HomeMy WebLinkAbout0398 ANNABLE POINT ROAD - Health 398 Annable Point Rd.
Centerville
A = 192 056
No. 42101/3 ORA
(a)na�� (;:O�cco;-] GE
�z
�o®a TINE E (�0�1-z
1000 +Q
0 0 0 0
No: V \'` lD� J Fee
THE COMMONWEALTH OF MASSACHUSETTS- Entered in computer: "-Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for Miopoml 6p$tem Conotruction permit
Application for a Permit to Construct( )Repair( )Upgrade^(,)Abandon( ) Complete System El individual Components
Location Address or Lot No. ✓ Owner's Name,Address and Tel.No.
UAK
Assessor's Map/Parcel
tea_b
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other 'I"ype of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 65-b gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank
Description of Soil 41 Y i Y )
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 Board of Health.
Signed 1 49 IW2 Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. b\ - Date Issued
. - ,� , .• . . 7t ....a,<.,4e......,r;w„_.�«-rs�` .•rw,a.ra.... r .... _ _.
Fee
Nor
;.
- / THE COMMONWEALTH OF KtAssACHUSETTS Entered in computer:
Y -.�. Yes
PUBLIC-HEALTH•DIVISION -TOWN OF BARNSTABLE., MASSACHUSETT`S
ZIpprication for Miquar *pgtem Construction Permit
_Application for a Permit to Construct( . )Repair( )Upgrade OO Abandon( ) Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel � -'VA
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building 'aS . 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. �Ll `_�4 1
Description of Soil; ��f X 1 3/
r
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 Board of Health.
Signed W2 tr Date
Application Approved by Date C)
Application Disapproved for the following reasons'
Permit No. n Date Issued �l
——————————— ---- '=-------------- --------- -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
3
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded()
Abandoned( )by
at e n j9\ POl►.5X_ �� C -� t V i has been constructed in_ac ordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. �D X OU dated tU
Installer Designer
The issuance 4 this permit shall not be construed as a guarantee that the syste ill f, nction as designed.
Date ) 7 Inspector
- No. ���` ' �}� -------------------------
� Fee `�✓v
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,. MASSACHUSETTS
Miopogai &p.5tem Construction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade(�)Abandon( )
System located at �?�� p v- r-\
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.
r
Provided: Construction must be completed within three years of the date of this permit.
Date: ' I )o I U Approved by
GLOB �" (,Loser
0VLTA l�
�a
� 4
'{jAtlA
Ll
�E�S AIL != :: �_
TOWN OF BARN STABLE cc
LGCATI'0N '3 19 .4 A1,VAffJf 0010 P,0 SEWAGE # ;Z a 0/m
VILLAGE C eA,,,1'eoP, IIdLL P ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. P. 44.4 C D.A1 e X t So A,
SEPTIC TANK CAPACITY A S-0 D
LEACHING FACILITY: (typef /.,J f'� L!1 e 1 PJV. (size) 'Yg 'f 13 '
NO. OF BEDROOMS S*
BUILDER OR OWNER MA �,
PERMITDATE: 1110161 COMPLIANCE DATE: 1 0'2-
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
��
�i �
i �
/j �
� /.
�`
� �6i
i � �� 63
® � , �
i� ` fit:
` � b� � �
. � / � a
� \. � � c �
�/
�A0
� � � �
C�3 �`�
` _ CUL1 \\ d
-i� � s
�_
Lo 7-e .3
6
a.
ate,
2d ,
ry Q
I
PLOT PLAN OF LAND �4
TO THE BEST OF MY KNOWLEDGE, THE FOUNDA TION L OCA TED IN
SHOWN ON THIS PLAN IS AS IT ACTUALL Y EXISTS AND BA FINS TABLE - MASS.
THA T IT CONFORMS TO THE TOWN OF BARNSTABLE Z OF
REGULA TIONS REGARDING YARD CKS `�. DA VID PREPARED FOR
DA TE: JUL Y 11, 1986 Q CFlt,RtES `r,�'i
sANICKI �,: MCSNANE CONS TRUC TI0�1/ Co.
a. 28085 0 K
`' Q^= _ _ —r ,L _ , R.L,S, y �"� R4 rC-�x� DA TE.'aIUL Y 11 1986 SCALE.• 1 90 FT.
