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HomeMy WebLinkAbout0405 AMES WAY - Health 405 Ames WayCenterville Is A= No. 42101/3 ORA ��4iC Yliidoo 8019 &K 1000, ® o 0 c v� ;� O ia FEE d COMMONWEALTH OF MASSACHUSETTS Board of Health, 51--&S4 MA. APPLICATION FOR DISP SAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location �� Owner's Name G, Map/Parcel# ,� U Address Lot# Telepho Installer's Name Designer's Name 42 CANTERBURY LANE Address Address 608/640-2534 Telephone# NK, Telephone# 5VX 'AZ X V9 /5 Type of Building Lot Size � o sq.ft. wellin - of Bedrooms _I YiL Ks- i Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria( ) Other Fixtures Design Flow(min.required) 3'3 D gpd Calculated design flow 'S-s a Design flow provided AA14 gpd Plan: Date — Number of sheets I Revision Date Title ,> Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator_ Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree t not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date In AMC—, s p r ` Nb. /Cl�.�it'J�I - FEE �dlJ t COMMONWEALTH Of MASSY RUSETTS �C1 c 1, Board of Health, —It s ArIL4E MA. a AEELICATION E®H DISC. SAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location At G Vx&J f { Owner's Name Map/Parcel# 0 7 / b 0 r Address 4 b ti`r� / G �, J[l-i Lot# •• r Telephone# S TEPREN J,DOYLE ANDhSSOCI_ ATFS Installer's Name — ' ' Designer's Name 42 CANTERBURY LANE C' o�iS �vtf:"v Address R0 /?j 3 3 �; ��� Address 508/540 2534 Telephone# / _ Telephone# Type of Building � Lot Size 4:5 to-a sq.ft. Dwellil���N of Bedrooms t'r-t'*, .• Garbage grinder O z t Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures I „J)e"sign Flow(min.required) p gpd Calculated design flow Design flow provided AA 4 gpd " �— Plan: Date 1✓l. -,q -�Q Number ..offs sheets s � i Revision Date Title �t-� r U l r ✓1:-A 11^. 'f� /1 4 u« `7 Description of Soil(s) t�+ Vie_ n �' ,s ,l)c9 e- Soil Evaluator Form No. Name of Soil Evaluator S tyv i Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS s The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree/sl-to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed � alAi G Date 1-i>-�i 1Zf Inspections V No. ')GU t--o FEE �Gv } COMMONWEALTIT OF MASSACITUSETTS 3 9 d Board of Health, &/P7 5 A11le MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired (Upgraded ( ),Abandoned ( ) by: - &C, 0 at `.4,Y7eS has been installed in accordance with the p ovi/sions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.�cjo k -D// dated //, /GJ . Approved Design Flow , (gpd) Installer ] 4 //%/�1 0 �/�{� 0- � / /� Designer: Inspector: �IL- t.n A/� if7U`/lff ,�Dat / / The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. G7� 0 -0 I FEE �G U R COMMONWEALTH OF MASSACHUSETTS Board of Health, &,"*' S MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( Vrupgrade( ) Abandon( ) an individual sewage disposal system . at /� _ A r 5 �/1/rr,� as described in the application for Disposal System Construction Permit No.? 00(f"01/ ,dated f rF�f1 Provided: Construction shall be completed within three years of the date of his erniilt. All I Cal conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date f 1 /�f� Board of Health_ �� � L�'%�� ' M ` Town of-BArnstable �F�`E'°�+- Regulatory;Services Qv ti Thomas F. GeHe Direct or snx'Srasi Public Health Division Al fog° Thomas McKean;Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 . Fax: 508-190-6304 Installer &Designer Certif cation Form Date: Permit# c2 00k-/1 Assessor's Map\Parcel Designer: _STE,PREN J.DOYLE AND ASSOCUTES Installer: EAST FALMOUTH,MASSACHUSETTS 02536 Address Address: 508/540-2534 On was issued:a permit to"install a (date) (installer) : septic system at 4 v 5-;' based on a design drawn by (address) `f) L q= dated Ia-ay-�zo�7 (designer) I certify that the septic system referenced above was installed substantially.according to s. the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the'soils were found satisfactory.. " 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.Regulations.'. Plan revision or certified as-built by designer to follow. Stripout if re aired)was inspected and the:soils were found satisfactory. oFP�,#s ®� ''®®��® OF / g4 `HRISTINE ` v 0�� w15TEy�c 3�3 FAIRIV'NY £. o STEPHE (Installer's ignature) No. 926 J. F w DOYLE G/ST�CR ® -37 S01TARIR� l OF o (Designer' ignatu ) (Affix Designer'.s Stamp ere PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. .CERTIFICATE OF COMPLIANCE WILL"NOT BE ISSUED VNTIL BOTH. THIS FORIVI AND AS BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEAL :.DrMION THANK YOU. QAseptic\Designer Certification Form Rev 03-09-06.doc TOWN OF BARNSTABLE LOCATION i-105 w4y SEWAGE#,200-11 VILLAGE C-V:/h ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY.