HomeMy WebLinkAbout0447 BAY LANE - Health 7te
Lane
i'
003003
011f f"--Word, NO. 1521/3 ORA
`o'� � 10%.
ID
• tIon
em2oat cC�toor+
411.
i
i 4WH VbAmc°p�� 110
uttFTtSrr['C
i dI
� of
a�
SEGON� FLOOR_PLAN
f�
1
� - COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
� E
11/AP i 7
w
PARCEL • �Z6 W 0 3
LOT
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 447 Bay Lane _ r Centerville MA 02632 R V.-
-aD
Owner's Name: Ann Ryan
Owner's Address: Same
AR 1 0 2004
Date c finspection: February 28,2004
TOWN OF BARNSTABLE
HEALTH DEPT.
Name(if Inspector: PATRICK M.O'CONNELL
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailin a;Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Teleph)ne Number: 508-428-1779
CERTIFICATION STATEMENT
I certify-that I have personally inspected the sewage disposal system at this address and that the information reported
below i a true,accurate and complete as of the time of the inspection.The inspection was performed based on attllt,,,
trainin!; and experience in the proper function and maintenance of on site sewage disposal systems. I a OF4,
appro;led system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: �����P�;.••••••.. s' �i���
X_ Passes TRIC
Conditionally Passes s 1
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: P0t-- ODate: 2/28/04_ ��i�,urtINS11111
PEG���`�
The sy:tem inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)v.fthin 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or treater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.T he original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authori)y.
Notes and Comments: Observed two feet standing water in leaching pit.Recommend pumping tank.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditi)ns of use.
Title 5 nspection Form 6/15/2000 page 1
Page 2 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 447 Bay Lane,Centerville
Owner: Ann Ryan
Date of Inspection: February 28,2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.30:: 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.
II
Answt► yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain
"'he septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsow id,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existin E,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 Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND ex:lain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstruc:ed 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 exl lain:
the system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass in:pection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND exF lain:
Page'I )f 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECCTION FORM
PART A
CERTIFICATION(continued)
Prope rty Address: 447 Bay Lane,Centerville
Owner: Ann Ryan
Date of Inspection:February 28,2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(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 iSAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 1 )f 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 447 Bay Lane,Centerville
Owner: Ann Ryan
Date of Inspection: February 28,2004
D. SyAem Failure Criteria applicable to all systems:
You niust indicate"yes"or"no"to each of the following for all inspections:
Yes No
X_ Backup of sewage into facility or system component due to 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 'h 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
X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
— __X— Any portion of 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 1 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. (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.]
_:No_..(Yes/No)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 mi ist indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
— _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"it: Section D above the large system has failed. The owner or operator of any large system considered a
signific.nt threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
A
Page 3f 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 447 Bay Lane,Centerville
Owner: Ann Ryan
Date of Inspection: February 28,20041
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ _ Pumping information was provided by the owner,occupant,or Board of Health
{_ Were any of the system components pumped out in the previous two weeks'?
_X_ _ 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`?
_X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
_X_ _ Was the site inspected for signs of break out?
_X_ _ Were all system components,excluding the SAS, located on site?
_X_ _ 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?
_X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
mainte:lance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes ro
_X_ _ Existing information. For example,a plan at the Board of Health.
_X_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance;is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 :)f 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 447 Bay Lane,Centerville
Owner: Ann Ryan
Date of Inspection: February 28,2004
FLOW CONDITIONS
RESIDENTIAL
Numb:•of bedrooms(design): 4 Number of bedrooms(actual): 4
DESH3 V flow based on 310 CMR 15.203 (for example: 110 gpd x 4 of bedrooms): 440
Numb! of current residents:2
Does residence have a garbage grinder(yes or no):No
Is laur clry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundr✓system inspected(yes or no):
Seasonal use:(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2002—133,000 gal.2003—104,000 gal.=324 gpd.
