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HomeMy WebLinkAbout0043 INDIAN TRAIL - Health ,,143 Iridiari j-rail 4,4' m , �, Commonwealth of Massachusetts', F - Title 5 official Inspection Fora Subsurface Sewage Disposal System form-Not for Voluntary Assessments 43 Indian Trail ,L Property Address C Stanley and Barbara Rosenblad , Owner Owners Name information is " ---- required for every Cummaguid ✓ MA 02637 page. = Clty/Town. June 7,_2016 State Zip Code Date of Inspection 0. Inspection results must be submitted on this form: Inspection forms,may not be altered i 'ny, way. Please see completeness checklist at the end of the form. Important:When A. General Information fitting out forms, on the computer, � . J l.o use only the tab 1 Inspector: key to move your . cursor-do not Michael DeCosta Jr. use the return . key, Name of Inspector ----- Wind River Environmental ,r Company Name — --- — -- --- 577 Main Street, Suite 110 Company Address — — ---- --------- _ r Hudson MA City/Town - - — - -- 01749", State Zip Code 800 499- 1682 13230 _ Telephone Number License Number -- B. _ ^ Certifi cation atlon I certify that I have personall inspected the Y. sewage disposal system at this address and'that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training.and experience in the properfunction*and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ -Fails r- ❑. Needs Further Evaluation by th 'JLoc Appr v' g Authority ' s° June 7, 2016 Spector's Signatu --- —_— Date The system ins ctor shall submit a of this inspection report to the Approving pproving Authority(Board of Health or DE )within 30 days of completing this inspection. If the system is a shared system or has a design flow of 1.0,000 gpd or greater;the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,,and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does;not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 kD -\ f. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments «� 43 Indian Trail Property Address Stanley and Barbara Rosenblad Owner Owner's Name information is Cu m r m a wired for Uld required every _ MA 02637 — _ June 7, 201-6 page. City/Town — _ State Zip Code Date.of Inspection B. Certification (cont)- Inspection Summary: Check A,B,C,D or E/a/ways 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 31.0 CMR.15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Inlet cover on 5.5'riser to grade. Outlet cover not accesible 5:5' below grade under bushes. 13) System Conditionally Passes: ❑ One or more system components as"described in.the "Conditional Pass" section need to be: replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not r determined," please explain. t 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 approv Health. ed by the Board of *A metal'septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years.old is available. Y ❑ N ❑ NO(Explain below): !Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official nspection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments 43 Indian Trail Property Address -- _ Stanley and Barbara Rosenblad Owner Owner's Name information is -- _--- --- required for every Cummaquid MA 02637 page. city/Town _ _ June 7, 2016 _ State Zip Code Date of Inspection — B. Certification (cont.) ❑ Pump Chamberpumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired: > B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of.Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑'Y ❑ N ❑ ND (Explain below): ❑ -obstruction is removed ❑ Y El N ❑ ND(Explain below): 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 Iwhich will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page of 17 i commonwealth of Massachusetts Title 5 Official Iinspection, Fore Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .43 Indian Trail'.. Property Address ----- --_---- Stanley and Barbara Rosenblad. Owner Owner's Name ---- information is - -- - - required for every Cummaquid - MA 02637 _ June 7, 2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of,-Health (and Public Water Supplier, if any) determines that the System is functioning in a manner that protects the public health; safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is withina'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 DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered;A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria`Applicable`to All gist 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 orclogged SAS orcesspool ❑ Static liquid level in theYdistribution'box above outlet.invert due to an overloaded 4 or clogged SAS or cesspool ` El ® Liquid.depth in cesspool isIess than 6" below invert or available volume is less r than Y2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 ix • Commonwealth of Massachusetts - - Title 5 Official Inspection .Fo' rrn Subsurface Sewage Disposal System Form Not for Voluntary Assessments 43 Indian Trail Property Address _ Stanley and Barbara Rosenblad Owner Owner's Name ---- information is -_-- - --- " required for every Cumma uld page. Cityrrown MA 02637 June 7,2016_ State- Zip Code Date of Inspection B. Certification (cont.) Yes No ® Required pumping'more than 4 times in the last year NOT due to clog ged or obstructed i e p p (s). Number of times pumped: ® Any portion of the SAS,,cesspool or privy,is below high groundwater elevation. ❑ ® Any portion.of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Z Any portion of a cesspool or privy is within a Zone 1 of a public well. t ® 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 DER certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other.failure criteria are triggered. A copy of the analysis and chain of.custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. .. The system fails. l have deterrrrined that one or more of the above failure criteria exist as;described in 310 CMR 15.303, therefore.the system fails. The .system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large-system the system must serve a facility with a design flow of 10,000 gpd'to.15,000 gpd. For large systems you must indicate either"yes" or"no"to each of the following, in addition to the > questions in Section D. Yes No . r. - ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area IWPA)or a mapped Zone II of a-public water supply well If you have answered "yes"to any 'question in Section E the system is considered a.significant threat, or answered "yes" in'Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. ° t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 aN Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 43 Indian Trail _ Property Address - Stanle and Barbara Rosenblad Owner -- Owner's Name --- information is — --- required for every Cummaquid MA 02637 page. Cityrrown — June 7, 2016 State Zip Code Date of Inspection i C. Checklist Check if the following have been done. You must in "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(arid 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 t. been determined based one r= ® ❑ . Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] R D. System Information - Residential-Flow Conditions: Number of bedrooms 5 (design):- Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(foc:example: 110 gpd x#of bedrooms): 550 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of.Massachusetts - Title 5 Official :Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments � 43 Indian Trail Property Address Stanl_y and Barbara Rosenblad Owner Owner's information is ---- — required for every Cum fPagyld MA 0263 7 June 7;2016 _page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of currentresidents: 2 Does residence have a garbage grinder? ❑ Yes Z No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? El Yes Z No Seasonal use?' ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 142 9pd Detail: - See attached records. " Sump pump? _ ----- - - --------- ❑ Yes Z No Last date of occupancy: Current .Date _• Commercial/Industrial'Flow Conditions: Type of Establishment: 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: t5ins•3/13 '" Title 5 Official Inspection Form:Subsurface SewagetDisposal System•Page 7 of 17 Commonwealth of Massachusetts - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Indian Trail" Property Address " Stanley and Barbara Rosenblad Owner Owner's Name — information is -- required for every Cummaquid MA 02637 _ June 7,_2016 page. City/Town State Zip Code Date of Inspection D. System Information Cont. Last date of occupancy/use: - - Date ---- Other(d escribe below General Information Pumping Records: Source of information: Wind River Environmental Was system pumped as part of the inspection? ® Yes ❑ No ;t , r.. 1,500 If yes;volume pumped:{. gallons — ----- ----— How was quantity Previous Pump records q y pumped determined? — Reason for pumping: To check structural I—_nte�rity of se tic tank 1 Type of System: Septic tank, distribution box, soil absorption system r` ❑ Single cesspool El Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if-yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be.obtained from system.owner)and a copy of latest inspection of the l/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEPapproval. . El Other(describe): . t5ins•3/13 - --- Title 5 official-.Ins Inspection Form: pSubsurface Sewage Disposal System Page 8 of 17 b Commonwealth of Massachusetts • Title 5 Official Inspection For Subsurface Sewage Disposal'System Form -Not for Voluntary-Assessments . `M 43 Indian Trail Property Address Stanley and Barbara Rosenblad Owner Owners Name — — information is required for every Cummaquid MA page. City/Town 02637_ June 7, 2016 State Zip Code Date of Inspection D. System Information (cont.) a.Approximate age of all components, dat e installed _ • (if.known)and source of information: 1993 per plans ' Were sewage odors detected when arriving at the site? El Yes ® No Building Sewer(locate on site plan): Depth below grade:. 6 feet _ feet —---- ~= Material of construction:- { ❑ cast iron 0 40 PVC a El other(explain): Distance from private water supply well or suction line: 0"/ N/A feet ---- Comments (on condition of joints, venting, evidence of leakage, etc.): All joints sealed. No leaks.Vent on roof. Septic Tank(locate on site plan): Depth below grade: 5*.5 feet feet —---------- Material of construction: ® concrete ❑ metal fiberglass ❑ polyethylene El other(explain) t: I If tank is metal, list age: years ----- Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 5' Sludge depth: x 10 inches . t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage bisposal System•Page 9 of 17 Commonwealth of Massachusetts: - Title 5 Official Ins e.ction, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 43 Indian Trail M Property Address Stanley and Barbara Roseriblad Owner Owner's Name information is - required for every Cummaquid MA 02637 page. cttyrrown June 7, 2016 State Zip Code Date of Inspection D. System Information-(cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet-tee`or baffle Winches - — Scum thickness 8 inches Distance from top of scum to top of outlet tee or baffle 6 inches__ Distance from bottom of scum to bottom of outlet tee or baffle 16 inches _ How were dimensions determined? tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ` 1,500 gallon H-20 septic tank 5.5' below grade. Inlet cover on riser to grade. Outlet cover 5.5' below grade under bushes. Liquid level normal, heavy solids and sludge.Tank appears to be structurally sound, but 5'of dirt on top-of tank making it difficult to check.Recommend removing bushes,to install, 5.5' riser on outlet cover with the use of-a filter.Tank should be_p umpe'vearly_ — Grease Trap(locate on site plan): s. Depth below grade: --- — -- feef" Material of.construction: ❑ concrete ❑ metal ❑fiber lass 9 ❑ polyethylene. ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle — Date of last pumping: Date --- t5ins•3/13 - - Title 5 Official Inspection form:Subsurface Sewage Disposal System-,,Page 10 of 17 Commonwealth of Massachusetts - __ - Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Indian Trait Property Address Stanley and Barbara Rosenblad Owner Owner's Name information is --- required for every Cummaquid MA 02637 June 7, 2016 _page. t; City/Town State Zip Code Date ofanspection D. System Information (cont.) Comments (on pumping recommendations; inlet and outlef 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): Depthf below