(type) 305'0 (size) NO.OF BEDROOMS 3 OWNER S, �v PERMIT DATE: /��" 0� 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 leaching facility) Feet FURNISHED BY y�0' Sri^t s YY�7 /1 P Li _ 3 Ll 5- 3J; 163 36 39 5-3 � 3:j 3/ r Town of Barnstable P# Department of Regulatory Services i .,,�, , F Public Health Division Date - U Ar >uea. 200 Main Street,Hyannis MA 02601 Date Scheduled/ � ��7I a �► Time Fee Pd. 0 U - U O Soil Suitability Assessment for Sewage Disposal Performed By: �� �,�lya� _- Witnessed By �411 LOCATION GENERAL INFORMATION Location Address p�/ �,Y� v /y Owner's Name Ur--r1 Address cl,o �M(t Wit,► �--f py....� Assessor's Ma /Parcel: P 1L) ��� (�17� Engineer's Name �✓� Z>��L� NEW CONSTRUCTION REPAIR Telephone# Land Use Lr�� —.J�/y_ Slopes(`�) `Z • Surface Stones Distances from: Open Water BodyT $D r ft Possible Wet Area tuft Drinking Water Well LI./A ft Drainage Way ft Property Line ft Other / ft SKETCH:(Street name,dimensions of lot,exact locations of test holes& c tests locate wetlands s n proximity to holes) zzO , 4:c:)i��3 ��--- Parent material(geologic) 1 Depth to Bedrock , ..—Depth to Groundwater. Standing Water in Hole:_��n \�t`�A41a, Weeping from Pit Face Estimated Seasonal High Groundwater g DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: � 's� Depth Observed standing in obs. In, Depth t0 Soll mottles: In, Depth to weeping fro ' o obs.hole: In, Groundwater Adjustment ft. Index Well# Re ' g Date: Index Well level Adj.&ctor— Adj.Groundwater Levil i PERCOLATION TEST bate t -_t; Thus Observation Hole# _ Time at 9" Depth of Pere Time at 6 Start Pre-soak Time @ 'lime(9"-6") End Pre-soak 1 Rate MinJtnch 2 U 14A Site Suitability Assessment,CSitc assedr_7;,�_ Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conseirvation Division at least one(1) week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Sdil Color Soil they Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistencv. ve tZ 3 i� Lori o. A A" �.y DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil they Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. consistency,%Grav h DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. j_ DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders. Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes ; Within 500 year boundary No es Within 100 year flood boundary No Depth of NOtUrBUY occurriniz Pervious MA eria Does at least four feet of naturally occurring pervi us material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what,is the depth of naturally occurring per ious material? _.. ._ Certification I certify that on =3 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,exp tise and experience described in 310 CMR 15.017. .-p Signature Date ►� -6'. g ! • QASBPTlc PBRCFORM.DOC Postal (Pomes6,Mail Only;No Insurance Coverage Provided) F For delivery m a a information , OPostage $ 1.39 �PN�11S Mq o C3 Certified Fee Retum Receipt Fee • 1/na Postmark (Endorsement Required) .ry V, re,2006 O Restricted Delivery Fee f —0 (Endorsement Required) rq ra Total Postage&Fees $ n a se t To f O V Iti - reef,ApGNo.;�OSmes �0. CL or PO Box No. C�ty, ZI ------------------ e �H Y•JCL.e, n/ Da63a P Form 3800,June 2002 Certified Mail Provides: esieney)Zoo?eunr'ooeekwodSd ■ A mailing receipt ■ A unique identifier for your mailpiece ¢ ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Maile or Priority Maiiii, ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. 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Internet access to delivery information is not available on mail addressed to APOs and FPOs. SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. X ❑Agent E Print your name and address on the reverse ❑Addressee so that we can return the card to you. Rec ived y(Print Na�me�n, C. Dat of elivery ■ Attach this card to the back of the mailpiece, I}�y'X1 J or on the front if space permits. h i D. Is delivery address different from it 1? Yes 1. Article Addressed to: If YES,enter delivery address below: ❑ No kUr'�)OIJaAd 1Sf1- 0.> /0, � Wa IService Type "/ � ❑Certified Mail ❑ Express Mail �e/fl��f✓'1/i�� rt DaG� ❑ Registered ❑ Return Receipt for Merchandise /T ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number 7005 1160 0000 0191 13 9 0 (rransfP✓from service label) f= PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATES P SAL, I mrr it s Rz O r�`age eziaF I USPS • Sender: Please print your name, address, and ZIP+4 in this box • I �, err, PUBLIC HEALTH DIVE ION.'.