HomeMy WebLinkAbout0011 MEDINAH DRIVE - Health 11 MEDINAH DRIVE, CUMMAQUID
A=355-014
i
a
11
5# No. / ` 17 a.- Fee $ 5 0.00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Appricatton for ;Digpogar *potem Construction Verna
Application for a Permit to Construct( )Repair kX)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 11 Me d i na h Drive Owner's Name,Address and Tel.No. 8 6 2—31 4 0
Cummauid,Mass. Maloney 11 Medinah Drive
Assessor's Map/Parcel
.3 �s0 Cummaquid,Mass. 02637
Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
J.P.Macomber & Son Inc. J.P.MacOMber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling XXNo.of Bedrooms 5 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building RES No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 550 gallons per day. Calculated daily flow 1 0 x 5 S ppr nPrs nn gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank E x i s t i n cl 1 000 & Box Type of S.A.S.1 —1 000 gALLON PIT
Description of Soil Clay to medium sand
Nature of Repairs or Alterations(Answer when applicable)Adding 4-500 gallon chambers packed
in 4 ' of stone.
Date last inspected: 3/1 6/9 8
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 Env onmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu . by this Bo d o el
Signed 4 Date �/1 7/A 8
Application Approved by Date Z
Application Disapproved or the fol owing reasons
Permit No. Date Issued 9'
No. 0'- '1 7-- Fee $ 50.0 0`
THE COMMONWEALTH OF MASSACHUSETTS' Entered in computer: ,�
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Application for Mie;paal *pgtem Conetruction Permit
Application for a Permit to Construct( )Repair(XX)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 11 Medinah Drive Owner's Name,Address and Tel.No. 8 6 2—31 4 0
CummaMquid,Mass. Maloney 11 Medinah Drive
Assessor's ap/Parcel
3 S,5 Q � , Cummaquid-,Mass. 02637
Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8
J.P.Macomber & Son Inc. J.P.MacOMber & Son Inc.
f; Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 026.32
Type of Building:
Dwelling XXNo:of Bedrooms 5 Lot Size sq. ft.. Garbage Grinder( )
Other Type of Building RES No.of Persons Showers( ) Cafeteria( )
Oth Fixtures
Design Flow 550 ' gallons per day. Calculated daily flow 10x55 Per persongallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Existing 1000 & Box Type of S.A.S. 1 -1000 gALLON PIT
Description of Soil Clay to medium sand
Nature of Repairs or Alterations(Answer when applicable) Adding 4-500 gallon chambers packed
in 4 ' of` stone.
Date last inspected: 3/16/9 8
Agreement: _ Y
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 Envir nmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issugfi by this Bo d o �e t
tt Signed _ or Date 3/17/9 8
Application Approved by Date ZG 4 .
Application Disapproved for the fol wing reasons
Permit No. Date Issued . -- 2 G` g
---------=-------------------------------
t THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance 4.
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired�XX)Upgraded( )
Abandoned( )by J.P=.Mace bez—=: —T_c.
at 11 Medinah Drive Cummaqui ,Mass. has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 dated 3- ZU- 12 .~
Installer Designer
The issuance of this e t shay' be construed as a uarantee that the s st wil function as designed.
Date P � / g Inspector Y g
---------------------------------------
No. / " / 71. Fee $ 50 .00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
li.5pogar *pgtem Conotruction Permit
Permission is hereby granted to Construct( )Repair�XX)Upgrade( )Abandon( )
System located at 11 Medinah Drive Cummaquid.,Mass.
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: L Approved by ��
lop
TOWN OF BARNSTABLE
LOCATION I .�fealle471';, SEWAGE # e4g� /70—
VII LAGE l,�ldA e-alPa 'i'Aa ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO. dr r,�1 Qwcc9T. 7
SEPTIC TANK CAPACITY L /
LEACHING FACILITY: (type) c1 ✓BOgq�/�'ac 4 C��y(size)
NO.OF BEDROOMS
BUILDER OR OWNER 0a ZOWe l
PERMITDATE: �� —� _COMPLIANCE DATE: ;3-
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility r¢ Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) I Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
;4 within 300 feet of leaching facility) * Feet
Furnished by•
S►� �s YOb �b -
�� �'e
CI �~ 10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I, Joseph P Macc)mhzr jr , hereby certify that the application foi disposal works
construction permit signed by me dated 3/17/98 , concerning the
property located at 11 Medinah Drive cummaguid mass. meets all of the
following criteria:
V There are no wetlands located within 100 feet of the proposed leaching facility
There are no private wells within 150 feet of the proposed septic system
iV There is no increase in flow and/or change in use proposed
Y There are no variances requested or needed.