Sump pump(yes or no): No
Last d;ve of occupancy: Currently Occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sitaitary waste discharged to the Title 5 system(yes or no):,
Water rneter readings, if available:
Last drr:e of occupancy/use:
OTHE.R(describe):
GENERAL INFORMATION
Pumping Records: None
Source of information: -
Was system pumped as part of the inspection(yes or no): No
If yes, volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE-OF SYSTEM
_X_Se ptic tank, distribution box,soil absorption system
_Single cesspool
_Ov inflow cesspool
_Pri✓y
_Sh;fired system(yes or no)(if yes,attach previous inspection records, if any)
_Inr.ovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtaine i from system owner)
Ti€ht tank _Attach a copy of the DEP approval
—Otl ter(describe):
Approximate age of all components,date installed(if known)and source of information:
Compliance date: 11/2/48
Were sr wage odors detected when arriving at the site(yes or no): No
Page 7 3f 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 447 Bay Lane,Centerville
Owner: Ann Ryan
Date of Inspection: February 28,2004
BUILRING SEWER: X (locate on site plan)
Depth below grade: 5'
Materi a Is of construction:_cast iron _X_40 PVC_other(explain):
Distan�:e from private water supply well or suction line: 20'
Comm;nts(on condition of joints,venting, evidence of leakage,etc.):
SEPTIC TANK: X (locate on site plan)
Depth t,elow grade: 5'
Materi;3l of construction:—X—concrete_metal_fiberglass polyethylene
_othcr(explain)
If tank s metal list age:_ Is age confinned by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimen;!ions: 10.5' long x 5.8' wide—1500 gal.
Sludge depth: 10"
Distance from top of sludge to bottom of outlet tee or baffle: 22"
Scum thickness: 6"
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: 7"
How v,ere dimensions determined: STICK WITH HINGE FLAP.
Commi nts(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as relat.A to outlet invert,evidence of leakage, etc.):
Tees intact,recommend aumnin8.
GREA iE TRAP: No (locate on site plan)
Depth t,elow grade:_
Materk I of construction:_concrete_metal fiberglass_polyethylene_other
(explaic i):
Dimen,ions:
Scum ticickness:
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:
Comm(nts(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as relati:d to outlet invert,evidence of leakage, etc.):
i
Page 8 :)f 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 447 Bay Lane,Centerville
Owner: Ann Ryan
Date of Inspection: February 28,2004
TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan)
Depth r-elow grade:
Materi;iI of construction: concrete metal fiberglass polyethylene__other(explain):
Dimen ions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date or last pumping:
Comm,:nts(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: 0"
Comm4 nts(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: No (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comme nts(note condition of pump chamber,condition of pumps and appurtenances,etc.):
I
Page 5, .3f 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 447 Bay Lane,Centerville
Owner: Ann Ryan
Date(ol'Inspection: February 28,2004
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X_ [caching pits,number: One 6x6(1000 gal.) pit.
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comrr.e nts(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): Observed two feet standing water and no high stains.
CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan)
Numb; 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):
Comm nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.):
PRIV`r: No (locate on site plan)
Materb IS of construction:
Dimen;ions:
Depthof solids:
Comm.:nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
n
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 447 Bay Lane,Centerville
Owner; Ann Ryan
Date of Inspection: February 28,2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchirarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
Bay Lane
I �
��ideU�wl
U `•
o
9 i � WN"1
Z i Z
I
Y
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 447 Bay Lane,Centerville
Owner: Ann Ryan
Date a I'Inspection:February 28,2004
SITE:EXAM
Slope None
Surfac:water None
Check cellar Dry
Shallow wells None
Estima led depth to ground water: More than 15 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
(:iecked with local Board of Health-explain:
C iecked with local excavators,installers-(attach documentation)
_X_Accessed USGS database-explain: USGS topo map and town GIS
You miist describe how you established the high ground water elevation:
Town groundwater contour map shows water below el.5 and topo map shows property above el.20.
Bottoma of leaching pit 10 feet below grade.
A Q ��-- t
TO N"OF BARNSTABLE
rl
LOCATION r SEWAGE
VILLAGE �� ��;��� ASSESSOR'S MA j..
a. Nib/
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) 4e,,4
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER_&2_
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED; // -'�-
V K
/ r
E
0
r3G9
;7
J
No.- -17 3-� Fps..._._..../...��.�
THE COMMONWEALTH OF MASSACHUSETTS
-
"BOAR® OF HEALTH
Teta!1/..................0F....a3i?jelI S7g9494� ....------•--••---••------._...------...-..._.._.
i`}
Applirdiiou for Disposal Works Toustrurtiun Prrmit
y
Application is hereby made for a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal
�J
..--St-••�' -- ' ....................................................
� ------
Location- ess or Lot No.
- ....... _ s!ta_5-_•1 i. Lz••••_l ix:--- ':hc..................... ----------------- ..........................................................
Owner Address
Installer Address f
Type of Building Size Lot__/�j_ ........Sq.. feet
Dwelling—No. of Bedrooms_______�'_l_r� _______________________Expansion Attic {(i/�) Garbage Grinder (K)
pa, Other—Type of Building ____________________________ No. of persons............... Showers ( ) — Cafeteria ( )
Q' Other fixtures _________________________________
W Design Flow................................S____gallons per person per day. Total daily flow.............'3.o....................gallons.
