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HomeMy WebLinkAbout0019 BLACK VALLEY ROAD - Health EB' ACK VALLEY RD., CENTERVILLE 7-100.673 i 1� i /f U06 12M4 No.z� �{ MASTINNS.UN, { Ao t No. ' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for �Diopaal *pztem Construction Permit Application for a Permit to Construct( )Repair( 4 Upgrade( )Abandon( ) El Complete System kfndividual Components Location Address or Lot No. �(� QG �o �/� Owner'`Name,Address qnd Tel.No. 7 / (/5 Glss.1/ Asses i M apPs-s c ew IoIUI�/e Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 A Lot Size��sq.ft. Garbage Grinder( ) Other Type of Building &02S92f No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow IM, gallons per day. Calculated daily flow 1330 gallons. Plan Date Z Number of sheets i Revision Date Title i/�I /9 Size of Septic Tank ,05-X%S,1--4 y Type of S A.S. /�4 Description of Soil � �bl(�G" S %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 ' ued b hi Bo d Health. ` Signe Date l Lv,5s Application Approved by Date Application Disapproved or the following reaso s Permit No. .� Date Issued sar �,. F — ' No. � _ P ' :� � Fee f. THE'COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS_ OL 0ppYication for Migpool.*pgtem Congtruction Permit Application for a Permit to Construct( )Repair( ✓)Upgrade( '.)Abandon( ) ❑Complete System [t individual Components Location Address or Lot No. C4 �✓/G`� Owner' Name,Address d Tel.No. I'•� Ass / s_a��/� Installer's Name,Addres�s,and Tel No. Designer's Name,Address and Tel.No. Type of Building: G Dwelling No.of Bedrooms p3 Lot Size sq.ft. Garbage Grinder f Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures -Design Flow gallons per day. Calculated daily flow 3 3�0 gallons. Plan Date fNumber of sheets Rex ision Date Title S! fC' ,`�/�•,' J� /Y .��! C e/_e l Size of Septic Tank > /��Ti /'Xl5%`i�y Type of S A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: ' V- 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 bee ssueeed b hi Boardd ff H alth�.'; � Signed Date Application Approved by � r v l Wff/(f el IS Date r t Application Disapproved for the following reaso s t � f �--- / A Permit r Date Issued -- __---_—=-- -- -- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance �, THIS IS TO CERTIFY, that the�Oyn ite Sew ge Disposal System Constructed( )Repaired ( )Upgraded( ) Abandon ( , )/bY ©. 71,,7e// / ,r. e�e at l�� v ��i�- ��� r l hasibeen constructed in accordance with the provisions of Tide5 and the,for Disposal System Construction Permit No. l r dated Installer fie; M Designer The issuance of this pe hall not be construed as a guarantee that th syste w+ unction as designed. Date U► Inspector -_ No. Kb/ Fee v r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE., MASSACHUSETTS ligogal *pgtem Congtruction Permit Permission is hereby gr ted to Construct( Repair(.11<Upgrad ( )Aband n System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construct on � st a completed within three years of the date of thi permit. Date: D`-� Approved b _. � pP Y JUN-20-2005 08 :05 AM DOWN CAPE ENGINEERING 508 362 9880 P. 01 Town of Barnstable Regulatory Services Thomas F. Geiler, Director a t r�eia, s Public Health Division Thomas McKean, Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: l f✓� Sewage Permit# 2495 -Zal,,L' Assessor's Map\Parcel40 y� Designer: 4�� ao e ng I^-U'n Installer: &r.-6 Address: --I' .J Address: On /?lUp �4r�lUIn �O/l5 was issued a permit to install a ( ate) (installer) septic system at r �' Va V kbased on a design drawn by (addre ) �f Gi.