illif the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the
proposed leaching facility will =be located less than fourteen (14) feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation (according to the Engineering Division G.I.S. map) v `
B)Observed Groundwater Table Elevation (according to Health Division well map)
SIGNED : DATE:
LICE ED SEPTIC SYSTEM INSTALLER IN THE TOWN,OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
q:health folder:Bert
/vl
I�vJI
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address: 1 1 Medinah Drive Cummaquid Ma
Owner: Pam McGee
Date of lns.peclion: 9/23/97
SKETCH OF SEWAGE DISPOSAL SYSTEM:
nciuoe ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supplv.comes into house)
Q
(7
C
Iy v1..0 G�/73/97) Page 9 of 30
'1
h
0
. o
�� '
J
Ir
• TOWN OF BARNSTABLE
LOCATION SEWAGE# �7Z
VILLAGEl Llr��/ Q�u�d ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. �vr r�Lerf`l Co�r6T 7t/.✓�3�9
SEPTIC TANK CAPACITY
��._ �BD COIf(size)
• `. LEACHING FACILITY:.(type)
NOti QF BEDROOMS ,
a � {
BUILDER OR OWNER. /w 190ile�
•PERMIT DATE:_ —COMPLIANCE DATE
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility
r Feet
Private Water Supply Well and Leaching Facility (If any wells exist q Feet
on;site or within 200 feet of leaching facility) .
;Edge,of Wetland and Leaching Facility(If_any wetlands exist 9 Feet
:>`within 300 feet of leaching facility)
.Fitmslied by.
__--
9 Eq
r
F
r •t j
.q A31, 4
O
.i
l/F _ �:
1p
i Cb
iIm 0C r 6
2000
°09
COMMONWEALTH OF MASACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS
`DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI ) DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 11 MEDINAH RD CUMMAQUID, MA 02637 M355 P014 L148
Name of Owner DENISE MOLONEY
Address of Owner: 11 MEDINAH RD YARMOUTH PORT MA.02675
Date of Inspection: 1012/00
Name of Inspector: JOHN GRACI
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.6Ob)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 608-564-7270
a
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 Evalu do By-the Local Approving Authority
Fails
Inspector's Signature: � ' r Date: 1013/00
The System Inspector shall su mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection. If t e 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
"The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.M,
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL
LIFE.
revised 9/2/98 Paoe 1 of 11
r:SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 11 MEDINAH RD CUMMAQUID, MA 02637 M365 P014 L148
Name of Owner DENISE MOLONEY
Date of Inspection: 10/2/00
INSPECTION SUMMARY: Check A, B, C, or D:
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.
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 o
the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances. If"not determined",explain why not.
nla The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate 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.
n/a Sewage backup,or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o
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
n1a 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
4 a '
h/
revised 9/2/98 Pape 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 11 MEDINAH RD CUMMAQUID, MA 02637 M355 P014 L148
Name of Owner DENISE MOLONEY
Date of Inspection: 10/2/00
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. v
1) SYSTEM WILL PASS UNLESS BOARD`OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM I:
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
,y
_ 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 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 pollutign 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 n/a (approximation not valid).
3) OTHER t 1
n/a fr
Y
revised 9/2/98 `01 Paae 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 11 MEDINAH RD CUMMAQUID, MA 02637 M355 P014 L148
Name of Owner DENISE MOLONEY
Date of Inspection: 10/2/00
g
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
a 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
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
_ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n1a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
_ X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with 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.
n
c�
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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary' to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply
well)
of o
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of
the Department for further information. a
`ii•
i
t�
!1"
revised 9/2/98 !' Paoe 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 11 MEDINAH RD CUMMAQUID, MA 02637 M355 P014 L148
Name of Owner: DENISE MOLONEY
Date of Inspection: 10/2/00
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health.