WSeptic Tank—Liquid capacity_1580__gallons Length_. -4t___. Width__5_-$'.___ Diameter__-- Depth_ _-' ....
x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. 1tj
Seepage Pit No---------/'.......... Diameter.___ Depth below inlet...37, : Total leaching area__.3Z_7.....sq. ft. t
Z Other Distribution box (7C) Dosing tank ( ) 1
aPercolation Test Results Performed ...... Date.../L- $'_- .l..............
,.a Test Pit No. 1.....Z._.._._minutes per inch Depth of Test Pit....l4A....... Depth to ground water______ _______________
f? Test Pit No. 2----=7:n.....minutes per inch Depth of Test Pit____Y_la_`_`______- Depth to grou ......................
vbsniiT----
O -OF- .................
- `�P�----- Ass
Description of Soil_�O__--£r9__�.1d1c,�A_ts�m__ __.tYitpse�..tar��yuire:Q_��G4____144__*_l—True__ _. ��,► A�,�
UdIOA,__.s�_�l_.TB°}eZ----- ----j-�Qsas -- rM j--�a`�" .Q--r._� __.�._ u�ob�li -.STEPHEN__..
W 911cs�tvlol._yak►rA___0!!lKt�!__!c��`�( Aee�----------------- �F ALLYN -
x WILStST( ...
0 Nature of Repairs or Alterations—Anse pglicable_____________________•_________________•.._ _._____. ti ..........
�` 1�1 i-NUINEEH MUST SUPERVISE ,o ,QNb:'3fl2tB�Q
---••------------------------ii�l��AtL y uji+i-•iii�iid CIEFiYIFY ICJ 1NRITING 9 F I 'T���
Agreement: THE SYSTEM WAS INSTAL�FSD IN S35
The undersigned agrees to install the;Cafo�r�,ede-sc`ibe�d, PI d�ividua' "ewage r ance with/,�-96
the provisions of iITl.ia, 5 of the State Sanitary Code— The undersigned further agree not to place the system in
operation until a Certificate of Compliance has been is ued b the board`of/health. 5
•--••-`� Cam, ° ` -------------- � Kat�
' �Application Approved B -. ............. ��/1 -=-----y
Date _
Application Disapproved for the following reasons---------------------------------------------•------•-----------------------------------------------....-•-•L.
G
......--•-•-•-•----------------------------------------------------•-----•--------------...-•-•-•----------•-•-•---•-----••-----••--•---•-•---••--•-------------•-••-•--------•----••••••--•---•--•--•-
Date
PermitNo.....F14.... �31---------------------------- Issued-.......................................................
Date
BAXTER & NYE, INC.
Registered Land Surveyors and Civil Engineers
7 Parker Road / Osterville, Massachusetts 02655 / Tel. (617) 428-9131
WILLIAM C.NYE,R.L.S.-President
RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering
October 3 , 1988
Town of Barnstable
Board of Health
Town Hall
367 Main ST
Hyannis , MA 02601
RE: Septic System Inspection
Lot F (86-1239)
Bay Lane, Centerville
Members of the Board :
This letter is to inform you that the septic system was
installed at the above noted lot and completed on Sept.ember 30 ,
1988 in substantial compliance with the plans.
If you have any questions or comments , please do not
hesitate to call this office.
Very truly yours ,
Stephen A. Wilson , P. E.
Baxter & Nye, Inc .
SAW/fmj
CC : Silva & Silvia-481143
Vince Bros .
MEMBERS OF
CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING
MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS
No...rf L--- f =}� Fss..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
7_P.,V /-.........---------OF.. 19aPyS739ld1.—'
Appliration for M-4p iial Workii TUtuitrurtion Vrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System �t: 1
L_a �..... _ ........... --------------------------------- --•------------�a------.-.------------------------ --------------------..-------......
Location-A ss ,{ or, Lot No.
y Awe
.........� VNI 'r ��t�E31 Z �1tr./P+GC .1.�LG L-------•----....---•------•---•-------•-......-••--•................•-.
Owner 4
C17. Address
...............••......•..................................