FLOOD ZONE C LIP, CAPE 6 ISLANDS SURVEYING
^''" R TEA TICKET — MASS.
bk[?v�OdM Ft`MIL Y ROOM j i Ki C14ENTO--
I
_—
4t tw �..I !' 1 I L..�J —_. � �_G11P7 916J
1iCa� 1/
c,tast:t i z.
_ cicx.
L �
•
1
BROOM 'v;
bEr1p5ca.�i � Fc fah i tr 4
7ltV}rac
--
�n
Eo V5T P-LoOk VLAr)
Tearures:
• Anderson vinyl clad windows. • Oak Floors throughout.
• Beamed cathedral ceiling • Ph"Ister walls & ceiling. L-�
• CLIstom crafted kitchen. • Open Hearth Fireplace.
CONSTR UCTTO
TOWN OF BARNSTABLE eC
LOCATION A il/.A1, &",F P01,07 X P SEWAGE # s2 O®/'
VILLAGE G eA,1'e9'i®d-/Z e ASSESSOR'S MAP & LOT 1 -n
INSTALLER'S NAME&.PHONE NO. _Zre MA e/Zt 50A'
SEPTIC TANK CAPACITY A S'00
LEACHING FACILITY: (typef (size) �► / '
NO.OF BEDROOMS
BUILDER OR OWNER MA H
PERMITDATE: lI d 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
Q '®
` �V
t / �
�'..� r
♦ A
C
n�F �
2
COMMONWEALTH OF MASACHUSETTS "
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Commissioner
Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
�. PART A
CERTIFICATION
Property Address: 398 ANNABEL POINT CENTERVILLE, MA 02632 M192 P056 L2
Name of Owner JOAN BUSSIERE
Address of Owner: 398 ANNABEL POINT CENTERVILLE,MA 02632
Date of Inspection: 6116/00
Name of Inspector: JOHN GRACI
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
Telephone Numbeir: 608-664-6813 FAX 608-664-7270
C�RTIFIGATION 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:
i
X Passes
_ Co4tionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date:5/16100
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 the system is a shared system or has a design now 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 ownerand 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.My
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its components useful life"
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM NOW AND EVERY ONE TO TWO YEARS TO PROLONG THE
SYSTEMS USEFULL LIFE.
revised 912/98 Page 1 of 11
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 398 ANNABEL POINT CENTERVILLE, MA 02632 M192 P056 L2
Name of Owner JOAN BUSSIERE
Date of Inspection: 6/16/00
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 of 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.
nta 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.
nla Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)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
n/a 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
nn revised 9/2/98 Page 2 of 11
I�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 398 ANNABEL POINT CENTERVILLE, MA 02632 M192 P056 L2
Name of Owner JOAN BUSSIERE
Date of Inspection: 6/16100
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 ENVIRONMENT:
_ 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.
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 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 nfa(approximation not valid).
3) OTHER
n/a
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
t
Property Address: 398 ANNABEL POINT CENTERVILLE, MA 02632 M192 P056 L2
Name of Owner JOAN BUSSIERE
Date of Inspection: 6/16/00
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
_ 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 Il.
_ 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.
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 Systern)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)
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.
revised 9/2198 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 398 ANNABEL POINT CENTERVILLE, MA 02632 M192 P056 L2
Name of Owner: JOAN BUSSIERE
Date of Inspection: 6/16/00
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.
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.
revised 9/2/98 Page 5 of 11
E
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 398 ANNABEL POINT CENTERVILLE, MA 02632 M192 P056 L2
Name of Owner JOAN BUSSIERE
Date of Inspection: 6/16/00
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):
Total DESIGN flow: 330 gpd
Number of current residents:2
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
COM MERCIAL/iNDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow:n/a
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 nla gallons
Reason for pumping:n/a
TYPE OF SYSTEM
X 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)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
THE SYSTEM IS 14 YEARS OLD.
Sewage odors detected when arriving at the site:(yes or no): NO
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 398 ANNABEL POINT CENTERVILLE, MA 02632 M192 P056 L2
Name of Owner JOAN BUSSIERE
Date of Inspection: 6/16/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 30"
Material of construction: _ cast iron X 40 Pvc _ other(explain)
Distance from private water supply well or suction line: n/a
Diameter: 4"
Comments: (condition of joints,venting,evidence of leakage,etc.)
