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Home My WebLink About0111 BERNARD CIRCLE - Health { 111 Bernard Circle A— Centerville A= 171-081 UPC 12534 ' No.2_ 15_R �ps� HASTINGS,MN Commonwealth of Massachusetts 19Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•/Not for Voluntary Assessments l ! l l e✓l��t r G' C.� l y' Property Address // � N Tl I �er� G0rc 0S0 Owner Owners ame I Information is �� e✓vi/�t i�/4 D�G 3:a 2� 8 /� required for every page. City/Town state Zip Coda Date of nspectlon Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information Men filling out -- , forms on the , computer,use 1. Inspector: only the tab key to move your cursor ado not /�/�CI✓�1' D /se, /� <' _. l�I i , use the return Name of Inspector key. Company Name O �7( Company Address CityfT state Zip Code Ste ) 25- 7� `fIt Telephone Number License Number B. Certification 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 the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 oaf Title b(310 CMR 16.000). The system; Passes ❑ Conditionally Passes ❑ Fails ` -:1 ❑ Needs Further Evaluation by the Local Approving Authority C, Le//0 I J�>l✓6 V Inspector's Si nature Date 3 —� 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. ""This report only describes conditions at the time of Inspection and under the conditions of use at that time. This inspection does not address how the system will perform In the future under the same or different conditions of use. 63ins 11110 f Title 9 OMciel M.- ubeurfeCe 24Z%27 I f _ � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments �� /J2✓yl ar� C!✓ ___ Property Address Owner cay'doso Owner's Name information Is ceo,�✓�i`�e Doi G 3oL -elf /oI, required for _ every page. City/Town State Zip Code Date of IneVection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): Ong•11/10 Title 5 MORI Dupedw Form:Subsurraoo Swmps Disoml System•Paps 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments /// Ile 0,0a 1" 6 l r Property Address / 6—a'ec'oso Owner Owner's Name I information Is Ce� t�✓f/� � N` 3J required for __ G every page. Ckyfrown State Zip Code Date of'Inspection B. Certification (cunt.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 18.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 9mm•11/10 TfIW 6 of loWl Imp"Om Form;8ubsudwo Sewep Obpml Syrbm•Pop 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments l/l �err��r� Cyr Property Address T �i'✓` OS 0 Owner Owner's Name // 0 o requirInformed tion is r- H-k vi Ile e �6 3�2 $ o 14 required for every page. CItyfTown state Zip Code Date o Inspeotlon B. Certification (cunt.) 2. System will fall 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 m provided pp , p that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You Must indicate"Yes"or"No"to each of the following for all Inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ tom,/ Liquid depth in cesspool is less than 6" below invert or available volume is less than'/day flow Offs•11H0 Me 5 OftW kwpeadw Form:SuMurreoe aswepe Wsp"W Sysj m•Pepe 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Owner's Name Disposal lSSystem Form•Not for Voluntary Assessments Property Address Owner Information Is required for H'f'e✓(/, Oc� 6 3�� -Y/8//.� every page. City town State ap Code Date Inspedon B. Certification (cont.) Yes No ❑ 2/" Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ [� Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ L� Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Ll 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system f�i• . 