HomeMy WebLinkAbout0524 MARSTONS LANE - Health 524 Marst®ns Lane
Barnstable F
A = 348 029
f' r
h w
s
i
.i
ei a
,
i
a
V
,
:
a ..
u
TOWN OF BARNSTABLE
LOCATION �-2 y �i9 A S7 ow,,' 0✓�/ -'� SEWAGE #
VILLAGE C-4, •14 ^ A cr. ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. 1-9OZ c..Y �o ✓s1 Co S o 7 r i 36�
SEPTIC TANK CAPACITY 4 x i s r !G e 15
LEACHING FACILITY: (type `f)3Os O lyyczfZ ) 3 Y !C /.3 Je
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: S�� J COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
L
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
1
GAC2
' F
mT 70 -- G/
�s o t JNo. 00
Fee
THE COMMONVI°IEALTH OF MASSACHYSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Z[pplirattan for Wood brwm Cow5truction Permit �
Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
4
Location Address or Lot No. j 2!/ ^0,i_ 1;.y,,A7 Owner's Name,Address and Tel.No. / a
Assessor's Map/Parcel w uflAV I D 14 n � / ��/`� `v �
Installer's Name,Address,and Tel. o. Designer's Name,Address and Tel.No.
4�d1 2 mac/ Y
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 ��/ gallons per day. Calculated daily flow �7 �/ gallons.
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)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with,the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this B of Hea h. _
Signe Date S
Application Approved y 0 Date
Application Disapproved or the following reas s
Permit No. Date Issued
Y a .. .
No. O ` Fee
-LO-0
THE COMMONil i LTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLI04HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
0[pplication for 30i!gpooY *p$tem Con.5truction Permit -
Application for a Permit to Construct( , )Repair( )Upgrade( )Abandon( ) O Complete System El Individual Components r,
w �
Location Address or Lot No. S�7 �'Jij(2`(S)yj�bm✓S �.q r" Owner's Name,Address and Tel.No. 4:
Assessor's Map/Parcel AV)�� Ap 4 A
3 y .
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
57-
t 5 0 8 � 7, 5 0'-3
Type of Building:
'Dwelling No.of Bedrooms y Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures `
Design Flow gallons per day. Calculated daily flow ��`/ gallons.
Plan Date Number of sheets Revision Date
Title.
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
T
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board"of Health.
Signed- �! Date 5 �
Application Approved�by _ J ! / Date
Application Disapproved or the following reasons f v
4R
Permit No. d Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( )Repaired ( )Upgraded( )
Abandoned( )by 1eq
at e- has been constructed in.accor ance
with the provisions of Title 5 and the for Disposal System Construction Permit No, 11l�.�� � da ed--
Installer G /-/ Designer _d
The issuance of this`pe t A all not be construed as a guarantee that the syste"'M w4.1 function as designed.
Date /., J - Inspecto�__
- — — ——— ----------------- —————— —
No. v Fee-
THE COMMONWEALTH OF MASSACHUSETTS /
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Oigozal *pgtem Con2truction Permit
Permission is hereby granted to Construct( )Repair,(,<Upgrade( )Abandon( )
System located at � A
\� 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.
Provided:Constru ion m4s completed within three years of the date of this pe it.
Date:_ � Approved by
7 — /�' /
f 9/16/03
D
Notice: This Form I9 To & Used For the Repair Of Failed
Septic Systems Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
I, hereby certify that the engineered plan signed by me
dated $ lco concerning the property located at
meets. . all of the.
following criteria:
This failed system is connected to a residential dwelling only. There.are.no commercial or
business uses associated with the dwelling. '
• The.soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data to conclude this fact or may conduct deep
test holes and percolation tests at the site without a health agent present.
There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The.bottom of the proposed leaching facility will be located no less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the.
