - -oX--q6------- - �' ------ --------- Installer— Driller Address Type:of Building Dwelling'--— -- ----- ---- - ' Other -.Type of Building --- -- - ---- -:_ No. of Persons-- ------------------------— -- ` Type of Well Purpose of We'll Agreement:The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private,Well Protection'Regulation - The undersigned further agrees not to place the well operation'until a Certificat °.of.Compliance has-been issued by the'Board Hof.Health. Signe - -- - - - ---- G //�s p �7Ct date'. Application Approved BY -- -d - �"�-' — -- -- date Application Disapproved for the following,rea s.— --=-=------------------- ----------------------- • ate Permit No.'. --�� - --= Issued --- dare-- ---- -- ------- ,. ec.4a'cps*•a� cw>7:.+aeciaea��nb�aflaT:i'ec�.aea7a�a�s�eas�as!secm:.Sow:Vax>a.ea:a�asE+o<csa��eurc±aacrow6.e:?..rr.9eeor.3wi•!�•!m {.,;.A.�e»,s+�i•v.zsa�wwsraraar.csia�;�z,.ep+.rrerra:+� :awYaw:ss BOARD OF HEALTH TOWN. OF BAR�NSTABLE - Certificate Of Compliance THIS IS TO E IFY, That the Individual Well Constructed ( ), Altered (.,. ), or Repaired b -------- Install --------- Cu� � e . M c.� GS . has been installed in accordance with the'provisions of the Town of Barnstable Board of.Healt Private Well Protection . =CE described in the application for Well Construction Permit No. bated----- OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE-WELL ''SYSTEM WILL FUNCTION SATISFACTORY. ' DATE- ------ --- ---- -- Inspector-------=--- --- -- L`.i±�i.w±illiwnYe4iRiw1n44w6N�iwi.TOwgTiSOR6964iei46a'awiF/Mi�iTi9alUli±iwiwiHL101pPalYsa4iKl�wBllt9i4a0i51ii9ilff ViT67i±i?L!iTi4i.,r±i'!i•tii±i?i±M!i!i�Y6±N M.i4a±614±i4•i±i±w±i,ti r BOARD.OF HEALTH TOWN OF BARNSTABLE Well �ongtruct on Permit P f No.-kAM_ Fee Permission is �A C4 N tia`l ----------— E hereby granted - --------- Ito Construct ( ), Alter (. ), or Repair (1/) an ipdivid ell '� No. ita bum- ct - - -- --------------------- street as shown o the applicati for a Well Construction Permit No.- —-- D d --- --C- -- -- r- - Board of Health- :DATE-- =- 4 :;' '.: - - :., I , , .. .. - _ - i - ,. , - ,. ':. - � , r - A . % ,,.,;;ik ..I -. e , >. 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'�1. 'N - - -, , R .. '. -. E L VAT t 17 / "..SIR f • T -. ON SCHEDVLE 1, i -1_ EL I �, t5r.,;: PROPOSED ` SITE PLd1J 4' -_ ►.,., i r p �� �. 1 INV AT FOVNDoT l ON _ �O• rJ > fr I . .• SE WAGE 3YSTE ___�--�I M D E S I G At ". 76 Z. (M V. I NTO SEPTIC TANK _ (-.I $ 4� �g/�y� ' 1 ..T M.D 11.4 3• 1 NY. Cv7 OC• SEPTIC TAallc 89.93 '1 eva .4L;r,EZ 4. INV. 1N70 DIsr2IBu- 1au 13ox .83 SCALE : I"- Zo' V14+ty. 19$0 c . .4 # S. 1 N1V. 01JT OF DI S TRISVTIDN 8ok ,-e / ; .: . CAP1� : COO , SU¢VEY ''LOIJ V .r ', PERC. RATE . t'.''!'.''Foe ..! lil x,. 61',40 s LTAN s 6. ' INY• iA!?O SEEPAGE PIT a '_ TE5'r SY ; s ltOu76 : 132 . T0*N" INSPiCTOft; p MZ,J�4 �l I -1 BOTTOM OF PIT v 63. 40 ' H'(AMNI5,)AAS5• r TEST AAAG[ Oli: '3 1A (> 8 13Ot TON' OF STOIJrr LAYFi7 ` ^3 ,Ao _ . t I i - - iI k { - Y.. • .. • - : t , .f `. : - i' ,,, t f . . .: r. - . , ii � � ii I � 11. -. -._.- -