grade:, Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): .. Dimensions: _ Capacity: gallons _—-- — --- Design Flow: gallons per day ------ - -- Alarm present: ❑ Yes ❑ No Alarm level: — -- Alarm in working order:. ❑ Yes ❑ No Date of last pumping:a Date — ----- Comments(condition of alarm and float switches, etc.): - ' Attach copy of current Pumping contract(re q ulred) Is copy attac hed? El Yes ❑ No t5ins•3/13 • - , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 43 Indian Trail Property Address Stanley and Barbara Rosenblad Owner Owner's Name — information is _ -- required for every; Cum ma uid MA 02637 June 7, 2016 page. CitylTown State Zip Code Date of inspection D. System Information (cont.) Distribution Box .(if present must be opened)(locate on site plan): De th of li 0 inches p quid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-20 distribution box on 7.5'riser to grade. Box has 4 outlets. Cannot see all outlets inside box due to 7.5'riser on box. Cannot see walls of distribution box to check deterioration. Distribution box appears to be in working condition. Pump Chamber(locate on site plan): Pumps in-working order: . ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber,.condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): . If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form : Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M s•°•v 43 Indian Trail • Property Address _ • —.._ _ Stanley and Barbara Rosenblad Owner Owner's Name — information is - required for every Cummaquid - MA 02637 _June 7, 2016 page. City/Town State Zip Code Date of Inspection D: System Information (cont.) Type: ❑ leaching pits number: -- ❑ leaching chambers- number: ❑ leaching galleries number: --- ❑ leaching trenches number, length: ❑ ' leaching fields - number, dimensions: - --..dim en ' -. - ❑ overflow cesspool number: i -- ❑ nnova i tive/alternatives stem . Y Infiltrators 10' x 65' Type/name of technology: — --- _—__ Comments (note condition of soil, signs of.hydraulic failure, level of ponding, damp soil,,condition of vegetation, etc.): Infiltrators 9' below grade with no access. Ran camera from`distribution box, infiltrators appear to be in good working condition.' Showing no signs of hydraulic failure. Vegetation normal Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number-and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer _ Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes No t5ins•3113 f Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection.for Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 43 Indian Trail Property Address Stanley and Barbara Rosenblad Owner Owner's Nae _ info m rmation is — --- required for every Cummaguid MA 02637 _ June 7, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cost:) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: -- Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic,failure, level of ponding, condition of vegetation, etc.): 7 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth ofrMassachusetts - Title 5 ®fficialA Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `M 43 Indian Trail Property Address Stanley and Barbara R senblad Owner Owner's Name information is - ------ required for every Cummaguid page. Cityfrown MA 02637 June 7; 2016 State Zip Code Date of Inspection D. System Information (cone.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: " ❑ hand-sketch in the area below ® drawing attached separately f t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts.. . r Title 5 Official Inspection Form Subsurface Sewage Disposal System:Form Not for Voluntary Assessments 43 Indian Trail Property Address --- Stanley and Barbara Rosenblad Owner Owner's Name - ---- ---- information is required for every Cummaquid MA 02637 June.7, 2016` _ page. City/Town State Zip Code" Date of Inspection D. System Information (cons.) Site Exam: ® Check Slope ® Surface water Check cellar ® Shallow wells Estimated depth to high ground water: 1_2.5 feet feet Please indicate all methods used to determine the;high ground water elevation* ® Obtained from system design plans on record If checked, date of design plan