Frimptor method when applicable]
Please complete the following: `
A) Top of Ground Surface Elevation(using GIS information). e
)
B) G.W.Elevation� +adjustment for high G.W. _ � iPf�ram
D \ETWEEN A and B
SIGNED. A . Q� IV
D TE l
NOTICE
Based upon the above information,a repair permit will be issued for bedrooms
maximum. No additional bedrooms are authorized in the future without engineered septic system
plans.
q ASeptic\percex=V.doc
Town of BarnNtableII r, ,
"E T°w Regulatory Services
y�P ~fit
Thomas F.Geiler,Director
• BARNbTABLE, +
9BUS&
Public Health Division
ArFD ,, Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office:,508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: Juk7f_
1 ,�� til _ -
Designer: � � Installer: Jg�l-f ��.�/ ��
Address: B v k Ct° Address: 3b )(
On l was issued a permit to install a
(date) (installer)
septic system at 2.� /� c5 j�J based on a design drawn by
(address)
6,11— dated O
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. LO-ACHIM6 W I
AS 34 x (z-/( oR G QE4-ir--
I certify that the septic system referenced above was installed with major changes*(i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State&Local 'ons. Plan revision or
certified as-built by designer to follow. -�H of MA ti
o DARREN o�
0 M
EY
(Installer's Signature) 1 /
C
GISTE��
V
SAN I TA����
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO B TABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form. ,
f
•. TOWN OF BARNSTABLE
LOCATION Sa'`/ MArSRCS /AA'L SEWAGE #
VILLAGE
QA�nSTn�� ASSESSOR'S MAP & LOT 3" da9
INSTALLER'S NAME&PIFoNWED INSPECTION
SEPTIC TANK CAPACITY �UllD
LEACHING FACILITY: (type) P,T GX t;� /ft (size) 3 STo,-.L
NO.OF BEDROOMS
—
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachin facility) I Feet
T^s'ACA
Furnished by un FO/C
A
`13
O /7 ao
3 oo 03
y a3 a(°
3
y 3D 3�
FAILED INSPECTIMv,772 z)-Z5
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
t
DEPARTMENT OF ENVIRONMENTAL PROTECTION
iOAP
PARCEL O Z
OT
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 524 Marston Lane
Barnstable, MA 02675
Owner's Name: Howard Nilsen
Owner's Address:
Date of Inspection: April 17, 2004
Name of Inspector: (Please Print) James M Ford linformationCompany Name: James M. FordMailing Address: P.O. Box 49Osterville,MA 02655-0049Telephone Number: (508) 862-9400CERTIFICATION STATEMENTI certify that I have personally inspected the sewage disposal system at this address a reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based'on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
✓ Fail
Inspector's Signature: Date: April26, 2004
The system inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
L
Page 2 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 524 Marston Lane
Barnstable, MA
Owner: Howard Nilsen
Date of Inspection: April 17, 2004
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 ( )
not whether metal or septic tank is structural)
P
Y
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:
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:
2
Page 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 524 Marston Lane
Barnstable,MA
Owner: Howard Nilsen
Date of Inspection: April 17, 2004
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
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:
3
Page 4 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 524 Marston Lane
Barnstable, MA
Owner: Howard Nilsen
Date of Inspection: April 17, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"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 %2 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 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 3I0 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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking 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.
4
r �
Page 5 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 524 Marston Lane
Barnstable, MA
Owner: Howard Nilsen
Date of Inspection: April 17, 2004
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:
Yes No
✓ 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)].
5
Page 6 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 524 Marston Lane
Barnstable, MA
Owner: Howard Nilsen
Date of Inspection: April 17, 2004
FLOW CONDITIONS
RESIDENTIAL
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: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system (yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd .
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings,.ifavailable:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Never pumped-per owner
Was system pumped as part of the inspection (yes or no): No
If yes, volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution.box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed on 2124192-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
- S
Page 7 of l 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 524 Marston Lane
Barnstable, MA
Owner: Howard Nilsen
Date of Inspection: April 17, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting, evidence of leakage, etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 22"
Material of construction: ✓ concrete metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: 28"
Scum thickness: 15"
Distance from top of scum to top of outlet tee or baffle: 4"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. Recommend pumping.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
7
c
Page 8 of l 1
OFFICIAL. INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 524 Marston Lane
Barnstable, MA
Owner: Howard Nilsen
Date of Inspection: April 17, 2004
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: Qallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
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: --
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.):
The D-box was level. Solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
8
Page 9 of l l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 524 Marston Lane
Barnstable, MA
Owner: Howard Nilsen
Date of Inspection: April 17, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits, number: 1 - 6'x 6'LOGO gal. w/3'stone(per as built card)
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.):
The pit had 1'of water on the bottom. .The scum line was above the inlet pipe. The pit showed signs ofpast failure. The bottom
to grade was 10'. The cover was 3"below grade.
CESSPOOLS: None (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 or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions.-
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
9
S
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 524 Marston Lane
Barnstable, MA
Owner: Howard Nilsen
Date of Inspection: April 17, 2004
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.
Q�
B
a
O a0
3 ao 103
y a�
3 a3
. O
y 30 3�
10
Page 1 1 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 524 Marstons Lane
Barnstable, MA
Owner: Howard Nilsen
Date of Inspection: April 17, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25.+1- feet
Please indicate (check) all methods used to determine the high ground.water elevation:
Obtained from system design plans on record- If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water.contours maps
Checked with local excavators, installers- (attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using a Barnstable topographic map and water contours map, the maps were showing approximately 25' +/- to ground water
at this site.
This report has been prepared and the system inspected and failed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL ATFRS
_ DEPARTMENT OF ENVIRONMENTAL PRO Cj t T TION ONE WINTER STREET, BOSTON MA 02108 (617) 292-550b �f 0
MAY 9 2000
YEei
TON7IIOF TRUDY COXF.
ftE I)MER S j`re ,
L
ARCEO PAUL CELLUCCI D�AVIDD B. STRUHS
Governor e�,y ' •Comnussioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �,
PART A
CERTIFICATION
Property Address: 524 ('narstons Lane Cummac ofOW W John Mitchell
Address of Owner:
Date of Inspection: 4/2 6/0 0
Name of Inspector;(Please Print) Donald K l i mm
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: Robert B. Our Co. , Inc.
MeifingAddress= _P O Box 1 539 Harwich, MA 02645 -
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true; accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X Passes
Conditionally Passes
Needs Further E tion B he Local Approving Authority
Is
Inspector's Signatur Date: 6
The System Inspector shall submit a py of this inspection report to the Approving Authority (Board of Health or DEP)within thirty(30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of-Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
r,
revised 9/2/98 Page Iof11
4% Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddress:524 Marstons Lane Cummaquid
Owner: John Mitchell
Date of Inspection: 4/2 6/0 0
INSPECTION SUMM.ArRY: Check A, B, C, or D:
L
A. .SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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.
Indicate yes, no, or not determined(Y, N. or NO). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificaie of
Compliance(attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(sl
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
revised 9/2/98 Page 2oru
l i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVJRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. _
21 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
revised 9%2/98 Page 3ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility�or system component dua,to an overloaded orclogged 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 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 Zon I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
—coliform bacteria, volatile organic-compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large,System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please cons
ult sult the local regional
office of the Department for further information.
revised 9/2/98 Pagc4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Prop"Addiess:524 Marstons Lane Cummaquid
Owner: John MItchell
Date of Inspection: 4/2 6/0 0
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_ Pumping information was provided by the owner, occupant, or Board of Health.
X _ None of the system components haw&been pumped.foratJeast two weeks and-the system hasbeen•recalvingmermal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
X _ As built plans have been obtained and examined. Note if they are not available with N/A.
X _ The facility or dwelling was inspected for signs of sewage back-up.
X _ The system does not receive non-sanitary or industrial waste flow.
X _ The site was inspected for signs of breakout.
X _ All system components, excluding the Soil Absorption System, have been located on the site.