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. For large systems, you must indicate either"yes".or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. mine•t 1n0 Title 5 MOM tnspecuon Form:subwrhoe Sawa"DlspoaM 8YOM•Pap 5 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposastem Form•Not for Voluntary Assessments Property Address !7e rkl a e, C 1 0- ca el JOSo Owner Owner's Name // information is GQ&A 4e v, Ile—le— o /9/U required for every page. Cityfrown state Zip Code Date o Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No Q/❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined?(If they were not / available note as N/A) ^tom,"/ Was the facility or dwelling inspected for signs of sewage back up? �Eol Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? L� u 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: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)1 D. System Information Residential Flow Conditions: J Number of bedrooms(design): Number of bedrooms (actual): �30 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Orm•11110 Title S Of WI Iropeclbn Form:Subsurface Sewage Deposal System•Paps 0 of/7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form/-Not for Voluntary Assessments 1 _ e✓j4GrC Cf r Property Address J050 Owner Owner's Name /"' vl ✓Vc `%C /��(� Uot(�� 8 oZ Information Is (� ! required for ---- every page. Clty/Town State Zip Code Date of I pection D. System Information Description: --^ b�•7`ro !/5o'( 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ET"'No Is laundry on a separate sewage system?(if yes separate inspection required) ❑ Yes ff"'No Laundry system inspected? ❑ Yes 9/'No Seasonal use? ❑.Yes Q No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes, No Last date of occupancy: pate CommercialAndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: — t5ins•11110 lido 5 of el Impeedon Form:Subsurhwe Sewspe Dbpml Syabm•Pepe 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal SystemForm-Not for Voluntary Assessments /// lyer✓iavd c r Property Address l G G.✓G DS r7 Owner Owner's NameInformation Is A required for Ile o` 41 O a every page. Cftyfrown State Zip Code Date of Vispection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: - --- Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: - Type of tem: 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Offs-t Ino nee 5 oM W WmpeaWn P«m:suomram amp ompow aymm-Pepa a or i 7 Commonwealth of Massachusetts Title 5 ,Official Inspection Form a Subsurface Sewage Disposal System Form.Not for Voluntary Assessments 111 Property Address Cart! 0So Owner Owners Name Information Is /T C�h ✓�! ` 4 .J'V /a required for every page. Clty/Town State ZJp Code Date of a on D. System Information (cunt.) Approximate age of all components, date installed(if known) and source of information: T4"4,, to Alp n-nL- — x4 S. 4•f (r.)tare Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Materi constructi;40 cast iron PVC ❑other(explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: f feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: — Sludge depth: !Sins•11Ho tale 5 ONWW kopecom Ponn:subawfs"sew".Diepaal sy tem•Pape 0 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal ystem Form•Not for Voluntary Assessments 11/ e✓klalecl GW Property Address fo Owner Owner's Name Information Is required for e t, l✓y Ae A1,4 qa 6 7 every page. City/Town State Zip Code Date of 1 Leon o, system Information (cono Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? ' ��A r7C QW Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I u v 1 ✓I ^ !