---,--'—m� TOWN OF BA°fST—AI E 200 MAIN STREET r HYANNIS, MASSACUUSEI'FS842�0 � e. A,r Town of Barnstable OF tME Tp� Regulatory Services Th BARNKABLE ; omas F. Geiler, Director MASS. 9q, 16;9. ��� Public Health Division ArED MA'S A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 28, 2006 Mr Donald Silva 405 Ames Way Centerville,MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located 405 Ames Way, Centerville MA,was last inspected on March 17th 2006,by, Mark Polselli, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has "Fails" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: System is in hydraulic failure. System needs to be replaced. You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. 4BSTABLE HEALT DEPARTMENT Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health t ' COMMONWEALTH OF MASSAC HL SETTS EXECUTIVE OFFICE OF ENVIRO'V'MENTaL FAIRS ' DEPARTMENT OF ENVIRONMENTAL PROTECTION 9.S-3 0 VG/�' /70 OO/ 0047( OFFICIAL INSPECTION FOR -r 5 NOT M SUBSURFACE SEWAGE DIOSPOSAL VOLUNTARY ST MFORM��TS PART A L CERTIFICATION Property Address: 40S AeS W� ehOa6 �— Owner's Name: Owner's Address: p CAN ✓Yi/ oZ � -_a Date of Inspection: Name of Inspector: (please print) Company Name: Cyi., Mailing Address: Telephone Number: _ C:' r CERTIFICATION STATEMENTCD t I certify that I have personally P y the sewage disposal system at this address and that theorma n reported below is true, accurate and complete as of the time of the inspection.The inspection was perfarnfed 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 eds Further Evaluation by the Local Approving Authority Fails /7 Inspector's Signature:. Date:-- 4z�& The system inspector shall submit 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. � P �ecoNclf - 69 - Notes and Comments- d 004 6sPo/ X 490 3 _ '51s _ !:�PCI XD0y -5, 61/ Gear aoo� _ soy _ ****This report only describes conditions at the time of inspection and under the conditions of use at thatP� _ 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 Page 2 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTNRY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 2&A e �I Owner: S V Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Svstem Passes: &�I have not found any information which indicates that any of the failure criteria described in 310 C:V IR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distnbution 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 HeaIth): broken pipe(s)are replaced obstruction is removed N-D explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNT_A.RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Imes G 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 public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15303(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 m the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pp ,pro rided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: _ o tV4 eve C��6.3.L Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes i o _ _ ckup 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 logged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or �sspool quid depth in cesspool is less than 6"below invert or available volume is less than'h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number times pumped �ny 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. //Amy 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 pp y 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/Ni o) The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ th ystem 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—I«�PA)or a m?^ped 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,..ith 310 CyfR 15.304.The system owner should contact the appropriate regional office of the Detiartment. T;H. ; r.�„o t;,. .,r., pit ci�nnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTE?N4INSPECTION FORM PART B n CHECKLIST Property Address: �62 v+ ✓'vr � tea`6 Owner: Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes �o Pumping information was provided by the owner,occupant,or Board of Health v 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 Was the facility or dwelling inspected for signs of sewage back up? Was the site ins ected for sighs —/— p of break out. v — 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 �o 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 approxirnation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ` _ T_ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR TS PART C C SYSTEM INFORMATION Property Address: 4-f05 ,-Me5 Owner: e✓v,' �7, /Zl/f 002 6 �� Date of Inspection: ^/ —0..r RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design):� Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): _�-Q Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):"[if yes separate inspection required] Laundry system inspected(yes or no): //v Seasonal use: (yes or no): O 0d,, of SS p o 6 Water meter readings if available a , last 2 ears usage 6 ( Y ge(gPd))� d 003- I �� 00 Sump Pump(Yes or no): IVo Last date of occupancy: �'t,,A/ � ;z 00 Z( _ oZ o6 0o O CONLMERCIAL/INDUSTRIAL 0,0 Type of establishment: Design flow(based on 310 CMR 15203): gpd Basis of desig n flow(seats/persons/sgft,etc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no):— IN waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): Pumping Records GENERAL INFORMATION Source of information: ZI—t/r/I Lk✓ ,_Dom, Was system pumped as part of the inspec Pon7yes or If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYP7'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 i known)and source of information: Were sewage odors detected when arriving at the site(yes or no): T,+io a 6 Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: I r Owner: of Date of Inspection: — /2— Ql BliILDING SEWER(locate on site plan) Depth below grade: -;�g Materials of construction:_cast iron _ �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: Material of construction:_cow ncrete—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) � X Dimensions: (� Sludge depth: oZ Distance from top of sludge to bottom of outlet tee or baffle: oZ 9 Scum thickness: /—PZ / Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bott�oJ of outlet tee or baffle: How were dimensions determined: 9 0�e R-3 --c7C4 c Comments(on pumping recommendations,inlet and outfl5t tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7'a r ee c h C4 GREASE TRAP: N(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 Ievels as related to outlet invert, evidence of leakage,etc.): 4/7 7 ` Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUTNTARY ASSESSNIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: T ^o WG�_ e�4enOwner: ,/(/ L 31 Date of Inspection: J TIGHT or HOLDING TANK:A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(expiain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in workingorder Date of last pumping: (Yes or no): Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: f i" ( present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 1/767/'/✓1 6 [' Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover; any evidence of leakage into or box, etc.): PUMP CHAMBER: &o ate 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 andappurtenances, etc.): T;+Ic : incnnr.+inn 4/1 C/7nnn 8 _ Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS:VZENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORT PART C �[ SYSTEMM INFORMATION(continued) Property address: ( � zgMej- 4C✓v p �¢ �— Doti 6 3� Owner: Date of Inspection: -/7 -0 L SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: �e C X leaching pits,number: t/ �r -�� S T 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.): / - / v�c� h o c,� vl v - �r �e Spa o? ✓1 rre /f/O o 12 0,- �c4 t Gi � G�O'IL�� CESSPOOLS: 4 (cesspool must be pumped as part of inspection)(loeate 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,IeveI ofponding,condition of vegetation, etc.): PRIVY: (locate on site elan) Materials Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.): i OFFICIAL INSPECTION FORM—NOT FOR VOLLTI T- RY ASSESSN EN-TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: i SKETCH OF SEWAGE DISPOSAL SYSTEM ll� Provide a sketch of the sewage disposal system"' ystem including des to at least two perman nc ent referee tan ��rs Or benchmarks. Locate all wells within 100 feet Locaterwhere public water supply enrfrs:he bui ir;nz. I O s c 6 ��- 3 9.j / 5 � "lnnnn 10 F. Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) Property Address: �S k4l s°( C—.-a ,� ✓vi' � � OoI��� Owner: -51 l(l o) Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells i D /f Estimated depth to ground water a 2feet Co 4�r Z0• / 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: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: r0 You must c cri e how you established the hLah ground:water elevation: vas ti S e o, ctn l f 0 t 2 0 0 �(. O O 0 l H '�oow► Pi� �"L= 32 �J 2�Gra 4 f 9 �'► - // / (- / r;+io G Tnencnt;nn Rnrm ui si�nnn 11 � v V Date: ���/�� TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: e/aT/ !!we- BUSINESS LOCATION: r MAILING ADDRESS: JOA Mail To: TELEPHONE NUMBER: -Ar - Board of Health Town of Barnstable CONTACT PERSON: �� G �. P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER- 5G �T/ lj9 Hyannis, MA 02601 TYPEOFBUSINESS: &&Zz &?z /d'l /!�6-!l� Does your firm stoke any of the toxic or hazardous materials listed below, either for sale or for you own use? YES ��/ NO ti This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site otherthan your mailing address: ADDRESS: ��oSi t(�S ✓!/ 'arleeZ11 ;z 4 r- eyi r?a-- TELEPHONE:(SG�/ "-/&Z!