_X _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption Systern on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[I 5.302(3)(b)1
X_ _ The facility owner(and occupants,if different from owner) were provided.with informatiom on tha.proper.main*anamrA of
SubSurface Disposal Systems.
revised 9/2/98 Page 5of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 524 Marstons Lane Cummaquid
Owrw: John Mitchell
Date of Inspection: 4/2 6/0 0
FLOW CONDITIONS
RESIDENTIAL:
Design flow: ®.p.d./bedroom. 4
Number of bedrooms (design): 4 Number of bedrooms(actual):__
Total DESIGN flow 440
Number of current residents: 2
Garbage grinder(yes or no): 0
Laundry(separate system) (yes or no):nV• If yes, separate inspection.required
Laundry system inspected (yes or no) YC�'S
Seasonal use(yes or no): no
Water meter readings,if available(last two year's usage(gpd):
Sump Pump(yes or no): no
Last date of occupancy: n0W
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: qpd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system:(yes or no)_
Water meter readings,if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_jlo
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
0 Shared system (yes or not (if yes, attach previous inspection records, if any)
--Q I/A Technology etc. Attach copy of up to date operation and maintenance contract
—� Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed lif knownj and source of information: - it --2. installed In 1992
Sewage odors detected when arriving at the site: (yes or no) no
revised 9/2/98 Page 6ofII
1 �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Prop"Address: 524 Marstons Lane Cummaquid
Owrw: John Mitchell
Date of Inspection: 4/2 6/0 0
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Materiel of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints, venting,evidence of legkage,-etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grade: 16"
Material of construction: Xconcrete_metal_Fiberglass _Polyethylene_other(explain)
If tank Is Metal,list age_ 1s_age.confirmed by Certificate of Compliance_(Yes/No)
Dimensions: . 8 ' 6" LX 4 ' 10" WX 5 ' 8" D
Sludge depth: 411
Distance from top of sludge to bottom of outlet tee or baffle: 2 0
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 5",
Distance from bottom of scum to bottom of outlet tee or baffle: 18
How dimensions were determined: rn 1 Pr 1 udge judge
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural-integrity;
evidence of leakage,etc.) check & pump In 2 years
taNK HAS NO .LEAKS
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction: _concrete—metal _Fiberglass _Polyethylene_other(exp(ain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom*of outlet tee or baffle: —
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
revised. 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 524 Marstons Lane Cummaquid
Owner: John Mitchell
Date of Irtspection: 4/2 6/0 0
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction: _concrete_metal_Fiberglass_Polyethylene—other(explain)
Dimensions:
Capacity: gallons r
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes_ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: Equal
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — —
no carry over & no leakage
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
revised 9/2/98 Page 8ofII
1, R
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PropeftyAddfess: 524 Marstons Lane Cummaquid
Ownef: John Mitchell
Date of Inspection: 4/2 6/0 0
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan, if possible:excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leeching pits, number: 2 6 X 6 Pre Cast Pit w/3 ' stone
leeching chambers,number:_ found with 41 liquid on 4/24/00
leaching galleries,number:_
leeching trenches,number, length:
leaching fields, number,dimensions:
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
soli c can no signs of Ny--draulic fallure at this time
CESSPOOLS:_
(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 (cesspool must be pumped as part of inspection)
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.)
revised 9/2/98 Page 9ofII
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
s:
�n:
VAGE DISPOSAL SYSTEM:
ties to at least two permanent reference landmarks or benchmarks
,II wells within 100' (Locate where public water supply comes into house)
4/L
6 �.
2�,
f .
SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
P*opeoYAckke==: 524 Marstons Lane Cummaquid
Owrw: John Mitchell
Date of Inspection:
4/26/00
NRCS Report name
Soil Type_ _
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep Yes
SITE EXAM Slope Yes
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater_Feet 15 t no Water
Please indicate all the methods used to determine High Groundwater Elevation:
N Obtained from Design Plans on record
Y Observed.Site(Abutting property, observation hole,basement sump etc.)