/I�/- f��E c'e ct '77�1 II �l!/nC Q►n !�/ GNS lVI �j 00C' r�0.�1 fP/qa,, Grease Trap(locate on site plan): Depth below grade: feet 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: Date oft•taro TM9 5 Of kW1 Inspac m Form:SUWWfW6 Sowago USPOW SyatOm,Pap 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form.Not for Voluntary Assessments Property Address G��of o Owner Owner's Name information Is required for Ge-n 4VV7 Ile- a a C ?.I e $Ilk required every page. cKyrrown State Zip Code Date ofinspMon D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons ~ Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Mns•I Wo Me 5 O&W Irwpr edm Form:subwdem Swmp Npoul 8yd m•Poo 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal 8 tem Form-Not for Voluntary Assessments Property Address / _.._____..-.__ ei�1�G✓ - ............. Owner Owner's Name Information Is required for — P✓� ✓!///!; �/� Od-6-7 8 -e l. every page. Cityfrown State Zip Code Date of I ectio D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert eEl�e�-7 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: �s•1 u10 TMN 5 Oftlsl Uapael On Fam;subsw faoa Sawap Mpaaal Syagm•Pap 12 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form•Not for Voluntary Assessments G✓j V-f 0 &e'AC%v Property Address GCA/ C-/oso Owner owner's Name Ce,^ requiretlfo is ✓v� �/� A�4DG31 $ s required for � o� every page. citirrown state Zip Code Date of 1 pection D. System Information (cunt.) Type: ❑ leaching pits number: leaching chambers number: Soo ❑ 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.): r S/ 1nI 0 �a �r c. , Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction -- Indication of groundwater inflow ❑ Yes ❑ No tuns•11110 TNe 5 omdal Inspoelon Fam:subsuRaco SawoDe Dh l SyoOPm•Pop 19 0117 K Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments derloav C/ 611 Property Address J _ G✓LfOSo Owner Owner's Name /�Q -- Information Is �, � �/,� / required for � every page. City/Town State Zip Code Date of lnspdcbon D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: -- — Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ,sr�•,v,o ��@iUn�rmsnreeBsain+rp�t4►ad,� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1� �Ue✓✓1u✓c C� ✓' Property Address Owner Owner's Name I information is cc N�C✓Vl required for every page. Citylrown State Zip Code Date of lnsoectl6n D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where p lic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately ��IoIn i' W po.-C t ' i 1 301• 103 3 o One•11110 TIN 5 Oftlal Inspection Form:8ubwjrrm owmpe Disposal 8ym n-Papa 15 or 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 /j"p ✓- Property Address " -- — �,-G v j Ol 0 Owner Owner's Name Information is required for ( P �p✓!i! l��_ Aj4 c)-) a 7a '�1-i/4z, every page. Q tyrrown State ZIP Code Date of ftpeaon D. System Information (cunt.) Site Exam: ❑ Check Slope �o D ❑ Surface water ❑ Check cellar 1 / ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: 11�11 101S ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must de be how you established the high ground water elevation: oy q a C-a L1 .a,►- h /0 4&A C!Li,-C,jLt, X6 C Before filing this Inspection Report, please see Report Completeness Checklist on next page. Ono•11110 Tltle 5 OW01 Inopectlon Form;Subeuffm Sewev DbpnW Sydw•PIP 18 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessmsnts l / darrh tir C C t Property Address -- G'✓ Owner Owner's NameInformation Is required for every page. City/Town State Zip Code Data of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked [inspection Summary D(System Failure Criteria Applicable to All Systems)completed LDS �stem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Ons•1 v10 TWO 5 01WW Irweeft Form:Subsurface Sewage 0bpoW System.pass 17 of 17 f� �_. ..