reviewed: 6/29/1_993 ...Date ❑ LObserved site (abutting property/observation hole within 150 feet of SAS): . '❑ Checked with local Board of Health-explain: ❑ Checked with localexcavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Obtained from copy of design records on file of Board of Health Office. Before filing this Inspection Report; please see Report Completeness Checklist on next page. t5ins•3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts R Title 5 Official Inspection Forrh a. Subsurface Sewage Disposal System Form Not for Voluntary Assessments" 43 Indian Trail Property Address — - Stanley and Barbara Rosenblad Owner Owner's Name information is required for every. Cummaguid MA 02637 page. City/Town - June 7, 2016 state Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked. ® Inspection Summary D°(System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high.groundwater ®Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins-W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 .,,NsBuilt. - Page 1 of 2 TOWN OF`BARNSTABLE • LOCATION• j r, :4.) `A;i SEWAGE # VILLAGE C � Ca l A t=ui A . ASSESSOR'S MAP & LOT !,[ Q INSTALLER'S NAME & PHONE NO. R�A:J 1�1 SSL ??j�'-.o Y Y 9 SEPTIC TANK CAPACITY 15" o as T LEACHING FACILITY:(type) r0;:Qr 4-r0cf NO. OF.BEDROOMS .S- PRIVA/TE'WELL OR PUBLIC.WATER Tns•" ) BUILDER OR OWNER STAAIL4�S DE�a�•9f� oSE�BL/ld DATE PERMIT ISSUED: : y z3 DATE COMPLIANCE ISSUED:. VARIANCE GRANTED: Yes No L/ / carr ZA.J i1 G, L- - IEl ti http://issgl2/intranet/propdata/prebuilt.aspx?mappar=336001&seq=1 5/10/2016 Printed.on 5/10/2016 3:31:00 PM Customer File Inquiry Page No.1 Account Number 1698 Account Status B~ Location. 43 INDIAN TRAIL= Type R01 Owner ROSENBLAD II; STANLEY-DEBORAH Section 4 Street PO BOX 457 City CUMMAQUID State MA Zip_ 02637'0457 Water $.00 Late Chrg $:00, Past Due $.00 Total Due $.00 Date Action Usage Amt Paid Amount Balance 7/2/2014 BILLED 00 35.00 35.00 7/15/2014 PAYMENT 35.00 O:DO 00 10/7/2014 ; BILLED 25": .00 110.00 110.00 10/27/2014 PAYMENT 110.00, 0.00 :00 1/7/2015 BILLED. .00 35.00 35.00 1/22/2015 PAYMENT 35.00 0.00 00 4/7/2015 BILLED 26 ' .00 113.00 113.00 5/5/2015 PAYMENT 113.00 -0.00 .00 7/2/2015 BILLED 00 35.00 35:00 8/4/2015 PAYMENT 21 35.00 0.00 .00 10/1/2015 BILLED25'` 00 110.00 110.00 10/26/2015 -PAYMENT 110.00 0.00 00 1/6/2016 BILLED .00 42.00 42.00 1/22/2016 PAYMENT 42.00 0.00 00 4/7/2016 BILLED t26` .00 120.00 120.00 5/3/2016 PAYMENT 120.00 0.00 .00 .BTU T A62U CH V;6 2 00C L+2 S; P L4 : TOWN,OF BARNSTABLE ° LOCATION li 3 SEWAGE # 73,3 7 6 VILLAGE C � � A Q ui,L1 ASSESSOR'S MAP ,i LOT it s A NAME & PHONE NO. t' L J;J P 0 y y�f INSTALLER'S S � y� �' � R A.� ! 5 �115� SEPTIC TANK CAPACITY /5'0® 65-r LEACHING FACILITY:(type) T-„y Q rAAf.,At I (size) NO. OF BEDROOMS Z- PRIVATE WELL OR PUBLIC WATER -fa49,•.) BUILDER OR OWNER /ceSgwgL/IQ DATE PERMIT ISSUED: ►� / 2.3 9 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ..�aa s 1� e z r fp Gva I THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ..............o .........OF............. J�..Q f.a sT�',O(� .._._..............._... Appliratiun for Dhip ial Workii Tunutrur#ion Permit Application is hereby made for a Permit to 'Construct or Repair ( ) an Individual Sewage Disposal System� at: /� - i ..._...L 1 _..1 e. i?>►.._ G i l u wt rr jj ......-- -• ...................---------I r�Lp ��•t L_•C�J►�.i ate rz,y O .... . Location-Address or Lot No. ... _.....I_�.Otn..._� ��P�- ......... �....t1..Y.. . Owner Add-ss Installer Address Type of Building Size ...Sq. feet 0-4 . Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage GrinderWj ( ) C4 Other—Type of Building ............................. No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .......................................•------ W Design Flow..............515- _.._._.___............gallons per person per day. Total daily flow..........5.�o....... ............gallons. WSeptic Tank—Liquid capacity.1�o.gallo Length_!:.'_--... Width..r..z-.'$_`... Diameter:��--- '.: ID. Depth....` x Disposal Trench—No.........�^!F'�.��fF_._.!?�___ Total Length.... s--- Total leaching area..: g3.....sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet...:................ Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b J� �a y....................................................•-----•--......._..... Date_:.. =-fl-,_5............. , ) Test Pit No. 1....L.Z..minutes per inch Depth of Test Pit.......)__--......... Depth to ground water........---.. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ :5..�k -fir:rr..c ,k r�.w .e..Y_�:!Q:..... .Sr. O Description of Soil...V'Eri S...•p,...IZ:s:.i5:..f;;jNC.-S!ti.c&5o 15'- 'o-"g)2 tAJ!0 ®._.�.-�:...-t ---...•............. -----t`_''vA,:!5. ....C�. D ............... t✓✓1. a_S-..t--.S---�' -'-'�----�'=S' �5 -�✓.-•s�..,'''------is"..`-----w` V Nature of Repairs or Alterations-Answer when applicable.............................................................:................................. --•--•-•---.......-•-------•--------------•-------•----------•-•-----------•----•--...._............---------.....-------------------••----•--•--------•-----•---••----••-•--------....-------.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LITLZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board o health. Signed---..n ....��6�`3........... Date Application Approved By............ .�.s `� ...... ......... ?.. 1. Date Application Disapproved for the following reasons:........ ............................................:........................................................ ;.................... --•----•----------•-•......................•-----........... .....---__-•--•- f ry Date Permit No.. ..::...�7.'-------------•..._._....} ? Issued........... - :�1.. ................ - r Date i � 3342 FFx THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH o. , ..........OF............. u -r:. a ` Applirtttion for Di.spuottl. Works Tonitrnrtion Ilrrmit Application is hereby made for a Permit to Construct ( 1C) or Repair ( ) an Individual Sewage Disposal System at: 9.J?....--•••-........ ....................................................G?......................... 7..—ti- s4-ti Location Addressor Lot No. f .. ...��n... -I „ �F?G��.. �.t.............. .�`.1`:T��/�:'� —' ......-,—�-'7... ..�..'.L0............................... ._......�...:.:.:�.. Owner Address _....._ / ...._..... ...... �3,a"rzIA� FF��I Installer Address Type of Building Size Lot. !. .`' ...Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Oar Other—Type of Building .............................................. No. of persons............................ Showers .( ) — Cafeteria ( ) d Other fixtures --------•-------•-------------------------- W Design Flow.............. r>...........•.......--..gallons per person per day. Total daily flow.......... --,- .....................gallons. G� Septic Tank—Liquid capacity.!.t."s2.gallon Length.! `_`::___ Width:.`?;: _..... Diameter ..._. Depth....' ._ ... Disposal Trench—No........ Total Length.................x Total leaching area._..O::�.....sq. ft. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) •.+ J........� .. � Percolation Test Results Performed by.................:....::.:.:.................................---•-•.. Date--- Test Pit No. I....�:..2-...minutes per inch Depth of Test Pit....... t ....... Depth to ground water...__...f J)A........ tz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water............__._..--_--. 'T H .... ca-1 T.... ' I• p .�j L.... r•�ara ! • -a.ta [.U A f •i O.:_. _`2:.�::'. � f= -0a. 12.5 D Description of Soil--�. �7•y,, >, I1.��• Ih' Fi^`�F �JA..rt,4 �`� - t`je—)7%,A-,/tJ c.G/._.Q_.I-._fi_f !s ---...------•--•---•----.....-•-•••..............•--•----•-••-----•-•---------•-•-... .... f,. s ,.,� �,a -c��.:_. "::.V (.e..n" ' ?• k3 fIn,t h,1.a �) p-I •�%P � Ste• I- '7S G- .A�; V ............................... --••--•--•-•-•..............•----•-•.......---------....__... .............---•-•----•-•--...-----.............-_..._........•-••...-•-•-----••-•- �4=5. .. ...'?A kr 2• ... .:. -...!O:S.._�.�`! .. /°-S=rS...���t gla,v�r -7tL- I10 .................. -•-•------•---•....................••------•• ••••. U Nature of Repairs or Alterations—Answer when applicable.............................................................................................. --•--•-•-•-•.......................