YDetermined from local conditions
Y Checked with local Board of'health
0 Checked FEMA Maps
Y Checked pumping records
Y Checked local excavators, installers
Y Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Hand Auger
I
revised 9/2/98 Page 11of11
4
�s�
01
LOT NO. ADDRESS:_ivn
�Ro f
OWNERS NAME:
SEWAGE PERMIT NO. : NEW: . REPAIR:
DATE ISSUED: DATE INSTALLED-A"
INSTALLERS NAME: Li`, G 0
INSTALLATION OF: , 'L 3
WATER TABLE: FINAL INSPECTION BY:
DRAWING OF INSTALLATION ON REVERSE SIDE :
• -- :j NSW
� �
j
����
`��
���
��
���
� � �
TOWN OF BARNSTABLE
LOCAnbN SEWAGE #
VILLAGE ASSESSOR'S MAP &•'LOT
M -INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED-
VARIANCE GRANTED: Yes No
LOCATION �a7 SEWAGE PERMIT NO.
1-7 h 0,4R .1y i.wv� C�
pn ,c O ly
VIILLAC-4
INS A LLER'S NAME & ADDRESS
e -,ik N ok sS
CO C'C' P
B U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ��y�
A Z 7 '
° /o oo n
S, TA 44 °
�pp 2� iti t� sr
Ccr
L,4 N p
No. Fss.:. Q._�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA T,H
Appltratiun for Disposal Works Tonstrurtion Frrntit
Application is hereby made for a Permit to Construct c ) or e/paiirr �an Individual Sewage Disposal
.System at: v3 hle�...... b6l ,
. . .... _.___.............._.............. _ ..__..
L on-Addres qr No.
--AC ...' �r -.Add
�............................... t�0 -! ......................................_.....
/� Owner Address
a 1 -c �...-- .............................................. ..........
--...............-
M Installer Address
Type of Building Size Lot............................Sq. feet
aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ........................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................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 by-------------------------
•------- •-•-•------ •........................ Date........................................
0.4
,.� Test Pit No. 1................minutes per inch Depth of Test Pit............_....... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ............................................................................... ----------------------•--------•-......••.........
.....
0 Description of Soil........................................................................................................................................................................
W
V ------
-------------
-----------------
•-.--•--
W ..................•--•----•••-•-•-.._......••••-•-•-•---------•--••---•--............................. 3 - ........
U Nature of Rep ' s or Alterations—Answer when applicable. .._�'J ! Cli ......0 1.............
.... ..... .....................................•--------------------•-•-•----------.. ....................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of LITA IE 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_b a bo of health.
2 Si . -----------------------------------------------------•---•-••--•. �........ .
l�L. Date
Application Approved BY--:. r_..._ - �"�.!lx,� ...--•• ---•-----•-=-`-...---�'��--�--�--•---•-�---
Date
Application Disapproved for the following reasons:.............................................•---................................---....................._._.
............................••-•------•--••---.�_.......-••-----•-•--------••----••-••---•----.......................--------•-----•-----... ..............................................
Date
--��yy
PermitNo. ._....?_.....�-•-/.................._ Issued...................................... .............
.- -- TM^ys., :s .->. .. nv.--- �.., .F,.vl:,,,•�:t'ti�. � r..�„r•--�x,.,.�t;;.z w
A �
No: _ .
THE COMMONWEALTH•OF MASSACHUSETTS
OF HEALTH
Appliratiun for Uiipusal Works 6nsitrudiun rani#
Application is hereby'made fora Permit to Construct ) or Repair `(a an Individual Sewage Disposal
Systan at:
Loca'on-Address or t No.
�. P �1: :..................... . ----......................................
Owner � / � � � • Address
,.a ....,.......�...... �� ---(..�, ......................................... - -,-.�±� ....................•---------......_.........................
+ •-•-----•_--.-----S feet
q� Type of Building Installer -_- Ex nsion Attic Size-,Lot r ............................