THE SYSTEM HAS TOWN WATER.
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 24"
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
Dimensions: 1000G L 8'6"H 6'7"W 4'10""
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: 31"
Scum thickness: 4"
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 NOW EVERY ONE TO TWO YEARS TO
PROLONG THE SYSTEM'S USEFULL LIFE.
GREASE TRAP: _
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions:n/a
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
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
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 398 ANNABEL POINT CENTERVILLE, MA 02632 M192 P056 L2
Name of Owner JOAN BUSSIERE
Date of Inspection: 5/15/00
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 gallonstday
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:_
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
n/a
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
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 398 ANNABEL POINT CENTERVILLE, MA 02632 M192 P056 L2
Name of Owner JOAN BUSSIERE
Date of Inspection: 5/16/00
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: (n/a)n/a
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 PIT APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO.SIGNS OF FAILURE.THE PIT HAD 1'OF WATER IN IT AT
THE TIME OF INSPECTION.THE PIT HAS NOT BEEN MORE THAN 3/4 FULL.
CESSPOOLS: _
(locate on site plan)
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
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: Na
Depth of solids: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
revised 9/2198 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 398 ANNABEL POINT CENTERVILLE, MA 02632 M192 P056 L2
Name of Owner JOAN BUSSIERE
Date of Inspection: 6116/00
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)
Q�CIL
QoA
g
�N
u
�c AC 4�
+� apI
� u6
revised 9/2198 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 398 ANNABEL POINT CENTERVILLE, MA 02632 M192 P056 L2
Name of Owner JOAN BUSSIERE
Date of Inspection: 5/16/00
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+
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.)
Determined from local conditions
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)
UGSS MAPS AND CHARTS-12+FEET
revised 9/2/98 Page 11 of 11
fi
MI
fs-
i �'.•'�� ! � � I Y IP�Yn�! r 1 16..�-1\. �'�•r `'ti F'�f / ( `r'�". .•� I...,,...
r
t
. FEE_/
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
o.w. .............oF..... ..9r..n. s. -�_. _ .._..........._......_.
Appliratiou for Bispvii al Works Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage D's osal
System at: S
� Loca Address,,t 1 ..........
-•.......................................
or Lot No.
Owner Address
�Wl ................................ / ----- �(A 14,A
� RAS ------••--v--------••---•-----------_______------________
� Installer Address
Type of Building Size Lot__Z4P7U__Sq. feet
aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
p•, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
0.' Other fixtures -----------------------------------------------•-
W Design Flow_______________________ 45. - .......gallons per person_per day. Total
daily flow-------- gallons.._
04 Septic Tank—Liquid ca acit/--°------egallons Length, Width,_0'.i�a_cDiameter---------------- De th__ _7_
Disposal Trench—No_ ____________________ Width.................... Total Length-------___..__._`Total leaching area--------------------sq. ft.
Seepage Pit No.---------f/....... Diameter/�_i._0_ _ Depth below inlet.... Total leaching area____2�_*._sq. ft.
Z Other Distribution box A) Dosing tank )
'-' Percolation Test Results Performed b &,pX2tt':� ......... Date---
Date__d
Test Pit No. 1__..__�..._.minutes per inch Depth of Test Pit...:�Ox----- Depth to ground water____
IX4 Test Pit No._2................minutes er inch Depth of Test Pit____________________ Depth to ground water_-___-_________________-
�16�,b Qf . ._..
Description of Soil-•-_-c� �` ----........�1 z!_�1 y"'------- �•G1 - -- h9 v ---------
x d ...........
V
W1. ....
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 iIT :c�, y g g p y
5 of the State Sanitary Code—The undersigned further agrees not to lace the system in
ope ation ut2,tp a Cert' of Compliance has been ' d the and of hea
Signed . ._.. ..... Af. - --•=--------- ................................
7 - - ••-- ---•--------
Application pproved By.. ..........
D e �� ]
- - ate----------
Application Disapproved for the following reaso ___............................................................._................................................