�iZ dated J ( es ner) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. _ ��`t�of MaS�o 24� ARNE H (Iris is Signature) OJALA CIVIL No. 30782 e (Design is Sign ) (Affix tamp ere) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION, CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL flOTH THIS FOR11A AND A,&pUILT CARD Ai3E RECEl,VED BY TFIE BARNSTABLE P LUB IC HEA6TTH DIVISION. THANK YOU. Q:Hcalth/Septi✓Designer Certiticntion Form 3-26-04.doc I TOWN OF BA.RNSTABLE p LOCATIONn SEWAGE #057, VILLAGE. l ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. U C UueC '� SEPTIC TANK CAPACITY Ulf i e i LEACHING FACILITY: (type) (size) - QX30 X O. NO.OF BEDROOMS 121 BUILDER OR OWNER PERMITDATE: (a ( — 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) N Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of le#ching f c' 'ty) Feet y Furnished b � �,JVL Ath d 1 � S � I ` o os TOWN JOF BAR7TABLE 4 LOCATION �"l 6 SEWAGE # VI,-.LAGE (2 ASSESSOR'S MAP & LO ` -10-03 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: - 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 �t e GO, , Ae 3g q2 Q CC • t ,per 4b A 01 0 2400 r COMMONWEALTH OF MASACHUSETTS � o �� EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS , "` DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 19 BLACK VALLEY RD CENTERVILLE, MA 02632 Name of Owner ALICE KALTSCHMIDT Address of Owner: 19 BLACK VALLEY RD CENTERVILLE,MA 02632 Date of Inspection: 7/25/00 Name of Inspector: JOHN GRACI /am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS. Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 Telephone Number: 608-564-6813 FAX 508-664-7270 CERTIFICATION STATEMENT I certify that I have personally inspected,the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes _ Conditionally Passes _ Needs Further Evaluati the Local Approving Authority Fails Inspector's Signature: 1 �� Date:7/26/00 The System Inspector shall submi la 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 flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. qr F ita revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 BLACK VALLEY RD CENTERVILLE, MA 02632 Name of Owner ALICE KALTSCHMIDT Date of Inspection: 7/26100 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. Wa 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. Wa 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). ',i! _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 (Y revised 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 BLACK VALLEY RD CENTERVILLE, MA 02632 Name of Owner ALICE KALTSCHMIDT Date of Inspection: 7/26/00 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 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 nta(approximation not valid). 3) OTHER n/a 'tfs revised 9/2/98 "-f Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 BLACK VALLEY RD CENTERVILLE, MA 02632 Name of Owner ALICE KALTSCHMIDT Date of Inspection: 7/26100 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 System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No - X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) 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 9/2/98 Page 4 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 BLACK VALLEY RD CENTERVILLE, MA 02632 Name of Owner ALICE KALTSCHMIDT Date of Inspection: 7/26/00 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 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 i 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 n&(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) Property Address: 19 BLACK VALLEY RD CENTERVILLE, MA 02632 Name of Owner ALICE KALTSCHMIDT Date of Inspection: 7126/00 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 Q. _ 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 System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No - X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) 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 