•(,arba a Grander
U Dwelling—No. of Bedrooms........................ pa ( ) g ( )
Other—Type of Building .............. No. of persons............................ Showers — Cafeteria
A•' Other fixtures -------•-----------------------------------
d' Design Flow............................................gallons per person per day: Total daily flow............................................gallons.
WW
WSeptic Tank—Liquid capacity............gallons Length...............\Width................ Diameter.........;...... Depth................
x Disposal Trench—No..................... Width.............'....... Total Length..................... Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet,.................... Total leaching area..................sq. ft.
,Z Other Distribution box ( ) Dosing tank'( )
aPercolation Test Results Performed by.......................................................................... Date.........................................
.4 Test Pit No. 1................minutes per inch Depth of Test Pit........--.......... Depth to ground water........................
0-4 -� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x --------------------------------------------------------------------------------•......---------...--.------......----:----- ..................... .
ODescription of Soil:........................................................................................................................................................................
x •..... .... ••• ............ ........ ..........
U Nature'of Repairs or Alterations—Answer when ......
-----•---------------------------------•--
Agreement
The undersigned agrees to install the afo edescribed Individual Sewage Disposal System in accordance with
the provisions of iITL U 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 bo•.r ,of health.
Signed...Z�qj_.
`_ .' Date
Application Approved By:._.----•-•-f�.�. � %u------ ........................................
Date
Application Disapproved for the following reasons:......... :............................. .................................................................
-.
..-----•--------------------------------•----............................-•------•---..................---•-•--•....._..............---.....-•-•--•-•-••--••-••-••••......-••--••--•••----•------------
Date
Permit No........ , . ��-----•--•-------- Issued... --!!a/-�--.. "` .%....�c.�.....
L• z�,J Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........0 F��v— ........................................
THIS. IS TO CERTIFY That the In ividual Sewage Disposal System constructed or Repaired
by...............................e,-.d....r) .........t�, ...................... .............................................................................................
Installu
at........... &- - .... .A ..............
................ A.....................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.___. .
4? 7— , tZ.............14"
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
Inspector..................................................
DATE.................................... ........... .........
...7-7....
THE COMMONWEALTH OF MASSACHUSETTS rF
BOARD OF HEALTH
.....
OF.. 0......—..:..................................
. F$E G................
Rs:pns#aVvrhs Tons trudian Permit
Permission is hereby granted.... .....................................................................................
to Construct or Repair (J.,) an Individual Sewage Disposal System
at No......... ....1,x............jC
...... ....Alit 0.........................................................
Street
as shown on the application for Disposal Works Construction Permit No...,.-........1K gate d.....
.............. .. ........ ---------
DATE_ � --A.. ... ............................. Board of HealHii.............. 7
�I
Jab.
ASSESSORS MAP : j�� TEST HOLE LOGS NOTES:
PARCEL: 1) THE INSTALLATION MUST BE M� war �e SUBSTANTIAL,COMPLIANCE WITH
FLOOD ZONE: �p� kp'-zklzo SOIL EVALUATOR : �� 1�eyerU ` HIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF
W1 TNESS: ur V.e1 I BOARD OF HEALTH REGULATIONS.
REFERENCE: g�- 13055 Wo
'Pr,- I A'3 DATE: SEP l M rSE 8 ?�
tHEN� quo "t PERCOLATION ON RATE: L �^ 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES,
+ S s U 2 ,1 LEA- SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO
HWY. &xv", FI; N CUSS = Q INSTALLATION.
SOILS (.T�}'1Q_.=O,�a'f tJ P�� Y
PY� TH- I E( �(d,irJ'� TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION
L,�► o k Leo &-j_qQ tw�,� FL17
f� A„�, p ONLY, . AND SHALL NOT BE USED FOR PROPERTY LINE
j -- DETERMINATION.
Tp� r1 I.