••• ----•-............... -•------•-.......................-•----------....---
Installer Address �� Z�&t
Type of Building Size Lot..____I.....................Sq. feet
U Dwelling—No. of Bedrooms.......TAic�------------------------Expansion Attic (�7) Garbage Grinder (x )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures ----------------------------------------------------------------------------••--------. ---------•-•••--
33co
WDesign Flow................................$S....gallons per person per day. Total d�ily��.ow_.__................__.___.__._....._....�_llA�ys.
WSeptic Tank—Liquid capacity_t500..gailons Length]Q_'4..... Width.A'�'_____ Diameter-_"".-"~ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area______ _ _ sq. ft.
Seepage Pit No.....__._�..__..._.. Diameter___,/2-_*... Depth below inlet_..r '`? Total leaching area._.�.:7_....sq. ft.
Z Other Distribution box ()C) Dosing tank ( )
aPercolation Test Results Performed S�?_«!� ..____ Date.- f."Zg� �.•......_..
Test Pit No. I---.Z.-------minutes per inch Depth of Test Pit...:IAgA,------- Depth to ground water._,- ---_•_-_-__.
Gz, Test Pit No. 2.....r......minutes per inch Depth of TTest Pit....2A*.......... Depth to grow ____________________
Obtci�l.e � -EMq�s
x Description of Soil_30---�s!�t1Aetll t.. ►ac ._U9�1� .?a4., *v.4 �4� i �j�a' � ��' 9i>- ............
bt)�+►�3C. 36u2+ L..T�=4. �•--�- 3Q �reWn '„culo&O!I q` STEPHEN $G
W �.. t ; i ---•----- `_ ......-----•••--- -------
J-7 ALLYN rn
l. �C1711d!R��-------------••--- - �:z i
U Nature of Repairs or Alterations—Answer when applicable------------------------------------------- a.____ -No:R2 . .... ---------•
-----------------------------------••------------•---------•------------------------•••-••-•..-------•-•--.
Agreement: ss C/u/[�
The undersigned agrees to install the aforedescribed Individual Sewage 1 s ys dance�v'
the provisions of TIT11 55 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by{the board of
health.
Application Approved B ......................... .._.°- -•-�--�-•=�•)--'••--=•-----•--------------------------•----•-- --•---
........................
Date
Application Disapproved for the following reasons:-----•--------------------------------------------------------------------------•-•-----•---......--•........._
.............•---•-...........•--...-------••••-•-••-•-----------.....•••-----•---------•...-------•---•---------------------------------------------------- ------------------------------------------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH -
..............................OF......... ::!�!�..:...7 f —
Tatifiratr of Toutplianre
THIS IS V4,ffRTIFY
That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by......................
••-- .... Installer
Lt1 cl >�
has been installed in accorhance with the provisions of ''TiZ j of The State Sanitary Code described in the
application for Disposai Works Construction Permit No.___��:__._�. �_._.__.__. dated____________ __ ___f_______.........•......
THE ISSUANCE OF THIS CERTIFICATE'SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
c, ..Q d
DATE...•••....•-----•---•-.•/.- .BOA.....---•-•------------------- Inspector............. t --------------..........................................
THE.COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ,
_ .. : .................................. J'
....f— = FEE........................
Disposal Norkv Tnnitrttd nn .unfit
Permissionis hereby granted........ ----------------------•---------•------------------------•--------------•--•----- .............................................
to Construct ( or Repair ( ) n Indiv�ival , wage Disposal Syst ��
_ C
at No.....- •=-• .... _.....v� �. cfr•xc.{` ,f<r ? "J'�•/ '
...... -•------ . ........................ --------- ------ •----••---••......•--•---_ ........
t :.
Street 1 /
as shown on the applica on for Disposal Works Construction Permit No� �°= Dated________ _ __
__..
DATE (� Board of Health
FORM 1255 Ho & WARREN, INC., PUBLISHERS ti
TOWN OF BARNSTABLE
LOCATION 42 SEWAGE*
VILLAGE�� s't�i/ram. ASSESSOR'S MA& QT _
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(tyge) 4e,,,c
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER fgb
BUILDER OR OWNER c�i rr/rs19 &E 5;jdiA
DATE PERMIT ISSUED: i I I
DATE COMPLIANCE ISSUED;
ARIANCE GRANTED: �X o
�1
1i SOIL TEST PIT DATA. INDICATES V INDICATES SEPTIC TANK DETAIL: oo GH�Lp/1/ DISTRIBUTION BOX DETAIL: r• ��- n�-r �� . REVISIONS
PERC. OBSERVED NOT TO SCALE u
TEST GROUNDWATER NOT TO SCALE `���vl i'N PI 1 VL. 1 ILA.