---------•-----------•-••-----•------•...............•-•------------•---•--•--•••._...-------•-------••--•-----•----•-••-----------------•-•-----••-•-••-•--••------•--------••------------••------_.._.
Date
PermitNo......................................................... Issued_.........................................................
Date
r ..
No------------------------, Fps............._...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/....e---- ."..............OF....... .G%, e?..5... - � _/.t'........
Allptiration for Diopaa al Works Tonstrurtion amit
Application is hereby made for a Permit to Construct (N or Repair ( ) an Individual Sewage Disposal
System'?at: L // /
G f 7 <7 �t '� t� / / G i '1 1.� 4—L Il
n l cj
...........^.___.............. ...' .. ...................................... ............................................ .......V ......'��.-_'-----........_.
f 1 Locat}°R'-Address / or Lot No.
.._........ ----- =
Owner Address
W
Installer Address
Type of Building Size Lot--- �,c` _U..Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
`44 4 Other—T e of Building No. of persons............................ Showers — Cafeteria
a' Other fixtures ........................... .
W Design Flow........................ _ ........gallons per person per day. Total daily flow______........._._3.3----0........gallons.
WSeptic Tank—Liquid capacity✓.0"?gallons Length.f._'.!L" Width-_f'_/�.'�Diameter---------------- Depth_.5L_-Z_.1`
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Ir
Seepage Pit No----------f------- Diameters .'__G..'.'. Depth below inlet....(•.•.v.... Total leaching area._...!�L5'4_sq. ft.
Z Other Distribution box (k Dosing tank ( ) _/
'-' Percolation Test Results Performed by����l-r? �!'..yl .......•.. ��_yJz Date...�J�. ...7-:f P'r
/2-
,� Test Pit No. 1......Z-----minutes per inch Depth of Test Pit....�56.__ Depth to ground water..................'.?-L-
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
�.....----•-.....--`-�....-`' —-•--- =---------•---.........--•-----•---......------......---•-•--
O Description of Soil....; Z... ..... '. . ...••••..�` ` ��------
� - -
U ............................••••.......-----•......--•---.....IU
M � ✓. � r � H 7 7-�-�
.... ... .. ... . _G,.GZ
U Nature of Repairs or Alterations—Answer when applicable.______________________________•_•_-----____________•__--_•______-__________-___••--------_--__.
--------•-------------------•----------------------------------------------------------.............•••---••••-•••••••••••••••--••••-••••••-••••----•-••••••••-•••-•-••••••••-••---•••••---------••--••..
Agreement:
The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of TIT I,Z'j 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
•ope ation u ' a Cer ' of Compliance has been 1pffrked Wthe oard of h
Signed•• ° •" .............
/��
�- /
Application Approved BY.....-....................-............ ------------- -•--•-•--- - D e /
ate /9,4
Application Disapproved for the following reaso :--•••-•••••-•---•---•-•---•-••-•••••--•----•-••••-••-••---•......••................•••--•••-•-••----•-------••
---------•-----------------------•-•-•--...-----....---------------------•-••----•------•--•------------.._.....------------------------------------------....--------------------------------------•-••-
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
v ...........0F........ ..................................................
Trrtif iratr of TontpliFanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (>et or Repaired ( )
bY..................................... .I-A.UAIn^-S----•--------------•------------•-------------.----•---•---••-----•-------------•-•-----•----------------------••--
! Installer >
at-•••---•••--•. s t............
" has been 'installed in accordance with the provisions of TI T i.E 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No_____________- ....... dated--.-------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYST,EWMILL FUNC ION S TISFACTORY.
DATE.............. D... . .--••--•------•--------- Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS �1a 1'I j4a► J
BOARD OF HEALTH
Z5 .�6 ...................OF....................... �pt�
No......................... - FEE................
Disposal Workii 05onotra ion unfit
Permission is hereby granted.................G^-ay---------`I's3��9� �L`�.*.....................................................................
to Construe , (�x or Repair ( ) an Individual Sewage Disposal System
at No...... ya f'++yN� /► ,i.w a olvrt-.............. ..°.---•••-- . V........................
. �.� `� �-v?-`��d --•--�j •--Ze------•--'�''i'-Q=�"Ki�'C--�---•-•--�Street r
as shown on the application f> or Disposal Works Construction Permit N ._ `._ 6..1 D ed_________________________
------------------------------------------------------
Board of a th
DATE--------------- s ., _.. ,..