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 19 BLACK VALLEY RD CENTERVILLE, MA 02632 Name of Owner: ALICE KALTSCHMIDT Date of Inspection: 7/26/00 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 19 BLACK VALLEY RD CENTERVILLE, MA 02632 Name of Owner ALICE KALTSCHMIDT Date of Inspection: 7/26/00 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:1 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 M ERCIALIINDUSTRIAL 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 n/a 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 r Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1989 w 9@wdg@ Odor§d@l@cl@d Am wfiving @t Ili@§It@`.(yes of no): NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 BLACK VALLEY RD CENTERVILLE, MA 02632 Name of Owner ALICE KALTSCHMIDT Date of Inspection: 7/26/00 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: n/a Comments: (condition of joints,venting,evidence of leakage,etc.) THERE IS 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 B'6"H 6'7"W 4'10 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY 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: 19 BLACK VALLEY RD CENTERVILLE, MA 02632 Name of Owner ALICE KALTSCHMIDT Date of Inspection: 7/26100 TIGHT OR HOLDING TANK: _ (Tank•must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction: —.concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:X (locate on site plan) 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 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 BLACK VALLEY RD CENTERVILLE, MA 02632 Name of Owner ALICE KALTSCHMIDT Date of Inspection: 7/25100 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 IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD 2'OF WATER IN IT AT THE TIME OF THE INSPECTION.THE PIT HAS NOT HAD MORE THAN 2'OF WATER IN IT. 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: n/a Depth of solids: n/a Comments: s. (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: 19 BLACK VALLEY RD CENTERVILLE, MA 02632 Name of Owner ALICE KALTSCHMIDT Date of Inspection: 7/26/00 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) 611c� &I �ec� ' o , A � Ab �s.p n� ya � ayY CAY C 8 ky Cc . revised 9/2/98 Page 10 of 11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 BLACK VALLEY RD CENTERVILLE, MA 02632 Name of Owner ALICE KALTSCHMIDT Date of Inspection: 7/26100 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) USGS MAPS AND CHARTS-12+FEET revised 9/2/98 Page 11 of 11 E O N OF ARNSTABLE *d LOCAT)ONLCITG73 /Ac� L-,Olf SEWAGE #?2` ASSESSOR'S MAP & LOTJ�7"M 9 ,,INSTALLER'S NAME & PHONE NO.'--R OC10, Ce q3Q- '"® !5-j0 Op SEPTIC TANK CAPACITY ` Q-V-0 oO i �� LEACHING FACILITY:(typeT /2 i--�— (size) ev c� NO. OF BEDROOMS —7 _PRIVATE WELL OR P�_ R BUILDER OR OWNERL T DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED_ VARIANCE GRANTED: Yes No -� 41. L� t' ___4 N 04 . 0 FRic...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...;'oLA-').A✓..............O F.......r�.. .--.------------------.-.-.---------- ApplirFatiuta for DiupuuFal Works Tutautrurtiuu thrutit Application is hereby made for a Permit to Construct (/) or Repair ( ) an Individual Sewage Disposal System at: ...... -..---.... . .... �------------------------------------------------------------- - Location-Address or Lot No. -----� � - -------------------•-- �_.Z. �!l4 Owner Address a �zo -zT.. . ........•-----------------•------ --....--.- !s ........................................... Instalier Address Q Type of Building Size Lot---_/ + '_.__...Sq. feet Dwelling—No. of Bedrooms...........v�............................Expansion Attic Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fix t s ..-----•---.......--•-------•-----•--•------•---------•--------------•---------•------- --•-.....