•------------•-•--------•--------•---•--••-•-----...--•-•-----...----•-----...-----------•-----•---••--•----------....---------•--•---------•--•--•-----••.....••--•• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of AITU'- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. / Signed... ........................ ....t' /. ..... .... Date Application Approved By........... �.�.�. ...::...............•--------•••--------...J.... "�, -.. .�q a.• ....•... Date —. Application Disapproved for the following reasons-----------------------••---.-•--••--------..._.__....-----------••-•------------_---•_..._.. •...•..... - -----------------------•----•---...-----•---•--•---•••••.....•------•-•--••.................•-••--•..................•••-•-•.........----._.........------•---•-.......----•---...•----•--•._...........: Date Permit No........ .�.....` ...76------------------------- Issued............ -= K-23................ Date ;+ r THE COMMONWEALTH OF MASSACHUSETTS 14. BOARD OF HEALTH ., �,. ............OF...... N..aXlt (Irrtifirtttr of Toutpliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (j or Repaired ( ) by................ .... ...---..........-•----...._. .....--•-•-----•-•--..........-----•----•--•-•-•-•----............---•------................... Installer at......... �. � -r 1I?A...............a.I �r?k4�MQ_1;_A I J--_.._..---•-•---_._..-•------•--•------•...............•---•-••-•-•---...............--•-----• t application lbee on for i o accordance with the provisions of TI i LE 5 of The State Sanitary Code as described in the PP 1 Construction Permit No.'--.... .-..r '7. -------- dated ....�r�>.� ........ ` THE ISSUANCE OF THIS CERTIFICATE SHALL,NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION/ SATISFACTORY. (� / --- Inspector.....................-`.. DATE................•----....�._--.:`...�.-------��:_....-•---........... ....-----••----•---------•-----...------............. ---- --- _ m , .. . __ m --- --- ------- -C) �� ,-..,...w...,..-.._--. .._..__,.-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ` ......... OF....... �� NO...,.— !!?. FEE...tIf7 Q......... Disposal Works Tonotrurtiun Prrmit Permission is to Construct �) or Repair an Individual hereby granted ... A�:....:... Sewage Disposal System at No....... .•.tl - ..0✓JO� Street :7 + � as shown on the application for Disposal Works Construction Permit No.._�__.ti..__=____ Dated.......................................... - � h - �3 Board of Ilealth DATE f ... .............................- �C 82,02 / BVW 1 81.78 / �e 82.04 7 BVW 10 \` % tea BVW 2/ ' � e BZ� oE� 1/ x81.39t3.16Bb 82.00 � f- x'83.11 / Q. BVW 9 B2 BVW.4 BVW-* / B \ XR3.8 84i 3.78� ao BVW 8�84� VW 7 \i N 86'09'40"E / 150, 15.0' j x 88.46 / I / /g2/ 90, / / 100.0 98.17 / sa / /Zpne I x 93.3� /00 BU fer / I 94.87 _-94 f X-92 02 Q �9B! ' x +' a6.0' 96.92 28.0' 98.66 ' / / Shed 100.01 ro Deed Proposed Proposed ' w Addition� - .Addition 99.21 o 16'x46'Deck 10 98,96 97.04 97.10 21.9' 98.91i, 47.3' 099.40 M. Existin Stone 8.94 Drive 99.88- V J143 AFoundo ion o 99.57 Existing Dwg. 9.T o: 98,96 W I c Q 99.81 itn m v - Proposed` r� o N I* I Addition 99.30 ' -' 2 Ct 28.0'. 99,4 I 99,76 L _ Lots4 & 4A 6ao' 74,262f-S.F.. \_ ,,. o' 0 909 + .' 1.7f Ac. - - 4 -'MAG SET x - \ ® 99,43 ' Map 336 Parcel 1 M � I• \ \ 100 , Q 1 SEPTIC C0V''GND 1 0°, 100.64 . \ \ Approx.. `©loos ' `o ZONE RF-2 \ \ ' SETBACKS: Fron t: 30' Side: 15' Rear: 15' 'oo 92 ` 91,14 91 33 \ \ 4 Born - \ 100.93 I 90.94 Ba9h'� 9a 91.93 LEGEND: ao, / 91.16 - t • - I _ • �. ' x 52.37 £rhfbq SPa1 a-11- a I \ ��- 2 Light P-f Utflity Pa. aa. i \ � � \ � Zz N„�t >q=\a" �' \ f \ Q Q U.1hg Sepffe Canoonent I - 0 wale serNro �� �, a ®..Electrfc linel-wee PLAN OF LAND 92.42 >?93` 0 G.s l/w- " \ 0 Tesf Hole locotim SHOWING PROPOSED ADDITION �� 6\ J0.0 - ■ 0-fe bound Pound IN \ ® uonhae ro v • t. _ - 100.0• ® £xlst/ng Nee . B.4RNST.9BL4 MA PREPARED FOR: BONNY' & AS 1,V O BRlE'N 43 INDIAN. TRAIL \ I SCALE. 1'--20' NOV. 8, 2016 Rev.rem 25,2of7 - - 95.98 92.44 M S TERRY.4. WARNER, P,L S" 0 1170 9-1 22 LONG ROAD -<e Scale: 1"=20' HARWICH, MA. 02645 88. ? . -x (508) 432-8309 C VERT I�VER 79 91.66 0 20 40 60 Project N.f6-31I ^6 ........... ......