�yt _ l l'w.i9oog' 'gLor,3. ty`�i ,'.I Fee �, / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0[pplicatton for Mtn o i§?Aem Cou0tructtou permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No. fj �•�. y�y,,, c� Owner's Nam Address,and Tel.No. Assessor's Map/Parcel ` Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �-k`c``�7tius� Type of Building: Dwelling No.of Bedrooms Lot Size �67 sq. ft. Garbage Grinder ) Other Type of Building No.of Persons Showers( ) Cafete pa ) Other Fixtures .�"� e Design Flow(min.required) �-�v gpd Design flow provided / gpd Plan Date-7% CLAY S i1U jLA of Number of sheets Revision Date Title q'ZC� ¢0 .9PQ 61 IZe.L,L Size of Septic Tank 1 000 Type of S.A.S. 2 — .S�V D 4 A�. L(-f4—C,J ALS_ Description of Soil srm 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 Certificate of Compliance has been issued by this Board of Health. �/ Sig ed Date S—?�=DQ Application Approved by Date S'^ ZC� ZOOE> Application Disapproved by: Date for the following reasons Permit No. zx--o a- L03 Date Issued S ZO^ ———————————————————————————————————————————— [7`�/'41 >,7*r�' Fee `- .� "`Entered in computer: S w THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION - TOWN OF.BARNSTABLE, MASSACHUSETTS Application for Mig o ' 4§pztem CCongtruction Permit Application for a Permit to Construct( ) Repair( Y`Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. ' �Q1Ty�q, r� C�t" Owner's Name,Address,and Tel.No. Assessor's Map/Parcel � 4 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. C c)v3s� � " "z ,j C 36 z— S y Type of Building: �} Dwelling No.of Bedrooms ` Lot Size I C7 ` sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria ) Other Fixtures Design Flow(min.required) �/gpd Design flow provided / gpd y Plan Date-7\TL�t Y <;i't rz- YQA wt Number of sheets Revision Date Title .6- /9- Z(--)119 f,3 9- 11 1 "PIFrL,AGY3 C t 12CLlf- Size of Septic Tank 1 0 U Q Type of S.A.S. Z L C IqA Description of Soil Nature of Repairs or Alterations(Answer when applicable) _ Date last inspected: ----- Agreement: ` / _ The undersigned agrees to ensure the construction and maintenance of the afore described.on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sig ed \ � Date S- ` Application Approved by Date Application Disapproved by: /, Date for the following reasons U Permit No. 2-�'y �' Z 03 Date Issued S Z. THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of ComplianceTHIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( r) Upgraded ( ) Abandoned( )by �A.CA" w t 4 at 1 k\ 0-e-`r has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ZGob' ZO j dated Sf ZC,- 2 oG� Installer C .e- C.., t l Designer #bedrooms Approved design flow t� — gpd The issuance of this permit shall not b cd, trued as a guarantee that the system wi IN. wc.. / / Inspector No. 4-C` 08%- �U� _ Fee J G d THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS migonl *p!6tem Co �tructton Permit Permission is hereby granted to Construct ( ) Repair (V) Upgrade ( ) Abandon ( ) System located at le/ and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three ears of the date of this P Y Date S - D' Z U U Approved by P�!M f down cape engineering inc FAX N0. :15083629880 Jun. 10 2008 12:28PM P1 Town of