X _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal 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.
t�
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 System on the site
has been determined based on:
X _ Existing information,For example, Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 1 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems. t,
zi f
revised 9/2/98 " Paoe 5 of 11
` w
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 11 MEDINAH RD CUMMAQUID, MA 02637 M355 P014 L146
Name of Owner DENISE MOLONEY
Date of Inspection: 1012/00
FLOW CONDITIONS
RF_SII)F_NTIAI ;
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 5 Number of bedrooms(actual):n/a
Total DESIGN flow: 560 gpd
Number of current residents:4
Garbage grinder(yes or no): NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): NO
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: n/a
f, -
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203) d
Basis of design flow:nla +u•
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped n/a gallons <i
Reason for pumping:n/a {
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
_ Single cesspool
_ Overflow cesspool
i
_ Privy
_ Shared system(yes or no)(if yes.attach previous inspection records,if any)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a I
APPROXIMATE AGE of all componenfsl date idit`alled(if known)and source of information::
1998 PERMIT 98-172
Sewage odors detected when arriving at the site:(yes or no): NO
J
�f
revised 9/2/98 Paoe 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 MEDINAH RD CUMMAQUID, MA 02637 M355 P014 L148
Name of Owner DENISE MOLONEY
Date of Inspection: 1012/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 14"
Material of construction: _ cast iron X 40 Pvc _ other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
TOWN WATER
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 8" ^:
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other ,
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a "h
Dimensions: 1500G L 10'6"H 5'6"W 5'8""
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How dimensions were determined: MEASURED
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.)
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS.
n;
GREASE TRAP: _
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions:nla
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: n/a ,t
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.)
n/a
1
r
revised 9/2/98 Paoe 7 of 11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 MEDINAH RD CUMMAQUID, MA 02637 M355 P014 L148
Name of Owner DENISE MOLONEY
Date of Inspection: 10/2/00
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other
Explain: n/a
Dimensions: n/a
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level: N/A Alarm in working order:NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:X
(locate on site plan) p
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments: ,
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
THE DISTRIBUTION BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER: _
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
i t
revised 9/2/98 Pape 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 MEDINAH RD CUMMAQUID, MA 02637'M355 P014 L148
Name of Owner DENISE MOLONEY
Date of Inspection: 1012/00 '
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:
n/a
Type:
leaching pits,number:(1)1000 GAL 6'X 6'
leaching chambers,number: (4)500 GALLON LEACHING CHAMBERS
leaching galleries,number: (n/a)n/a
leaching trenches,number, length: (n/a)n/a
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool, number: (n/a)n/a
Alternative system: n/a +,
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic.failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH FIELD APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE.SOIL PROBED DRY.
CESSPOOLS: _
(locate on site plan)
.r
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer. n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a inflow(cesspool must be.pumped as part of inspection)NO
�r
Comments:
(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
n/a
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a Ind
{
L .
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
t .
revised 9/2198 Paoe 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 MEDINAH RD CUMMAQUID, MA 02637 M355 P014 L146
Name of Owner DENISE MOLONEY
Date of Inspection: 10/2100
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least-two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
5vA Raor►
1 yo
a
_ y 3q
oil
4�
6
. r
zy.
revised 9/2/98 r'' Paoe 10 of 11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 MEDINAH RD CUMMAQUID, MA 02637 M355 P014 L148
Name of Owner DENISE MOLONEY
Date of Inspection: 10/2/00
i
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n/a }
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water _
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet+ u
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
t
Determined from local conditions `=`s
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-12+FEET
.T
n
t
revised 9/2/98 Paoe 11 of 11
00
FVI
A T I 0 l® �Le cl�-��� '�'L``tS E W A G E PERMIT NO.
- 3!
LAGE
&fAfillf IQ ex (o
INSTA LLER'S NAME i AD.DRESS
mm,c /J d/V
BUILDER OR OWNER
e VE 7-%a/L/
DATE PERMIT ISSUED
7
DATE COMPLIANCE ISSUED �.
n aIr
y a., N
\ ,e7 /1A
,LL ,
7' N
Q� d
THE COMMONWEALTH OF MASSACHUSETTS r
BOAR® OF HEALTH
ApplirFatinn for Uiipnoal Vnrk.6 Toutitrnr#inn 1hrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.Y.f�f.�Ql ....-----•-------•-------------- �.7�... ...............
Lo ton-Addr S rr+or Lot of
.._.. ... .................... `
Own r A dress
....................................... ... f. .
Installer Address
Type of Building Size Lot... 6,.,..��.4�..Sq. feet
Dwelling—No. of Bedrooms.______.________________________________Expansion Attic ( ) Garbage Grinder
Other—Type T e of Building ............... No. of ersons.....__._._......_.......... Showers — Cafeteria
a YP g ----•---•---- P ( ) ( )
Q' Other fixtures ............................
W Design Flow...............5
W ...: _ gallons per person per day. Total daily flo.w........... ......_............gallons.