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
ASSESSOR,'S MAP NO. PARCEL
LO•CAVION SEWAGE PERMIT NO.
VILLAGE
INST-A L R'S NAME i ADDRESS
R DE R OR OWNER
10
DATE PERMIT ISSUED
i
DAT E CO'MPLIANCE ISSUED ( mli�P
L
�! yS
A
--
a
P
r
_.
i 1•
� k. �
Tm 777
77T77777=
kl�
�k -,
Vx f7kT—�7 7- 4 k,
Frr""T Km
x�
6*
f e1114��,'lk' 4e 5 i
"Zn-e"7 ��%Ok
7' '
7177
-iTV
g
iLi
4,*
-s' Ae 1-1,
�,5'
-Tv
Xl
SYST, U-L,`
tf P
B ROF
71�, I,i.i
�,:k, T�
O)qA DE
DIS T.� �"O
>
k� T:1 1, i,
r
SEP TIC TAW,�,`e - 1� i �
7AW/MV
N
'\Y
b.. RIES MMf/JAN N(IIAN 11A\N f 7 X17
N AM
Tk_
3
OR
�RICK, 1AR
_CONC
le
REC
Tom A ST
'Nj I I -,:, ,
_k : , , � , 11: , , , - �2, - WA
b
—MA
OU TL ET PIPE 'LE VEL
TO: 12 iBELOW
FOR
N
A-
7
41J? 0,1)
:V:
40
I.: OR Pvc TSES
bt
T�
o v,
Sm FLR.
GAL'LON,
T.
�:_Box
DIS TRIBU TION
314 TO -112
ST,1' CONCRETE,
Ot
INS TA LL V 1EVEL 'BASE,
PRECA
PRECA
Li
5
VA ST
REJAjFoRCED �,:''_ SHE
C
RUSHED
CONCRE TE
S TONE
k:
'Ht; 0.
SEPTIC TANK ,:
_4: i%"o b..,
INS TALL ON L E VEL BA SE, E
NO TE.*, XCA VA TE . TO ELEV.�
LOWER TO REMO VE A L L IMPER VIOUS.
0;"
MA TERIAL BENEATH , ME L EA CHING AREA
_�o _P,
REPL ACE EXCA VA TED MA TERIA L MI 7H,
eL
AN
CLL E
A Y SAND f 41
0 ;Co
EFFEC TI VE. DIA ME 7ERL
67 430'40 jvV S 86*43*50*)V
NOTES
'GENERAL
S PIT ,:"
'L EA CHI NG
37.4.3
JN9 TA L L 'ON LEVEL BASE
1 ALL EL EVA TIONS SHOWN ARE �BASED OMASSUME0
E SYST
H
PIPES IN T E
M
P. ALL MUS T, BE CA S T ,IRON
OR SCHEDULE 40
OBSER VA TION PIT
3. THE BOA RD OF HEA L TH MUS T BE NO TIFIED k
,"'MECA.9 T CONCREM
WHEN CONS TRUC TION �IS COMPL E TE PRroR NYE- P74925
LEACHMG PIT
R
A
PERCOL A TION TE.,
TO BA CKFIL L ING ", 1 -11 11 :�
. ��1, : MIN. IN.
NGES
iPLAN MUST BE APPROVED 2
4. ANY ChA
B y
B Y THE BOA RD OF HEA L TH AND CAPE ISLANDS JVI MESSED
INC.
SURVEYING Co ,
1000 SALLON
J.: eO/VL ON
PRECAST CONCRETE .5. MA TERIA L S A NO INS 7A L L A TION SHA L L BE
Jw N
SIG
TIC TAW
SEP OF, HEAL TH
WITH �THE STATE SAVITARY RNS BRD DE
COMM JA NCE TA
TITLE
CODE
DA TE
V A AD LOCAL, APPLICABLE _QCr�'7 J985
RULES AND REGULATIONS ,
H ARROW IS FROM RECORD Pt A IVS A ND
IVOR T NUMBE)� OFL 'BEDqOOMS
6.