NOT TO 3CALE No� �
NOTES: I. SEPTIC TANK SHALL BE STEEL 4. INLET AND OUTLET TEES TO BE CAST IRON, �)AT�
..�
TP z c r TP TP UI'rw ��Nt� L �f TP REINFORCED CONCRETE. SCHED. 40 PVC OR CAST-IN-PLACE CONCRETE. TEES / NO. OF OUTLETS: LOAM 8 SEED
GRD. EL. 24.6 GRD. EL. GRD. EL. I GRD. EL. TO BE CENTERED UNDER MANHOLE COVER. NOTES! MANHOLE COVER OR PAVEMENT
2. SEPTIC TANK TO WITHSTAND H-10 LOADING BROUGHT TO FINISH GRADE,
GW. EL, GW, EL, GW. EL. GW. EL. UNLESS UNDER PAVEMENT, DRIVES OR I. DIST. BOX TO WITHSTAND H-10 LOADING
TRAVELED WAYS,WHEREIN H-20 LOADING I I UNLESS UNDER PAVEMENT, DRIVES OR
2 MIN OF I/8
n,i <-r u 4•u,, ,i SHALL APPLY. U PRECAST I TRAVELED WAYS WHEREIN H-20 LOADING
23.8
/_3KGW/J �/►!vlr;' I F SHALL APPLY. TO I/2" 12"MIN. FILL
,1 rr0,-. n, 3. ALL PIPE CONNECTIONS AND CONCRETE MANHOLE COVER /� I I DIST I I WASHED
v/..�,.,U/L BROUGHT TO FINISH GRADE I,- ST0i1E 1
S�,vU CONSTRUCTION TO BE WATERTIGHT. BOX I 2. PROVIDE INLET TEE OR BAFFLE WHERE SLOPE OF .�
501J•50/4- INLETPUMP PIPE
EXCEEDS 0.08 FT./FT. OR IN � .r, o� s ,.a� _ . p C- • a o o ❑ ;���
12"MIN. L_-- J PVC INLET PIPE
r� 3. FIRST TWO FEET OF PIPE OUT OF DIST. 1? a
COVER -ra r- GENERAL NOTES
IkIC 1- 9.4
�I11x�D NUr./�,rc`A /�/ � ,. . PLAN VIEW � � �� s
BOX TO BE LAID LEVEL. p �+ 13 M C� o a a a c a NOTE:
Pr.,+,� !J/CaKNsit:c' u� U.=.G.S _ rj oR 1 �� 0 IT TO . THIS PLAN IS FOR DESIGN AND
•NORMAL WATER LEVEL REMOVEABLE� a o �oV ❑ C� co c 1a a c o ❑ _-� a o WIITHSTALEACHINND IH-10 LOADING CONSTRUCTION OF THE SEWAGE
UNLESS UNDER
- - _ _ - - - - - - - - _ _ _ / 7 COVER o ' ° PRECAST Aa. DISPOSAL FACILITY ONLY.
/ 1Jf "6 PAVEMENT,DRIVE OR
< 2. ALL CONSTRUCTION METHODS AND
w 3/4"TO 1-1/2" ❑ > a �- Q o ❑ MATERIALS SHALL CONFORM TO MASS.
TRAVELED ',�'A1 WHEREIN
I I PROVIDE -1 ►. , DOUBLE LEACHING PIT oo H-20 LOADING SHALL
i. 7 D.E.Q.E. TITLE 5 AND LOCAL BOARD
INLET TEE WATERTIGHT • �. U WASHED ❑ .� � o a Q o c ❑ APPLY. OF HEALTH REGULATIONS.
c��6rzNVEL_ (�B; GRouNu- _ _ I JOINTS(trR) I- ,� STONE °
v4" 17.6 _ I 4'-0• MIN. OUTLET - y f'l SEE
�U �-- WATUk► j. �s I PRECAST I,_
_ TANK _ � - �� LIOUW DEPTH TEE 4 INLET , • l� I I 1 1 ❑ p p [� C� C Cl C ❑ -
f iti� 9� =i g NOTE z I w (no f roes t�. �o _ 3 ALL PIPES LOCATED UNDER PAVEMENT
l , �`- �� r OR TRAVELED SHALL BE SCHEDULE
=}Lid 4' OUTLET I o o P� Q v/
i�aTro,•> �„- H, T I I I ` L. : . ", 40 OR EQUAL.
I 4.
1 ��� � I n ❑ c� n o o C7 o a ❑ - �J e .fin '
I I I.