---•••---•-••••-----------•-------------•----------- W Design Flow...............ems.......................gallons per person per day. Total daily flow------------ .....................gallons. Septic Tank—Liquid*capacity!_0 ..gallons LengthBa......` 4__. Width. `.49`_ Diameter..__. Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......../----------- Diameter-----.f_�1----- Depth below inlet._.3_5__.... Total leaching area.Zq a_....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_._-__--___-_-_------_-. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------_---_-.-_-_---_--. a -... •----------------------------------------------------------------------- •................ .---- -------•-•--•--------------------------------------------- 0 Description of Soil...................................................-----.........-•---..•..---------------------------------------------.............................................. x U .......................................................-................................................................................................................................................. W --•--•-----•-----------------------•-----•---...-•--._...------------------------------------------------•---------•---------•--------•-------•-----••-•--••-•••---------------•-------------•-••--•--•- UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- -----------------------•---••---•--------------------------•---•-•-•----•------•-----------------------------------•----•---------------•-------.....--•--••-----•--------------------•--------•--.----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iiTL% ;of the State Sanitary Code— T*ard ther agrees not to place the system in operation until a Ce tit-, in nce has been issued h. Signed. �DateApplication Approved By--. -- ---•-•---------------••- Q ----•- ....................Da.--.............. Date Application Disapproved for the following re ns:-------•--------------------------•---•----•---•••---•••---•----------------------------•--------••--......----- Date Permit No...e--? --- Issued------•--.......---•----•.....................•--•----- Date .. s No. . L � Fims..... ......... THE COMMONWEALTH OF MASSACHUSETTS BARD OF HEALTH ...... ca -----.---.OF.... ApplirFation for Disposal Works Tonstrurtion Prrmit Application is hereby made for a Permit to Construct fat ) or Repair ( ) an Individual Sewage Disposal System at: Location Adams- or t N Owner Address Insta.Fer Address Type of Building Size Lot_f-�2_a:Q: '..._.....Sq. feet Dwelling—No. of Bedrooms......... -'..............................Expansion Attic (U--) Garbage Grinder ( ) Other—T e of Building No. of ersons............:............... Showers a YP g --------•------------------- P ( ) — Cafeteria ( ) Otherfixtures .._......--•------------•-----...-•--•-•--------•----••--•••......-•--•------------------------------------------•--•••••••••...................... Design Flow.............! ............_.....•..____gallons per person per day. Total daily flow.........=�??.��........._..........�gallons. WSeptic Tank—Liquid'capacitgn!!X.'.....gallons Length-�.�--_P�.. Width!_ : Diameter----"'--------- Depth ............. x Disposal Trench—No. .................... Width.................... Total Length......................... Total leaching area____...._. .._.__sq. ft. Seepage Pit No------ _...._______ Diameter-__-�.?d_.___-___- Depth below inlet.. _c.:?........ Total leaching area;?:Y ......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) W Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-__..._.___-_-____-____. �T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ M •••••--•-•-•----------------••-------•-••-•-•••-........-•-•-•-•......._..