. -v4 A
4) ALL PIPING TO BE 4 SCHEDULE 40 @ 1/8 / FOOT. (UNLESS
SRO lb � SPECIFIED OTHERWISE)
LOCATION MAP N. 5.
Af
T' 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A
1
GARBAGE DISPOSAL.
6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED)
Z.S/ 4 MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON
A BASE OF 6"OF CRUSHED STONE.
r 7 E�(15TINl �E G�+. ['lTsb -3c=_ PVMPEo CfUSt}�n ��cc�l
) -- _ )
r
No KNO AI F'F-1 VAtr— wEc,(,S W/rN 150 OF-
SEPT I C SYSTEM DES I GN 4_6,-wE 1 s-wht /50 OT Pew, t.rr"c 114.
V - 10. NO U-t 94 A-IJ CL'S Fi2p M T1 T t-E Y O!Z-
�\ FLOW EST I MATE
}-- ---- Tbw N o� B M2nK',
I�P. OF- Heott )f l?,EjV i,A-77 0x)5 969Vi'lp.
- --_ \ BEDF+OOHS AT Il o GAL/DAY/BEDROOM -T-Tu GAL/DAY M o
!t� r159t, _4b c. M qS. �o
Z SEPTIC TANK LL. 1 rk$ SHrjwN)� :
Pr�vENT- BR�h acoor.
-- — - - -- - —.
,�A� IZ� k.'�Adov� it-�c.,_UNSV�t�t _,�o_►t„�_��_�-ovnJb Cr�lt-rl�
\ `4-6 GAUDAY x 2 DAYS � GAL
bla--tv�P O F C fin-'"/hT�►�
\ o USE p,)D GALLON SEPT I C TANK 6/11-Ld n1 _ - --- --
� � �_ E7aSn�� • �'°`''tt.�wlli5�' _ _------
SEa�r T� I F Fsf- t,Cn D�1 A-:i cd
SOIL A83ORPT I ON SYSTEM oc. vN �e.StZ,w>
ftIS
a \ S SOIL. (zs- 0VAt T-0 `�lE ONS/OE�S ,t I 1
N - 2, ! 34. Lk12•Ito
a ) EL gt.02 00--taP
IOF SIDE AREA: � Z{-�z-u. 31 x D, 7�j �3(0 . (03 J 3 Srls
BC-TTOM AREA:
34 - x 12.iG x: 6� 7Y = 3os.94 3 G ` Y� 5
0001
` �42.5��►�D
SEPT I C SYSTEM SECTION k
I EXISTING
{ DWELLING >sr►N4 ti EL. 9 s L p BrZIN Co vE� To wI ,j - EL, 71•S— Flo u ) �1 i
1 000 AI!� o b 4 I i .TOP OF FPoDN I � I Q`
EL - 99.33+- 1 G Op �9 '�� ✓Q�< N M b� fyt� EI...I fad
rr. / IEP77 D SO Insfxit
100
/ D-BOX
t, GAL y.so �ua, r�sf 3 14,
4 I \ SEPTIC TANK
bUSnN1� _3 (4) H2-o 40t+PE0 30S0 ^
T"T1�� UN (.J A�
j cm� ti CROSs SE&'Ra;� A), T s l ,�
9•
oy>
ZZ =
A �
39.91 0� TE,STffaC.E EL 83,DZ.
rya �'oo 4 3/y ovi h
a 36g 0 2Z WOW SITE AND S
MAAt
ZN OF k� SEWAG
E PLAN
. n�i _ � �,1. has a °Z4"
o�RR `� , LOCATION : 52 (/VIA-2Si GnIS i9 t/�IUE
v6lc 4N5T&-1,1G77NJ
PREPARED FOR :
0/BT Do
?4R �NlTA �` DARREN M. MEYER, R.S. scALE: 30'
a
W
43 VINE STREET --
DATE: `I-IG •6
Z _
DUXBURY, MA 02332 > 'ev. '5-1610s—
W .. DATE HEALTH AGENT (781) 585-0293
3
W