----------- 5 U' -._. - -- - - - - -- --- ' _ - _ r 1 - l _ __ r- -- r —� It 1 , - IT l�T I TC I � 1 I T I I Tr---I 1 r� _1 t-r �T tL-,T i', —, T�, r-ram- t! L� /' I I.7 � - � ® I 1_ _ -� , _ �Trl rm Tr'T��-f 1—I� `T I rY1 . r..�(.Il�-LI ..1.. - — _ �' 1 1 IJ 1 T� � 1 r..i .,.. � T I ..� �� I -TL ' ..._f'sc4v3 I I � 1 : � I . l Ib I 1I I 1 , • ' ' - -PVSo r o P P " :N EWp SIOELTh. 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C t? i • 15. 8♦ BENCHMARK: m1AN FIRE HYDRANT TAG BOLT �,n 15.33 f88 AT SL, $0.61 HILL RD. 17/ 8.4 LOCUS .s7 2 2� 18Ca--°�. �arl,w q �---19 z 4.39 2 ,RAR. 16 4� - 2 a- ti� sA PROP. STALED 50' ~fit SAYBA.LS WO �rIT LINE 22 5 LOT `4 -,� � TEST HOLE LOGS 23 _sz.s • r f.44 area g ENGINEER: JAMES C. JODICE WITNESS: JERRY DUNNING DATE: MAY 6, 1993 i g PERC. RATE: < 2 MIAIIINCH • �5------- sx' r 2 PERC. #8052 zs FETLAND LOCATION MAP (NOT TO SCALE ---27 33 Q C7 Q BUILDING ZONE: RF-1 0' SL. 34_2 EL. 34_5 EL, $5.2 SETBACKS: --- 3.5 h 1 T + S ss.2 f T + s ss.a T + s FRONT = 30' D CK 1' 34.5 SIDE = 15' CLAY 2.5' 31.71 CLAY REAR = 15' PROPOSED GARAGEASSESSORS MAP 336 PARCEL 1 BEDROOM SLAB%/'� 3 CLAY 6' 28.5 CLAY FLOOD ZONE G 5 AND FANG •.s � DWELLING EL 32.5 MIN. LOT SIZE: 43,560 s.f. //////LUNG SAND 7• SAND 27.5 7.5' 27.7 MIN. LOT FRONTAGE: 20' o TOF EL. 33.5 �. 8.5' 25.7 SAn MAX. BUILDING HEIGHT: 30' CLAY CLAY 8.5' 2s.7 CLAY f 0' MED. 24.2 10.5' 24.7 NOTES PROP. PROP. GRAVEL DRIYS f2.5 SAND 21.7 .12, 22.5 FINE DRY.WELL PROP. 1600 o PROP. GALLON SEPTIC FINE SAND DRYWELL �_ 13, Ste' 21.5 15 �fED 20•2 1. DATUM NGVD TAKEN FROM HYANNIS QUAD (ASSUMED). PAR. f 9 TANK 0 9 f5, SAND 19.2 PERCHL'D WHITE 2. MUNICIPAL WATER IS AVAILABLE. 1 CLUSTER lL9TER dT OF BUSHES DIRTYING g8 B gL. 22.0 f6' SA1voD 19.2 3. PIPE. PITCH TO BE 1\4"/ft UNLESS OTHERWISE NOTED. ExrsTIN r TRacgs 18, s` 'D f6.z WATER 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO-H-20. TREE I No FOUND 5. PIPE JOINTS TO BE MADE WATERTIGHT. l 1P.�TER 0 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE MASS. FOUND r o E107RONMENTAL CODE TITLE V. tt D BOX cl� q r*r, nB 7z1 pVT pr;n p.t T£R .4T £t Fc. 15.s +/- 7. THIS PLAN FOR PROPOSED CORK ONLY AND NOT TO BE USF,D Nto THZ 8. SCH 40-4" PVC 7"0 BE U.�ai uh&i;t,u��." �... 1 :." 9. D'BOX TO BE WATER TESTED FOR LEVELNESS. Oq SEPTIC PROFILE 9\PROPOSED __ -----= 10. PROPERTY LINES BASED ON PLAN TO BE FILED THIS DATE IxFnTRATORS WIT (NOT TO SCALE AT BARNSTABLE PLANNING BOARD. 4' OF STONE A SS ) 81.34 AROUND TH1 TOP OF FOUNDATION AT SL. 33.5 RESE VS -- FP,AXFS AND COVERS TO WITHIN to OF GRADE 33.0 34.0 34.0 POSSIBL 10' �? t N REMD V 29.5 PIPS SLOPS 9.5% f 5OO GAL. -` �_ INFIL TRA TORS 29� TANK 29.05 EL. 23.5 23.57 noo p00r 23.40 °oo ° °p°° �&2,0 -PAR. 2 D-� c� i�t' R- o n n. 2z.98 o o TEE SIZES: INLET DEPTH = 10" ZAfIN6" CRUSHED � s.eOUTLET DEPTH = 19" E UNDER 3/4' To 1-112' WASHED STONE I VXDXRCAO DEPTH OF FLOW = 4' D' BOX No WATER AT EL. 16.2 j s�'Raur � \ LEACHING 93` FOUNDATION- 10' SEPTIC TANK 58' D' BOX 22' FACILITY SEPTIC DESIGN: (NO GARBAGE DISPOSER) I DESIGN FLOW. 5 BEDROOMS '(f 10 GPD) = 550 GPD d wn cape engineering, inc. ' 550 GPD/.75 = 733 GPD (BARN. REG.) SEPTIC' TANK: 550 GPD (1.5)) 825 GPD AND ,.:]E T`�TA GE PLAN USE A 1500 GALLON SEPTIC TANK SI1 E CIVIL ENGINEERS SOIL NOTES LEACHING: (WITHIN 250' OF BVW) FOR PROPOSED DWELLING IN THE TOIFN OF: LAND SURVEYORS SIDES. (64.25+1)(11+1) (1.0) 783 GPD - 1. CONTRACTOR. TO VERIFY SOIL CONDITIONS IN AREA OF LEACHING FIELD TO DETERMINE TOTAL: ` 783 •s. . 783 'GPD 1�M AO IID Rae - ,a, YARM_D,UTH, 1t�A f- BARNSTAB,LE, MA THE. SUITABILITY OF SOILS WITHIN, 101 OF THE r .. ,,, •. . USE 9 INFILTRATORS 6.25 LONG BY 3 FACILITY PRIOR TO ANY PROPOSED LEACHING FA I TY WIDE) WITH 4 OF 'STONE ALL AROUND. PREPARED FOR: CONSTRUCTION. S ANLE�' G. A1V1� EFF. LENGTH 65.25 BY 12 WIDTH 2. 10 -.REMOVAL OF UNSUITABLE SOILS IF ( ) , : " F TH - , .; ENCOUNTERED IN :AREA .`OF LEACH 1�'IELD. BOARD o HEAi D.�B ORAH S. R O SENB,LAD - . . �. , :DArE:' MAr zz f993 _ SCALE. 1 -30_ , P ROYED DATE_ A P AIZNL', H..: OJA R.Q.S. DATE , , x rz . i e . ^ 93 48 , e r a , r , n