GApSA GE DISPOSAL
�3 SOLAR PURPOSES WO
is NO T TO 'BE USED FOR L
FL 'ZON
H
AZ
AR
D E Topson
7. 000
; ..'DAILY F 330
L W
e4e A
7'nW
8. AIA TER SUPPL Y A/ WA Tg"p
3611,
J 000, GAL
SEPTIC ;rA NK ,REG "D
0
SEP TI, C TANK, "PRO VID8D.,,
0, GA L!:.
330
GPD
1E PEOUIRED
ACHING
xv L 0
M
E
DIU
M SAN
to D &
GRA VEL
-f 8, S.F
SIDENALL AREA
470
f'Bg �S �2.:,5
F. &/S.Fi
BO T 7'OM AREA jw 76 S.F,
S.
LEGEND . X,.
76
_G
C
�A
L EA HINO PROVIDED -:54bf_dp,5
f
PROPOSED EL EVA TION
156
SJDENCE,� ,a
'RE
V
A.T110N SINGLE F4 MIL y
-.5oe EXISTING CONTOUR
PIT
DIST
RIBUTION BOX
0
s;r
OSED 'L.-SEIVA GE
PROP
--LEACHING PIT
FOR
t4o. 29894 PREPA RED
7,JON ,�r
Mc SHA AtEl VONS TRUC
'co
sEpTrc. TANK
Tk�.
AMA z.
;�
BEL,�'.�::POIN.T ROA D::`
IA OF At
RESER VE 2-'
L,0T
BA RNSTA
A
ZNVERTLE�EVA TION"
PIPE
DA TE.�
7*0_P 'F'DN "IN
GR
EL .
FIMI
7M
'"INC ,
f7V
SLANDS S VE YING,
N CA
334
SCALE A S 'NO TED lk �� , , T ' 'T ,
'UP
'PLOT PLA
130X'
SCALE,
Tilcl
"TEA
(ET-� MA
/* 0,
AF
'P �Aff!`NO
ra,
TpT
-7 ik
(c,
G
ASSESSORS MAP � , 0
`C.
-TEST HOLD LOGS _,
PARCEL . ,
r
o M
Li/ T PpL/G G _ SOIL EVALUATOR . VI �1 ,
FLOOD ZONE: _ _ '` .. I '� �.� / -I 1-I'l W-- I �i. .. .._ 5 _. - _
4
oT G ,.�'" /WITNESS : 1ri r.x' J`
�d
REFERENCE. f2' /
i` � ?^.- -__.....,. DATE . , Cp 1 ,
p PERCOLATION RA,E ,-1. 2'Wt1t�1 !
All
_ :, _
TH ,I TH 2
fL I l !
`�
441
C,nm p -LCt� la,
2�
LOCATION MAP �o k
c , r }
57
. . ..
-- d
a P, w� _
�37 ,
57
Gv �
1
e � SEPT I ... SYSTEM DESIGN 1 / Y1
�
� ' ..' FLOW EST M�TE �lL�
VOICD
i D i
- B DROOMS !D 00 � G DAY �
� I � E _ AT GAL/DAY/BEDROOM M AL/
f p
o I � ~7
_ SEPT I C;JANK
zr; _. '� . CAL/DAY x 2 DAYS I/OD GAL
USE J GALLON, SEPTIC TANK
/. _
O O Q
G .�
y, 0 .
SOIL i BS RPT I ON SYSTEM
i r IIL / µyn �.7f
Cl7pt)l
m
!
1
/
i x_ _,"7
S D ARE / X
E A � Z�
r ...... :..y BOTTOM AREA: > X, 7
.... -"'
- EPTIC SYSTEM SECTION
�J
1 1
WC
U
a ;_, � b�� ►
19
'.GAL.
,. I r y
Ik }
SEPTIC TANK u! 'I _ L
6,71
l�t"1 1
{,.
r :. .. SITE AND SEWAGE PLAN
LOCAT ION :
.-,
11
•• g
h
PREPARED FOR .
>gM ,) L
_ r
f
SCALE:
`DAV I D B . MAS O N DATE: d/
DBC ENVIRONMENTAL DESIGNS
�..
EAST SANDWICH . MA
:.
19
�., DATE HEALTH AGENT
W ( 508 ) 833- 2 17.7
Z