�- 4*1 LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics.and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar 49d�Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids 4zQ�1� (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Date: .2 1,41-4 ` TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINE-SS:''� � /l/T/ BUSINESS LOCATION: MAILING ADDRESS: ,F,0 Mail To: TELEPHONE NUMBER: Board of Health Town of Barnstable CONTACT.PERSON, -,, iAII�L , ��z'/ P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER• �Gd' %vG 6 1 Hyannis, MA 02601 TYPE OF BUSINESS: /� ✓y lwll"410Ci z Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site otherthan your mailing address: ADDRESS: l� ��� y/�! /lr��®l�i��y. ill"• t>Jd �-- ' TELEPHONE:,/SG4/ LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that i you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine,.and,radator.flushes__.,: __ .Road_Salt_(Halite)__ _ Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink. Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine, '--,,,,Rustproof ers Lye or caustic soda Car wash detergents Jewelry cleaners Car- and polishes Leather dyes Asphalt & roofing tar S Fertilizers Paints, varnishes, stains, dyes _ 1 PCB's Lacquer thinners Other chlorinated'hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint &varnish removers, deglossers Any other products with "poison" labels - Paint brush cleaners.. (including chloroform, formaldehyde, Floor& furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers. Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) .. Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS t-z r 14 o.._ .N .. Fz�s... .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Ali-lVoottl Works Tonotrurtion lirrutit Application is hereby made for a Permit to Construct (" ) or Repair ( ) an Individual Sewage Disposal System at AAA .......... l M .... -. ........... 11 k ................................................ Locati n-i\d css/ A ' , or Lot No. ...................... ......-� !..................• --•-•••----------------••••-••--•--•••.....-••-------...•--------•--........_...._..............._ O er Address ...............................................© , �.��_��•--•-•-•---•-•-------------• /Y/_�!?1.......... Installer Address �� ` UType of Building Size Lot------___--,________3..Sq. feet Dwelling— No. of Bedrooms________________-3-----------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures --------------------------- ----------------------------------------------------------- ---------•-----•••---•--•-----......---•---•-•--............. IT, Design Flow..........................._.......___.gallons per person per day. Total daily flow.......................... .��3.....gallons. WSeptic Tank—Liquid capacitv_�Qt?a_gallons Length---------------- Width---------------- Diameter---------------- Depth................ x Disposal Trench—No- -------------------- Width-------------------- Total Length............__. Total leaching area....................sq. ft. Seepage Pit No.............. ----- iameter--------��...... Depth below inlet.........�Ct_.___. Total leaching area.... D&.sq. ft. Z Other Distribution box ( Dosing tank ( ) ILL '~ Percolation Test Results Performed by.......... Al �._._."{-_�. ________________________ Date____._.__.. ...�'-...� ......_.. Test Pit No. I...... minutes per inch Depth of Test Pit------- Depth to ground water.....-- G14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ --------•------------------------------ •--•------•--- . 0 Description of Soil.......................... ......•• .4!✓1..7� ----ow ,................................ x W •-• --•------------------------------------•.........------. -------------------------------------------------------------- -----------------------------------------A , ------------ txj Nature of Repairs or Alterations—Answer when applicable............._..._..__.___.___.__._.....__._________..._........5.?- ---------__. ----••-••-••-•••-•-••-••---••------------------•-•-•--•••-•-•----••-•••••-•--------•-•-•-•----•--------•-•-----•-_...----------••........----•-------------------......------------•....--•---...----•. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issu d V the board of healt Sign :... .-. ._......:....- ........................................ Application Approved By .......tfollowningreasis: ! _. ... .. ........ ............ .... ................................... ................Ihce.................. Application Disapproved for t . ......................... ....... . ....... A ----- ............................................ ................................................ - ---- --- ... ............ ....................................... 151 Permit No. r -_ r .... ------ Date Issued .... n o PCL-� � 1.00 No.....