BOTTOM ON LEVEL STABLE BASE O. .4u ��, �.� -BOTTOM ON
r7oAlG/rU✓nlU l.Ji,TCiY o9 • � a� u oo LEVEL STABLE 6 DI A
PLAN VIEW CROSS-SECTION VIEW CROSS-SECTION BAD "
CIA
6
INVERT ELEVATIONS. CONSTRUCTION NOTES:
DATE: DATE: DATE: DATE:
�8 Lvov i 9 84 _',3 NDy ryFq
TEST BY: TEST BY: TEST BY: TEST BY:
s, /-a w s/4 -�,L��" 4' INVERT AT BUILDING .
WITNESSED BY: WITNESSED BY: WITNESSED BY: WITNESSED BY: 4' INVERT AT SEPTIC TANK(in) z
PERC. RATE: PERC. RATE: PERC. RATE: PERC. RATE:
4' INVERT AT SEPTIC TANK(out) 17
MIN./INCH MIN./INCH MIN./INCH MIN./INCH 4" INVERT AT DIST. BOX(in) a 2.: 7
4' INVERT AT DIST. BOX(out)
DATUM:
R INVERTS AT LEACHING FACILITY:
VERTICAL DATUM: � EOT TOM OF LEACHING PIT �Z as
4 L CO J
BENCH MARK USED: i ! '� U. S. G.S. MAX/MUM GROUND
4� ► ( � ' WATER EL EVAT/ON 9,
OBSERVED GROUNDWATER
EL E VA T/ON
! I
"F-1
CONSTRUCTION NOTES Al
,I� �,y' 7 J - may, cy „w _�5'' `,b � 6
,\
1) Septic system leaching facility setback from wetlands 150 ' 'IZ ° t TP f J
minimum. (See attached site plan) 610 12
2) Septic tanks to be located a minimum of 10 ' from house �lA 6c
foundations or retaining walls. z� �o
� s
3) Leaching facilities to be located a minimum of 10' from
property lines and 20 ' from house foundations or retaining \ °`� LI �EY�,c Tiyar, �., 'v•'
walls . ��. , � �I � � `� � ;�� � s_
�� 2 � , ,. DESIGN CRITERIA:
4) Topographic information shown was taken from a plan by DESIGN FLOW:
\ „
Baxter and Nye, Inc. and does not represent an actual surveyr` •/ -r- i -
-� BEDROOMS AT //0 G.P.B./D - - G.P.D. -
on the ground by Cape Cod Survey. .,,,d.�° y p' �p� q�
5) Perimeter compiled from Open Space Subdivision Plan records Nit I
in plan book 402 , page 78 at Barnstable County Registry of C40
Deeds. 11-�
The BSC Group
= sway easement recorded in plan book 420 page 36 . REQUIRED SEPTIC TANK:
5) D1 t Dr
iveway , \ �io fir- /J � . .►Y1 'ha r
.r< �2�''�� c 6ta0 GAL.
'Ci ISO r
/ `'`► \ �" �` <� zz ` SEPTIC TANK PROVIDED: _ �.- in GAL.
SIZE OF LEACHING FACILITY REQUIRED: Cape Cod Survey Consultants
�..,, ,Ii DESIGN PERC. RATE:"Sk MINJNUCH
�' * 3261 Main Street
s
5 t I1� Ic�tl � � nrca r u
-.r 7; cam' V (41' - r,,E. Route 6A
pa ° ° \� ./<, it /9c', _F r c-.
� f / � � _ -3�-� �Po Barnstable Village MA
4
-406 G P D 617 362 8133
/ -
JA .
SIZE OF LEACHING FACILITY PROVIDED: PROJECT TITLE:
SEWAGE DISPOSAL
0
I a,'`\ I �Tt x �,��i � ��� SYSTEM DESIGN
07 Z07
- `
LOCUS PLAN: -- - -�`�`'`'�2 ��Y
/ `, G'HIc�J�TAI3LC? CC_,vT�o��ll �� )
s .i• / � /I/�SS
r\a
PREPARED FOR:
0• 1 N C_
,
L
•. Ir J
L7 t �V
' < DATE: /o - -3
COMP/DESIGN:S.9�.s
PLAN VIEW DRAWN
SCALE: 1' = FIELD:
O -- --F,-7OFc SS/ON,4! --
ENv//'►'E E,�-S/;//L DATE FF,OFFS /0N,4L LAND SURVEYOR D.4 T c FILE NO
0 , <<- FEET DWG. NO. I zoI SHEET
JOB NO OF /