Barnstable Regulatory Services (( 'Thomas F. Ge ler,Director f eaasra�,B�, F A Public Health Division Thomas McKcan, Director 200 Main Street,Hyannis, MA 02601 Ot'ilce: 508-862-4644 Fax: 508-790-6 iO4 installer & Designer Certification Form Sewage Permit#�or� � �03 Assessor's MapTarcel 04. Q. 4 installer: M �„rlilr'esgo ,3 / l a. �. • Address: Nl was issued a permit to install a � (date) (installer) s,,:,,pf i,-, system at ! �e'�d1 Ci rck based on a design drawn by (address) dated (Cles ggner.) l certify that (lie septic system referenced above was installed s«bstantially according t6�-,-- the design.. which may include .rn.i»or approved.changes such as lateral relocation cif dac` distribution box and/or septic tank. at 0 changes l certify that t1�e 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 accord.fa,, ce with State & Local Regulations. Plan revision rn° certified.auilt.s-b by designer to follow. 9 A RN E H s� _... ...... �' OJALA { lees i9nature) civil. N No. 30792 90 1F /DNAL �1 (Affix Designer's Stamp ll.ere) 1 : ;�E.�1� i t7i21�1 T() �AIBWSTADLE PUBI:IC HEALTH DIVISION CERTIFICATE tDl? C;V.DATPLIANCE WILL NOT BE ISSUUD UNTIi, BOTH THIS FORM A.ND AS-RIJiLT CARD AiRE, 21.4:`;Fax t9 RV THE BA9tNS'TABLE PUBLIC HlEALTU DMSIOiei. THANK YOU. Q Fla-ilil/Selstic/[SesiFncr Ccrtifeal.ion.Forrii 3-26-04.iloc TOWN OF BARNSTABLE 0, LOCATION I 1� / �w.a-� ��' SEWAGE# aU6$-": .VILLAGE ASSESSOR'S MAP&PP�AyRCEL M 17 f PSI . INSTALLERS NAME&PHONE NO, &fc ke)/ C a• ; SEPTIC TANK CAPACITY /, O LEACHING FACILITY:(type) 6L (size) NO,OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: ' Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility pet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If an w an ist within 300 feet of leaching facility) Feet FURNISHED BY a 1 z � FROM►:down cape engineering inc FAX NO. :15083629880 Jun. 10 2008 12:39PM P1 OEG� iI IOP� 0? EXISTING 3 RR DWELLING 1' GAS I 1 _ _ PORC I 1 O SYJ O �I a t; • ae LEACH PIT PUMPED AND T' °V h FILLED 14 N SAND 4p (; i t� F r Ott-..I,�,C f !.�l"WIC �® IT AL" P9.?EPd;RIE-1) EXCLUSIVELY FOR THE HEALTH KEPT.. NOT FOR ANY OTHER USE LOCAY)ON . III BERNARD CIRCLE SCALii: - 9" 20' ®ATE . JUNE 9. 2008 PREPARE® FOR: �j tl'E' E!FlE".NC_E MAP 171 PARCEL. 81 DICKEY C0NST./CARID0(,_v'0 t ARNE cy= j H. T off 3(F-:967.-49a1 1A �oA ?A$"36Z-9@IW Gowncopn.com ® ,o No, 2 o vivid el?rgi?)6ars � E� landsL1Pv6ydPs � SUf$ 935!, Vain V,enet ( Rte 6A) r,.wrf+POR7 AfA nPg7_5 13ATE REG_ LAND SURVEYOR ALL SHALL SYSTEM PROFILE M Rk SYSTEM ITHCr�IAGNETICTTAPE OR BE NOTES COMFARABLE MEANS FOR FUTURE LOCATION. (NOT TO SCALE) 1. DATUM IS APPROXIMATE NGVD ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCREi COVERS TO WITHIN 3" GRADE CO Lane 2 PEASTONE OR GEOTEXTILE 2. MUNICIPAL WATER IS EXISTING Fa ono, TOP FOUND. EL. 59.5't FILTER FABRIC OVER STONE sfo9�� 57.0' 29� SLOP;; REQUIRED OVER SYSTEM 3. MINIMUM PIPE PITCH TO BE 1/8 " PER FOOT. MINIMUM .75 OF COVER OVER PRECAST PRECAST H-to BLOCKS OR 4. DESIGN LOADING FOR ALL PROPOSED PRECAST RISERS (TYP°) PRECAST RISERS UNITS TO BE AASHO H-M of 2'0 55.6' 4"OSCH40 PVC H-10 or PIPES LEVEL 1ST 2' �ENDS4' COMPS NENTS 53.4 SIDES 5. PIPE JOINTS TO BE MADE WATERTIGHT.**1000 GAL H-10 (TYP) 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE *EXISTING 10" " ,`:%?D,�,, ,, SEPTIC TANK 14 a u i .. °.. w WITH EXISTING TEE TEE *54.2' °°°° ®®®® ®®� ®®®® -®®�® 310 CMR 15.000 TITLE V. 00 °o°o°o°o°o°o' O °o°o°o°o °o°o°o°o Q GAS BAFFLE::, co°°°o°°°o°° ,°o°o°o°o °°°°°°°° Q O O °q0 0_ ° ° ° ° ° O O ° - ;°°°°°°°° ®®®®®®®�®®� ®�®®®®®®mr ;og°g°o°o 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND �- Cir c 00000000 a 53.8' 53.63' ° o ° ° . t La S ,°°°°°o°o ° ° ° ° NOT TO BE USED FOR LOT LINE STAKING OR ANY ' 4 LIQ. LEVEL (ACME OR EQUAL) . OTHER PURPOSE. 