- - FE$...... .. .... I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE , AVV iration for Uiipnial Mork,6 Tonotrurtion ramit Application is hereby made for a Permit to Construct (" ) or Repair ( ) an Individual Sewage Disposal System at: �+ ' ........................ Location- \dtlmess� j , or Lot No. .................•---._.......-------.......... . 4. .. W �— 0 nv AAddress ,-I J - -- Installer Address 2'3� � � Type of Building Size Lot.....4....{__.._ ._Sq. feet Dwelling—No. of Bedrooms.__•.---__-------3-----------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a � l Other fixtures,•------------------------------------------------------------------•------------------- --------------------------------- -------------........--•- WDesign Flow.................... ....................gallons per person per day. Total daily flow.........................3_ ,.0...__gallons. W Septic Tank—Liquid capacity.`.000galIons Length---------------- Width................ Diameter................ Depth---------------- x Disposal Trench—No_ ____________________ Width.................... Total Length-----------_ ....... Total leaching area....................sq. ft. Seepage Pit No_____________t...... Diameter........�_Q_---- Depth below inlet......... *.?...... Total leaching area.._.�� .sq. ft. , Z Other Distribution box (�_< Dosing tank ( ) ~' Percolation Test Results Performed by....... ........1........... Date...........-3-."3-24� I Test Pit No. I......- _minutes per inch Depth of Test Pit--------1_7—... Depth to ground water-------- "—'"'*.--.-. Gi, Test Pit No. 2................minutes per inch Depth of Test Pit__.____-_---_---•_-_ Depth to ground water_.---._-_-_--___-. ---- --------------------------------------- --------- -•r -•----•---••-•-•----------.--------------------------------- ..-.------------------.- D Description of Soil........................... Z /I wi '� 5-(/fSl .......................... � tn �5 -1 M ..................... ----------------------------------------------------------------------------------------------------------------------------------------------- A! --- U Nature of Repairs or Alterations—Answer when applicable.............................___._-.----..._-_______--_-------_ 3............ .. .............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of healt . Signed ----------A--------//^1 ------- y~.................. 9 S7. -- I^.:............... .-................ ..Dace Application Approved B � -� -G!..� ,�fi�" '../C1 _: PP PP y --�-.: ------------------------ -- - ........ Y Dace Application Disapproved for the following rear ns- ---------------------------------------------------------------------- ----------- -----------......---------------------------- ..._..........._............................. .__....^l..i...........-.._ :...._..._;....._............__..........__.........-.............--------------------------------�............ I-�: .......Date.................. / '`-. ► /�Permit No. `1: ---------------- --- Issued --- ! - - ...................... D�e / ------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARl.�NSTABLE Tern crate of CII>lY plianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) Repaired ( ) by -------------------------------------------------------------------------------- ------------------------ -------------------------------------- ----------------- ------------------------------------------------------ Installer at _--------------------------1or----Z--------- yl'1 5- / .`-. ---------------..._--------------------............------------------------------------------------------------------------------- has been installed in accordance with the provisrfons of TITI. of—The State Environmental Code as described in the application for Disposal Works Construction Permit No. ---- ----!77�0_._. dated _......_.---------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------------ --------l----------- ............ �..------ ---------------- ---- ------ Inspector -----------1 - -------------------------------------------------------- ---------------------------------------------------- -------------------- THE COMMONWEALTH OF MASSACHUSETTS �i „ ,`0 BOARD OF HEALTH TOWN OF BARNSTABLE /1'_ ' No. - FEE............ t �i��.o�ttl ork� �unotr�trtion �rrmit Permissionis ereby granted--------------------------------------------------------------------------------------- ...................................................... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo.......................... A= 165---------au -- = ,' ---------------------------------------------- Street as shown on the application for Disposal Works Construction Permit Noq_�--- Dated........................................... _ ............................ --r-!'--oard-----_.._.-_-.------------------------------••--------- '��y •--- � Board of Health DATE _�............—.1 6,���//f FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS - 6,N -PATH- SINGcZ FAMILY 3 13&vgcomir ewe E i4o 6•AZ5AG G1zIIJ�ER, / :..'DA►L�( Floe/ 3><f 10=330 � " • lei G to oo 6Ac� i Ott AM _ o�°fir BP.�^t;wd:y kgk .21 PFVAI - PIT i-lopo 6AL S-mijm , — — — 51DEW4LL Aw" = iot3sF' i. z2o — a 3i i ' 8r'TTOM � . 18 SF,-114 . TuML t*516 W = 5443 Gib. � ✓ �._ . o. , . `TorAL- VA►Ly-ter/ _sr3ol�b %- �� +�.., � 1 � - ag�3 1:;,E¢6oC.AT7oN ¢ATE ' �0,orr � � o�tl4yaSR of, �� N �� ✓ _ ± , pOw,noA. _. . tra2ioae M SULLIVAN No. 29733 �7 , �Al so . 4L OLE- F6 1410(3 kT.F.=ZT,0.5, T�5 T 3/3kts ` P ,Nr ¢• 1 . ° 000 DKT ,AV GAL io.✓ sG.6 i ' LAIS r&A zBorc �,� 46.6 S�rlcas T�NL IVA w�SDrv�t* WMF�EA_ ►`!�I�;. :A�l..;i5mi—�ru.QES. SM sTogE Mv¢B:Tua� q!vrEp Q4A L''BE 14-Zo ' f Srn�£ Z�-- 6' :--•)z ag ! MAP I-7 o.PC IL- - } I --1 t �1. 3S 90 scQL.� � LoG��oN :,� GC-tJ�t�►IiL.LG-- IIII T� ,-t97 i 5 li CEzTIfij �kr T4G-'bw;a c-�� PLAN ROJc�a� ���S�aw) SFlow w MF S w1 P�Q I� TDWt� o ¢.NSTA&.r✓ ' A 15 }. —l-oCA w Tu1 T41� Coate t-r , PL B . d-23 Pam. '1S DAXYEl/ NYt: PEORZ-`fi1W4L -LAU-D :TFUS. Ft:.A� I � S Nc'r' +3A�p oN AtJ t1J4'TL'otitEl)'T" .� , 5ueVrr/o;z5 Sutzv�-^/ ANv -rN� o s s 4 4oULD u cr BE uSL�� TD ESTA•e-.I q �PEZT`/ �laweS STErzi ut ,ua ; APPLIc.ANT-; - C.AN TOWN OF BARNSTABLE LOCATION 4-t /2 SEWAGE # 9S-ro 0 VILLAGE (�''� vs ��� ASSESSOR'S MAP & LOT��(kS(-Qp INSTALLER'S NAME&PHONE NO. �O�"'L /� �4 s 2$_g s q r SEPTIC TANK CAPACITY /SD o 'LEACHING FACILITY: (type) DOO (size) C� x /o NO.OI~BEDROOMS BUILDER OR OWNER pcH Iv a PERMTTDATE:_ 9' S"— .g 7 COMPLIANCE DATE: Separation Distance Between the: Maximum.Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site.or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility) Feet Furnished,by . 00Ss9 <ftia s -• hsy. h s �416j- nf ar G 49 11 TOWN OF BARNSTABLE i7CATION �of / �� [�S u/a SEWAGE # "VILLAGE �^% 11� �� /l f ASSESSOR'S MAP & LOT�G INSTALLER'S NAME&PHONE NO. �o`"'` 9 A 1-; y 1� SEPTIC TANK CAPACITY SD LEACHING FACILITY: (type) /®Oy Z Of (size) X / NO.OF BEDROOMS _ BUILDER OR OWNER toy 5, IL,a PERMIT DATE: 9 S, g 7 COMPLIANCE DATE: Z a—-2 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet . Furnished by ` GoYJ P , 0 P TOWN OF BARNSTABLE 'OGATION '2 �"'Q3 W y SEWAGE # 9r VILLAGE CAIh�1a-% �� ASSESSOR'S MAP& LOTS ,GO 1-oa INSTALLER'S NAME&PHONE NO. 304n 04 SEPTIC TANK CAPACITY /S LEACHING FACILITY: (type) L r (size) /x /0' NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: 9"'s" 9 7 J COMPLIANCE DATE: n22n Y a 7 7 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) Feet Furnished by f93 o3 /� Sy'y•• APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS LOCATION NO. VILLAGE �'GN'Tb�7'LOi APPLICANT (:AA:� vwa a.� FEE zf-e ADDRESS (Non-ref ttndabl E � TELEPHONE NO. ENGINEER TELEPHONE NO. � � DATE, SCHEDULED �.�`^! 1�0 . . . . . . !.:. . . . . . . (Applicant� •ssignature. e . . . . ASSBSSOR'S b .iAP S; OT NO: SOIL LOG SUB-DIVISION NAME DATE TIME EXPANSION AREA: YES ' NO .� ,� y ENGINEER''N' TOWN WATER �/ PRIVATE WELL g2 -" - BOARD OF HEAL? EXCAVATOR SKETCH: (Street name, etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: Amw, WXY iDF • � 4-3,1v33� rM .. PERCOLATION RATE: � I t� GiVt j,I .0�. TEST-HOLE NO: - A_ " 'ELEVATION:_ TEST HOLE NO:1 ELEVATION: 1 2 3 3 4 � �lz 4 5 - 5 6 6 S�JO 7 8 8 9 � 9 10 10 11 11 12 12 13 13 14 14 15 15 16 `. SUITABLE FOR SUB-SURFACE SEWAGE: - LEACHINGIFIELD AC PITS LEACHING TREN:CHE§_L�5G UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE,: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED .ON PERC TEST APPLICATION ORIGINAL': COMPLETED IN ENTIRETY p COPY: RETAINED BY APPLICANT RNED O BOARD OF HEALTH t 8— — EXISTING CONTOUR 50.3' EXIST. SPOT ELEV. `'�--APPROX. WATER SERV. !G LUPOND T �� 40 EXISTING UTILITY POLE �Fp ACES wAY —?` EXISTI o LOCUS _ S7 G 35 T p,G46 ,,, Y Y LOT 12 ! �' 44 / w �, ROUTE 28 43,632 ±SF i 220 00 / ^� CB VL 45 FND. d 4.8 I ASSESSORS DATA- MAP 170 PARCEL 001—004 N / / fJ LOCUS ADDRESS.- PAVED '0 ,V405 AMES WAY, CENTERVILLE � DRi VE 130' / DEED REFERENCE- 10743-25 EXISTING � ZONING DISTRICT RC OwEtL11V P!_A NONE OVERLAY DISTRICTWP & RPOD #40,5 P ARK I N G BUILDING SETBACKS.' FRONT — 30' 50.4' �L SIDE & REAR - 15' 118' C r I FEMA DATA: ZONE »C,» co / PANEL 250001 0015 C ' 71 o VENT �tH OF MAP REV AUG. 19, 1985 EXISTING qp' �q lrJ / I 1500 GAL. �R, . 0 y, '—b SEPTIC TANK ' c c ��� g� CHRiSTINe �yG TO REMAIN \Dg ,' ti3 �'' No 6Y y SHEET 1 OF 2 _ 1STE� SE"P TIC R-'PAIR PL,A \-100% SAS RESFicVE_� y AREA % ABANDON EXISTING' r S01TAR� Prepared For.