Septic Tank—Liquid d capaci___igallons Length.. Width..,/.'_/0" Diameter.._ Depth. ;V..t �
x Disposal Trench—No..........:.......... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..J-`.A...... Diameter..........._...... Depth below inlet............... Total leaching area._'®UQ...sq. ft.
z Other Distribution box (Al') Dosing tank ( )
'-' ► Percolation Test Results Performed by.Z�.,� ate..,9.6.'1Y_..6;--1.%.?7
Test Pit No. 1....4.Z..minutes per inch Depth of Test Pit....IA.:...... Depth to ground water..._Y(Z _.-
Gi, Test Pit No. 2._A ,....minutes per inch Depth of Test Pit__--1_3.......... Depth to ground water._1Vv1v.4..
x )01 7._-'!!.1---- ----- ---------------------------------.......................F�T:nz......--------
0 Description of Soil------- - a .__.. .4�1 ._,$' , ?�S<�1. .-----------------------•-----------•--------------------------- ...... . ------•-----.
x 0 .. ---------------/ • _ /N s!� !,Q 1� ' r�1�' ' c5' C.� ------- -
v ......._
W ...........................-.............................................................................................................................................................................
UNature 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 1 i a 5 of the State Sanitary Code— The undersigned further agrees not to place the syste in
operation until a Certificate of Compliance has been d b the bo d of heat .
Sined..... .. _.. ....... ......... ....-.....--� ---�
,,/ Dat
Application Approved By.......... ......-•••-....`.. 1i..sl... - -- -- -- ---- ---------•------- ......14....&4_ .- ' ......
at
Application Disapproved for the following reasons:..............................................................................................................
....•-----------------------------------------------------------------------------------------------•--•--•-••-••--••----_-_...-------•----------••-•----••------------••----•-•---••......------
Date
PermitNo......................................................... Issued-.......................................................
Date
No-------------------- / Fps.,..�..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
G�1 ......OF... � _ ...................
Appliration for Dhipoiial Works Tomitrnrtiun lirrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.. '.d ,!/'��. r`a��-J 1t✓ ................................r.. a/`"�•.. � ' ''.....----•--••--
t Loc i n-Add G6 �.'or 2,ss
i�-_t� ...��..�!-!..i t..7fY_........•- � ""'• /.wn A
.::.......... .............................. .....0
Installer Address
� Type of Building Size Lot__������.G_?Sq..feet
Dwelling—No. of Bedrooms____.___.___.__________________________Expansion Attic ( ) Garbage Grinder Vit j
Other—Type of Building ____ No. of persons____________________________ Showers — Cafeteria
Otherfixtures -----------••-• •-••-------•----••......-•-••-••• ._...---
W Design Flow_____________S_S__..____.______.______.gallons per person per day. Total daily flow...........IV Y.Q__fr___...._______gallons.
CW Septic Tank—Liquid capacityl Vgallons Length__V^_6_ Width__ 'nt�Q Diameter__.41 4__. Depth_
Disposal Trench—No. ______________ Width f ._._ Total Length_________ � Total.leaching area....................sq. ft.
Seepage Pit No._J.FAe .. Diameter------__ter__.__...... Depth below inlet...._�� _.__..... ToteLljleaching area__.-.V!2!...sq. ft.
( y g
Percolation Test Results Performed b �.C1�4_._E, . .. Gt _ 't_t �.�3fi!C?fDate_/`�U __._
Other Distribution box H'' Dosing tank
Test Pit No. 1....:G_�r___.minutes per inch Depth of Test Pit----/3_______. Depth to ground water_.1 .4 _.
Test Pit No. 2__�:.___._minuutes per inch Depth of Test Pit---z,3......... Depth to ground water...°
xP/ "----t-'---...............................................................................----------------------- ...............
0 Description of Soil E= ' l�tv4t --•-•---•-------• -------------•----------------------------------.......-••------
x ---------------------------------------'.._./.A3.__.1�7! p_ _t 'l�vt' S!�/y' 'S----1 __!�?_€ �i' '....----------c r .. ----------
V
---------------------------------------------------------------------------------------------•------------------------------------------------------.....-----------••-----------------........---.-•••-
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` T L 5 of the State Sanitary Co e—The undersigned further agrees not jplacee syst in
operation until a Certificate of Compliance has b y the bo d Of*
ned- --• •--• �0 APPlication Approved By----•--.•••-.--•--••--•--•-•••-•. ._........ ------•................................. e....---..
/ Date
Application Disapproved for the following reasons_______________••__________________________________________.._.....______________________.___.___......____..._..