---•-•---•------....•----...----•-••-----••-•---..........•-•...........-----.--•-- 0 Description of Soil....................................................................................................................................................................... W U ..................................................-•--•---••---•--•-•-------•-••-•-•.....---•-••--.....----•••-•-••-•••••-•---••--•-•------•••-•--••----••-•••-•••-•--•-•--••-•-•-----•••--......-_.•--- W x •-•-----•------------•------------•-----•----------•----------------------------------••-•••-•••-•----•-•-•--•-••---------•-------•-•------•••--------•--•---------------•--••-••-----•----------------. 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 i_:..E ; of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a C rtiii o ance has been issued by the,board of health. ,I 3� f sir_ c'1-�c- cr` 1�«! -2 . Signed.-- <s•------------------- -------------•...----•-••-•-•••-- Date Application Approved By._ __ ..'?'�...... ✓d_._„ ...........e --•-----------------------------•---•-- � Date Application Disapproved for the following r ons----------- ---------•--••---•-•---•--•---•-------•-••-••--••-------•••-•--••-••••------•-•-------•••••--•-••--- ...........................................................-...... - -------- --. ---------- ---•-----------•--------------•-----•-•-------------•------•---------------Date-------------- Permit No._ / .... . -----..- Issued ...... Date c- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT /� �(/.............. .......OF.................. ..... ............................... Trrtif iratr of T.o utplitanrr X THIST C Y That t qIndividual Sewage Disposal System constructed or Repairedby ( .-----•----- ---------•- - - -•----. --------•----•-•-•-•--••-• ---------------------------•------------ has been installed in accordance with the provisions of TT' j T e tate SanitaryV,4kdas d rib in the application for Disposal Works Construction Permit No.__G�- -� ��..... dated_.. )��.............THE ISSUANCE OF TINS CERTIFICATE SHALL NOT BE CONSTRUED AS A G �TEE THAT HE SYSTEM WILL FUNCTION SATISFACTORY. DATE.........................� •----=y o .._........-•---•-............. Inspector.............................. --•---------•----------------•------•--- THE COMMONWEALTH OF MASSACHUSETTS OAR F H �LTH _' i O 1/.UV..........OF... :.. ... .... `'. ........................ L ...f� BYO._.__. -._.. - FEE-_... 1 .....--.---•- �t��o��t �ez`anit Permissi s hereby granted........ f._..-.Q .71u a e � Sto Construct R In � /r-------- Ser eet L� as shown on the application for Disposal Works Construction Pe N .:� ated. �.j�. ...� ....... .... 00 r ' -.-•--- -- Board i ealth DATE. a ---------•-- FORM 1255 HJ./. BBS & WARREN. INC.. PUBLISHERS _ st5 cti- � -z d ;,,sue} I2:Z. x"h'v,T 'rti+': •.... i .' ___.— _. liz i , 179.55 _ t . 1 Na.Gu>c � C�x►N >c 1 S19ara t3 , b SEPTIcTiwiC :. USE 1 ODa C-MLLCu 1 SQM wsK. \ f�ezo Pe¢rci7 -IA N j7is�os+�L�rt usE )ot.-�> ErAL1.0u t�cr. '��glctH, 1� GR�.15>4+�•p 5To!`lT� .. . 3S' r Uk9l1Gt>,(*lSOyi: C 2.6 s 3't 5 Gtf"L j' , __ C�l4�Cfi�(�6pSR Lp+r CC) caft . -�.� �Z7. 6 OF -Qr-4t6c&t FLOvI: 4VS E-zQ7 : pC I r R .n LAIM1al�1R�TM 1.Veo9 tea ZK%kA.c)aLt45 SULLIVAN a �.a . ' No. 29133 " 8 TER 1 t t p. . '�. + __} SS�ONAL ENS', � ��a SIP ,. L ; - t - . ... 1 wvC, A X 747 Of F4V 1 .w,, �.� A7,O f J u T sus •:a 2 4"'PJL 1sr. c ► t000 44,o . cx � •43• GAL �4'�.$ 4• I- H tNd Sync __j i 13,2. 43.1 OVP C ERTIF'I ED La s-raur P T 'P1N.A _ Lam• 673 EL 3�.0 LocA- tat�;..C' .rr �,�i►�a as )�h ss i $• ! Urst k, eL33' Pl-AK RMF9:R�NcF_ . _ A I? � ��Y�•'�ER. { !'"-� , � r W ._. i a ,. ��1�1 �.TV � �.1��.� �1-E7t 1"'4�..�s�V I 44 f , -; , • Yam, � �-E&l's-IEREEr2 wQ��>a�A�ror.