- DIST. BOX AND L.P. �� 5c:-,S�l �` PROPOSED INFILTRATOR SAS 3p a PER TITLE V �� 4 0 5 .A1a%�-El WA Y X — � 79 , ®®a►a�a� 46.07 70 '�`V ,.� ®�P�tN Or r�tissq��® In O%8 S 11 1z, SEP : Centerville, Massa ch use t issusi ,50,JE 4 J. 37 #DoYLE 37559 N jib. Scale: I" = 40' Date: December 29, 2007 r4.5 � e A ,r � � 06 CB o ° sss\o Q) w Prepared By FND. °o e4 S U���y��° Stephen J. Doyle and Associates BM: TOP CB GRAPHIC SCALE S C LE ® 42 Canterbury Lane, E. Falmouth, MA 02536 ELEV. 50.44' 12 -30 --o�i Telephone: 5081540-2534 DATUM: GIS± ao U 20 ao so 160 -Z ( IN FEET. ) °� 1 inch 40 ft. NO. DATE DESCRIPTION 8Y i TOP FOUNDATION EL. 51.0' aS°e -tea e ,S°ys t e m Z�r®fl Z e Vs e -� IV. 77 ,S°. 4„ PVC 1/8" TO 1/2" WASHED STONE CHARCOAL � AT 3' THICK VENT z I 1i}'nish Grade El. 50 f FYnish Grade El. 50 f 6„ 8„ llllllll 1 I 11 11 6„ ll l llll llll ll 11/ 11 1111 /717, Fin. Grade El. 50 f 3/4" TO 1 1/2" WASHED EL 0 Dia. 0 Ilia. -- OBSERVATION 46.8E STONE AT SIDES AND ENDS PORT iX a WW ® (TWO-SEE PLAN VIEW) BREAKOUT L. 45.72' Of i INV Eva "Id 10"Alin. 14" AlinINV EL —� /-- INV 45.2246.45' Below Floer Line 46.2' sump INV EL �iQuid teye� 4a" INV EL 45.40' d:d d. d. d: -- '45.60' d d- .I 15"-aa� -- / -- --- — 15" EL. 43.22' 4 HOLE DISTRIBUTION BOX �37.5' 1/8" TO 1/2" WASHED STONE 40' AT 3" THICK FIVE INFILTRATORS 1500 GALLON REINFORCED CONCRETE SEPTIC TANK TO REMAIN ' Fin. Grade El. 50.t 35" STONE AT SIDES AND 15" AT ENDS Tees shall be constructed of Schedule 40 PVC and shall extend a " Design Data: 3 4" TO 1 1 2 WASHED - - minlmum of 6 above the flow line of the septic tank and be on OBSERVATION / / Three Bedrooms - 3 X 110 gpd - 330 gpd Required the centerline of the septic tank located directly under the - PORT VIEW STONE AT SIDES AND ENDS Allowed P TWO SEE PLAN ) No Garbage Disposal ( clean-out manhole. INV. EL. 45.22 45.72 g The inlet pipe elevation shall be no less than 2" nor more than a."?''`'''`"'. ` `'` "". Use: Chamber Trench 401 x Ill x 2' Eff/Depth above the invert elevation of the outlet pipe. a as a'° HIGH DL'NSITY °a a aAd,�f [40' + 40' + 10' + 101 x 2.0 = 200 SF Septic tank shall have a minimum cover of 9 . d a a° POLY INFILTRATOR d • .d 30" 40 x 10' = 400 SF d .d a 24" ad ' MODEL 3050 • '° •a• Add gas baffle on outlet tee as required. Err. Depth d d :'d•ad 600 x 0. 74 = 444 GPD Total Design Flow LEA CAMBER Add risers as require 1 a ° d CHING d ° 1 1 s" d. (114 GPD Rese ve Flow) 7 a a �0 •d'd° El. 43.22' 10.0' GENERAL CONSTRUCTION NOTES PROPOSED HIGH DENSITY 1. All the workmanship and materials shall conform to R E.P Title 5 INFILTRATOR TRENCH and the Town of Barnstable rules and regulations for the subsurface disposal of sewage. (10 VIDE X 40, LONG) kd 2. At least one access port over tank tees shall be accessible FIVE INFILTRATORS - 7.5' LONG within 6" of finish grade, with any remaining access ports brought 35" STONE AT SIDES AND 15" AT ENDS SHEET 2 of 2 to within 6" of finish grade. Bottom of Deep Observation Hole El. 38.2' 3All components of the sanitary system shall be capable of �S-EPT.IC' R- RAIR RLAIV withstanding H-10 loading unless they are under or within 10 ft (NO GROUND WATER OR REDOXIMORPHIC FEATURES FOUND) Prepared For- of drives or parking. H-20 loading shall be used under or within 10 ft of drives or parking unless noted Plastic equals may be used SOIL TEST DATE: 12/27/07 P#12056 4 ®5 AA11_E`,S TEA Y- in lieu of all precast units. All crushed stone shall be double washed SOIL EVALUATOR: S. DOYLE HEALTH AGENT: D. MIORANDI 4. The exca va for/contractor shall call dig safe and verify the location TP #1 TP #2 In of all site utilities prior to any excavation, and shall be responsible for <2 MIN/INCH EL. �50.2' <2 MIN/INCH EL. �50.2' Centerville, Massachusetts all matters relating to electric easements SL O A SL O 5. Sewer pipes shall be 4" Schedule 40 PVC laid at a min. 0.02 slope. A 10YR 3/2 6„ 1OYR 3/2 6" Scale: As Shown Date: December 29, 2007 6. Any masonry units used to bring covers to grade shall be LS B LS mortared in place. B 1OYR 4/6 1OYR 4/6 Prepared Bp 7. Finish grade shall have a minimum slope of 0.02 ft per foot. EL. 47.37' 34" EL. 47.37' 34" Stephen J. Doyle and Associates 8. Abandon existing system Title V. 42 Canterbury Lane, E. Falmouth, MA 02536 g m per C MED. TO C MED. TO Telephone- 5081540-2534 9 The excavator/contractor shall be responsible to check all grades FINE FINE vi i o z-� �.Z o c and elevations and to contact Doyle Associates of any discepancies, SAND PERC 60 SAND prior to construction. � EL. 38.2' 2.5Y 6/4 EL. 38.2' 2.5Y 6/4 144" 10. The exca va for/con tractor shall be responsible to contact 144 Doyle Associates 24 hours prior to any required inspections NO WATER OR NO WATER OR NO. DATE DESCRIPTION BY z REDOXIMORPHIC FEATURES REDOXIMORPHIC FEATURES