.._..._....•--••••--••-•....•-•••---••-•...-••--....-----•-•••-•---••---••-------•••--•--•••--•••-----•-----•-•---••._...••---•------•---•••-••--•--•-------------•----•-•-•-••---------•--••-•--.......
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
+.p•�+ � ,pry �y.•�
........../....�✓P��✓I ✓�........OF..,K7 1 � �i�r�a'l .! tc� "......................
. Trrtifirat� of Tomplinttre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by...............A# ._..... .
Installer
has been ins aped m accordance wit i .lie`prbbis ons;------.----�-------------------------------------- --...................................................
at....... - .__.
o 5'�o nitary Code as described in the
application for Disposal Works Construction Permit No. �_ggr�__,,_,�____________________ dated............................................THE ISSUANCE F THIS CERTIFICATE SHALL NOT P CONSTRUED AS GU RANTEE THAT THE
SYSTEM WILL n/N TION SATISFACTORY.
DATE......:/Q .. ........................................................... Inspector......../..
THE COMMONWEALTH OF MASSACHUSETTS '
BOARD OF HEALTH
N FEE........... ,.r...
Y. Disposal Workii CUnnstrnrtian op"nutit
Permission is hereby granted._....: ......... _. .__ ___':_ `
to Construct�i') or Repair ( ) �'n vl al S�€;i�: ; ystem
at No....- T ..T... . . .. . �r •-
` _` f _ �
as shown on a pIication for Disposal Works Construction Permit No..................... Da ed_._._.__ _.____.___f
DATE.._. Z .................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
x"
_
55 -- 7 P -� St14-
rtA.
NJ Yl
/j pQ
YZ2 It`
J.
o
.w SE"trxG 14 q s• ESN } ' -
S pt�o Po S e t7
r� i+ 0-
9 ' '' err-+ !+
594.9
� svSsc?r
�jiu/w
' •' aClc y
P.
. n/6 TZ� • G .
Af ca
OAJ-7'
o S
TJf' JF.F�FJni �1 "/ �'jAlv:r�t�L E ; � J f✓E "vX TE�/ 7-0F /S C,c�r�E. 0
-i'V V.
r -17�/1 N
U L E ✓. � L E,tt L.H A,e_4 141^1, 2
y 24"r?1A �� ��: s . Io 8cx r- /S r z" �� '= •sroti�Aw�
P✓"Eer/vT, .�uinJE o�✓eC5� r l
:
� a r�/D 4
'' y;v F/,1//b / / = 7 J�
✓c I-,�"Er;✓L �At>E./�. n/�f r a Tin✓
.-"":-_`-�,�.. _ C'� M/N �. ., - M!M Fy:/T "� - ' t..•� �.r .�ii. mom.
.�.�'.5::'-/.4G P✓C ! �� �L�vv� L1.VE A -,i� �
/4' 1,47. '
2 i
�� r �j C�® M,r✓ I °l / I• /rc�✓ l4 i`Fr !�,���o Q x - 1000 �,3q
\S� o.,! i ^WASHE1
/ram✓Et'T + !N✓��'T t' /N✓ T {✓. ee� 1 Lcx/. { {` JTbL-
E
_51. 7 CgPac�TY 4 'NJlN i „Gr �� { t ✓35 i Ar2JJnli� .
�.v✓F�T {{ '(WA TE�Ti+�f 1 T) v �: J' .N�/E e7 0�� j J zoo
!/✓✓�.�T LC/q'Gy7i: t
SEPT/C S -7'STr=M CON'
elr✓ -51 /- 7? �307 -rEsr `2
RAYMOND
TG G Z �I!iV'. f//v i
Al, ,. � 1�;>i.�./��n��. ,�sCjS f� �", PE�✓��v 4:' �-`� i?=s-I '.t7G.
S4
D2/tiLvVAy ,v 0 7- 7-0 BE
A ; � Y�; TG T/ T SITE PL AN
s � , �� 17
57-�M 7Z r� �•. 4 �O�f-�Tr �/\,` C[U ''T�U/v MJ`f
rC - t'S�S> C.
»• R? �Q Irc1 AJ GJ cG}j.t15 TL1 P L�
i3r.tc LC�T . E-
;4lRM fir '! -
s/,9,8z BA YS I.D46 s URVEY co e)=:,
--- _ -'- - -. ..- -_"- - --- ----._ _..--_ -_._.__.-. . ,¢ Eft -n E L1 O.t= ..2L-• ..
:FO M �:Y i..Firs:r.J �`. R Y._. �..z- •`1,12,R T/O'V✓