8e EL 51.0 LH-10 500 COAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL. 8• PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. DEPTH OF FLOW = 4' 3/4"-1-1/2" DOUBLE WASHED STONE 4' MIN. (2) UNITS REQUIRED ALL ROUND PRECAST STRUCTURES 9. COMPONENTS NOT TO BE BACKFILLED OR TEE SIZES: 6 CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.00 X 12.83' CONCEALED WITHOUT INSPECTION BY BOARD OF INLET DEPTH 10" COMPACTION. (15.221 [2]) HEALTH AND PERMISSION OBTAINED FROM BOARD OUTLET DEPTH = 14" OF HEALTH. 10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS MAP .5' BOTTOM TH-1 CALLING DIGSAFE (1-888-344-7233) AND 45 ( 2.5 SLOPE) ( $ SLOPE) ( 12.6% SLOPE) 45 GROUNDWATER FOUND VERIFYING THE LOCATION OF ALL UNDERGROUND & SCALE 1"=2000't OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF .. FOUNDATION EXISTING SEPTIC TANK 5 D' BOX 8' LEACHING ( WORK. ASSESSORS MAP 171 PARCEL 81 FACILITY 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE REMOVED 5' BENEATH AND AROUND THE *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **THE INSTALLER SHALL CONFIRM MIN. PROPOSED LEACHING FACILITY. LOCUS IS WITHIN GP OVERLAY DISTRICT r UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS SEPTIC TANK SIZE AT 1000 GALLONS AND PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM ITS SUITABILITY FOR RE-USE ., 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. LEGEND 99 EXISTING CONTOUR a' X 99.1 EXIST. SPOT ELEV. j - PROPOSED CONTOUR JJ I, (98.4 O 3 PROPOSED SPOT EL. 7Ht SHED TEST HOLE LOT 69 2, SLOPE OF cRourlD 16,307 SFf SYSTEM DESIGN: �Q> UTILITY POLE GARBAGE DISPOSER IS NOT ALLOWED FIRE HYDRANT -- WIM,Wr ALL SYMMS MAY APPEMt N WWNfi _ ! DESIGN FLOW: 3 BEDROOMS ® 110 GPD 330 GPD 1 GRAVEL USE A 330 GPD DESIGN FLOW DECK DRIVE TEST HOLE LOGS \ SEPTIC TANK: 330 GPD (2) = 660 ENGINEER: DAVID FLAHERTY, R.S., SE2755 **RE-USE EXISTING 1000 GAL. SEPTIC TANK WITNESS: DON DESMARAIS, R.S. EXIs1Nc 3 BR \�\ LEACHING: DATE: MAY 15, 2008 DWELLING h� \\ �\' / SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD \ \ / BOTTOM 25 x 12.83 (.74) - 237 GPD PERC. RATE _ < 2 MIN/INCH / s� G TER �9. \ / �' TOTAL: 472 S.F. 349 GPD CLASS I SOILS P# I2-2- 0S / / \\ / . p0 /PAVED / Rcl Ljfl w �/ USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) DRIVE ELEV. ELEV. / � .., / WITH 4' STONE ALL AROUND I 1 z / s� oft4 56.0' 0„ 4 56.0' // r\ _' o co A A LS -LS \ \y"Ss MA I 10YR 3/3 10YR 3/3 EL APPROVED DATE BOARD OF HEALTH ' loft TITLE 5 SITE PLAN 8 B 4& OF LS LS 111 BERNARD CIRCLE ;...,.. 10YR 5/6 10YR 5/6 GRAVEL ^ -H 2 \ �, �� 34» 53.2 30 53.5 14 Fo\ AREA �.,• _ _ / (CENTERVILLE) BARNSTABLE, MA o PREPARED FOR PLA NGS HICKEY CONSTJ c c \PERC �P GILBER ARD� O i \ L=4 DATE: 19, 2008 M S M �' /S / BENCHMARK \ 55 / CONCRETE BOUND off 508-362-4541 i ELEV. = 55.86' fax 508-362-9880 2.5Y 6/4 2.5Y 6/4 CAUTION! GAS SERVICE IN THIS - - - - AREA! USE CAUTION DURING downcape.com �ZH A,{,S QF A�gS�c9c • • • CONSTRUCTION! (SEE NOTE #10) OF q down cope engineering 14C. DANIEL �`�� , o DANIELA. A. a OJALA OJALA civil engineers CIVIL q N0.40980 land surveyors 126" 45.5' 120" 46.0' „ No. CGS 10,, 939 Main Street ( Rte 6A) Scale:1 = 20 G NO GROUNDWATER ENCOUNTERED '�> f 1°►Cn� FF 'srER ��' su e j^ YARMOUTHPORT MA 02675 DATE DANI A. OJALA, P.E., P.L.S. DCE #08-- > 00 0 10 20 30 40 50 FEET 08-100 HICKEY_CARDOSO.DWG (DDF) s