�sHatiu�! �` i R� l craMl�l—Y5 W MA 774E 5 E=s 1-mv:: �„rl E�.tEct�l Qs :.:5TZ.T I Ae—K "EiE�1tQE)r4�N'T'S aFT�IE �s ��11,1�E.� i�lhx ovs/�1�F A.�xsc �E u� IS N o acis- ;WIT14i1.1'> F_ F PL.11%.1 TH S R.qN 15 NZ�'$AS�p oNAN INSTRtJNI NT ' 5UKVEY ANO THE OFFSETS 5HOWN 5Ht)ul'D �p-r t3E Lser Ta ESTh�3LaSN L aT L,1NES. - }��yy SANENE t GU10F 1:i vi 10 5641 to to TO,TNE INCH 1 TOP FNDN. AT EL. 48.4' SYSTEM PROFILE TEST HOLE LOGS ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) PROVIDE INSPECTION PORT WITHIN / ACCESS COVER (WATERTIGHT) TO 6" OF FINISH GRADE ENGINEER: LISA LYONS, RS o�N NO�NG MINIMUM .75' OF COVER OVER PRECAST /� WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 42.5 WITNESS: DON DESMARAIS, IRS LOCUS .`- ELEV. 41.5' RUN PIPE LEVEL 2" DOUBLE WASHED PEASONE DATE: 5/31/05 _I 10, EXISTING 1O O LFOR FIRST 2' 3' MAX. PERC. RATE _ < 2 MIN/INCH TCALL ANK (H SEPTIC 40.1 't* 40.3' CLASS 1 SOILS P# 10,977 5 > cAs 39.58' BAFFLE �� M I-] 1= 0 O CI 71 Ck L7 39.5' F-I C O O 17-J 6" CRUSHED STONE OR MECHANICAL 0 0 ED C [=1 COMPACTION. (15.221 [2]) 2' 0 0 0 �-I C u ® ! 0 37.5' ELEV. DEPTH OF FLOW = 4 MIN 1 % SLOPE • 0„ 43.5' TEE SIZES: ( 1 % SLOPE) ( ) 3/4" TO 1 1/2" DOUBLE WASHED STONE A INLET DEPTH = 10" LS OUTLET DEPTH = 14" 12„ 1OYR 3/3 LOCATION MAP NTS EXIST. LEACHING B FOUNDATION SEPTIC TANK 23 D BOX 10 FACIL.ITY ASSESSORS MAP 147 PARCEL 100 S' LS *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL UTILITIES AND ALL 10YR 5/6 BUILDING SEWER OUTLETS AND ELEVATIONS 26" 41.3' PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM 32.5' C I MS 46.1 + 4 4 L=18.45 71, ! 10 . R=25.00' _�_ 2.5YR 6/3 - '� I. 44.2 + 4.8 + 1 + 47.0 132„ 12" S (SAVE) x,+ "8 32.5' 1 NGWE + 43.7 46.5 NOTES: I 4 YWELL + 6.9 ► SEPTIC DESIGN: (GARBAGE DlsFosER Is NOT ALLOWED ) 1 . DATUM IS APPROX. NGVD B (RE-LOCATE TO B 43 MIN. 25' FROM V a a DESIGN FLOW: 3 BEDROOMS ( 110 GPD) 330 GPD EXISTING ' 2 MUNICIPAL WATER IS 4 AS) 47.3 I USF" A 330 GPD DESIGN FLOW ---- 7 M1N1`"U1 nlDr_ ns �-�� -rn_r+'- -�- o , -,ter -,.• -- lyt 4 H I+ a7.o SEFTIG TANK: 330 GPD ( 2 ) = 660 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10 + 44.7 � 2.8 41.0 I 1000_ 5. PIPE JOINTS TO BE MADE WATERTIGHT.0 2 5 47s I � USE:. A GALLON SEPTIC TANK (RE-USE EXISTING**) LEASHING: 6. CONSTRUCTION . DETAILS TO BE IN ACCORDANCE WITH MASS. 44 + 1- 48.4 r I 2(30 + 9.83) 2 (:74) 118 ENVIRONMENTAL CODE TITLE V. S 12• Rr o SIDES: 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT EXIST. W + 47.5 + 47.3 TO BE USED FOR ANY OTHER PURPOSE. 4 LP 30 x 9.83 (.74) - 21 g + a4.9 4 TOPWFNDN = cn r BOTTOM: 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. 11 48.4' TOTAL: 454 S F 336 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT + 4" -G 47,� .t USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED 4s.� FROM BOARD OF HEALTH. EQUAL) WITH 2.5 STONE AT SIDES, 4 AT ENDS AND 5 w 147s BETWEEN UNITS 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) FAILED LEACH PIT 2.8 4 c° 0 47.7 I **CONTRACTOR TO CONFIRM MIN. SIZE OF SEPTIC TANK n I AT 1000 GALS AND IN SUITABLE CONDITION FOR RE-USE PAVED DRIVE \47.6 TITLES SITE PLAN 7.7` LEGEND OF L__ 47.7 19 BLACK VALLEY ROAD � 100.0 PROPOSED SPOT ELEVATION BENCHMARK: USE TOP IN THE TOWN OF: OF SEPTIC TANK AT ELEV. 41.5' �\ 1OOXO EXISTING SPOT ELEVATION (CENTERVILLE) BARNSTABLE �- 47.9 100 PROPOSED CONTOUR PREPARED FOR: B O RTO LOTTI LOT 673 15,985f SQ. FT. 100 EXISTING CONTOUR CONSTRUCTION/RUSSELL 20 0 20 40 60 BOARD OF HEALTH _ MA SCALE:: 1 20' DATE: JUNE 2, 2005 APPROVED DATE i ^ off 508-362-4541 fox 508 362-9880 ����ZN OF M4s �A �pH of�e4s69cti down cape engineering, Inc o ARNE o ARNE H H �� OJALA CIVIL ENGINEERS � OJALA � CIVIL N No.26 , 30792 LAND SURVEYORS AS01 NA L LNG' f 05-088 939 vain st, yarmouth, rya 02675 H. OJALA, P.L. DATE