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HomeMy WebLinkAbout0096 BRALEY JENKINS ROAD - Health 96 Braley Jenkins Road Centerville A = 171 181 S M E A D No.H163OR UPC 10259 smead.com • Made in USA 2 i arf .__ .. ORDER NO: 675 ITEM: 1 DATE: 06/03/11 Floor Plan 2 Lit Whdow51S 2LIt WI�d�51S H 123 _. 2 LIE Door 595 2 Llp W Ittbw 51 S 2 A W lkdow 81.5 2 LIP W hdow BIB 192tS7Ql17 Dimensions Attachment Height: 1181, B Wall Height: 86.25" B Wall Width: 192" A Wall Width: 123.25" C Wall Width: 123.25" Roof Overhang: 6" PAGE: 1 of 1 i ORDER NO: 675 ITEM: 1 DATE: 06/03/11 A Wall CD CD co A A t 123 114" Dimensions . Attachment Height: 118" B Wall Height: 86.25" A Wall Width: 123.25" Roof Overhang: 6" Layout 0.625"(BASE PLATE)+51.5"(2 Lite Window)+5.0625"(Wall Mullion)+59.5"(2 Lite Door)+ 6.5625"(Corner Post) PAGE: 1 of 1 ORDER NO: 675 ITEM: 1 DATE: 06/03/11 B Wall �. ------------------------------------------------------------------------------------------- W C'3 N 96" 96" Dimensions Attachment Height: 118" B Wall Height: 86.25" B Wall Width: 192" Roof Overhang: 6" Layout 6.5625"(Corner Post)+4.7812"(Foam)+0.625"(WINDOW PLATE)+81.5"(2 Lite Window)+5.0625" (Wall Mullion)+81.5"(2 Lite Window)+0.625"(WINDOW PLATE)+4.7812"(Foam)+6.5625"(Corner Post) PAGE:. 1 of 1 ORDER NO: 675 ITEM: 1 DATE: 06/03/11 C Wall CD Co 123 114 Dimensions Attachment Height: 118" B Wall Height: 86.25" C Wall Width: 123.25" Roof Overhang: 6" Layout 6.5625"(Corner Post)+51.5"(2 Lite Window)+5.0625"(Wall Mullion)+51.5"(2 Lite Window)+ 0.625"(WINDOW PLATE)+7.375"(Foam)+0.625"(BASE PLATE) PAGE: 1 of 1 ORDER NO: 675 ITEM: 1 DATE: 06/03/11 Roof N � N (D p ? 104 2322" 104 23M" Dimensions Attachment Height: 118" B Wall Height: 86.25" B Wall Width: 192 A Wall Width: 123.25" C Wall Width: 123.25" Roof Overhang: 6 PAGE: 1 of 1 No. 00 Fee A96 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: l PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes y RpPlication for Mtgpogal *pgtem Cow6tructfon Permit Application for a Permit to Construct O Repair"( Upgrade O Abandon O ❑ Complete System U Individual Components Location Address or Lot No. ��492F.,?�L�f �C~ �'°' Owner's Name,Address,and Tel.No. Assessor's Map/Parcel-,�Z — ""0 +I-ns�taller's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building �'C `-� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets / Revision Date Title Size of Septic Tank Type of S.A.S. 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. q S' ned Date `�� �✓ Application Approved b Date t f Application Disapproved by: Date for the following reasons Permit No. � Date Issued t3 ' ti'���.'�"-�.F-1�aN•.•-. � v—,r,.��.iw�.+--.--:.i.+.�—.' ".�r-../ti..-r.-.�;a•.e�yy.? Y'y„S.i... µ �A,,,ra, '.v^.+."--..Ist,v. .. ,- � /e� .. No. c ),00 7 ��/ C/ �: .a \fit, Fee ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: F/ :- PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitation for Oigpogar *pgtem Congtruction Permit Application for a Permit to Construct O Repair( .) Upgrade O Abandon O ❑ Complete System eindividual Components ;'Location Address or Lot No. htr��G�.�'lG�y �N Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building aOP `� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date 7 Number of sheets / Revision Date Title Size of Septic Tank Type of S.A.S. 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 Compliancethas been issued by this Boar of Health. ` S'gned Date 3 9/ten Application Approved b Date Application Disapproved by: Date for the following reasons Permit No. lD Date Issued 3 -------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (" ) Upgraded ( ) .�i Abandoned( )by 9L! �'G > le% ore- A,,, ,>,/'r C at �-� G�" P�L�— has been cco-n�structed in accordance with the provisions of Title 5 and the f r Disposal System Construction Permit No. �-},�� "z �17 dated Installer Designer 0'1 p #bedrooms Approved design flow V 3 C� gpd The issuance of this permit shall not be co strued as a guarantee that the system will-function as,designed. Date Inspector \ r s�'�,�ooy� I --- -- �" ----- No. -7 �o Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Iigpogal *pgtem Congtruction Permit Permission is hereby granted to Construct ( ) Repair Upgrade ( ) Abandon ( ) System located at �t� �G�'.��'�y c Tc�`i✓ �'"./' G cEi°' , 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 ust be completed within three years of the(date pe. it. Date /9/7 Approved by 1 Town of Barnstable' 4o. e Regulatory Services h Thomas F.Geffer,Director Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6301 Installer&Designer Certification Form Date: 3 2 1 Designer: Installer:. Address: . 1P, ►�1-) Address: ����i ' L^i ✓ 6 On 3 was issued a permit to install a (date) // (installer) septic system at b L ` based on a design drawn by I (Id dress) !2�7 dated (designer) septic system referenced above was installed substautiall accor certify that-theep cyst y din to design, which may include minor approved changes such as lat : elocation of the �c}�stiriburion box and/or septic tank. I cezti _that the septic system referenced above was wed with major changes greater twll0' lateral relocation of the SAS or any verticaE' elocation of any comport of the.septi"id�, i s stem)but in accordance with State&Local Regulations. Pbn revision or certified as b*t by designer to follow. _- OF DAVi[�}� (Ins er s Signature) - � VASON " *, No:ffl66, esigner s Signature) �A$x _: . s.Sump Here} PLEASE A T URN TO BLS.TARLE �IOAT. `PERT CAT-E OF C4IYIPLIANCE '65"N .= BE ISSUEDwiWM BOTH TMS FORM AND AS- BUILT CARD ARE REOD D BY THE.RAWNSTABLE PUBLIC Ac i'DIMI. -. THANK 3LOU. Q:HealtMeptic/Designer Certification Form. TOWN OF BARNSTABLE LOCATION 1e 4r0rit SEWAGE#JO©-7 `p14< VILLAGE ! ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. %ty /,W SEPTIC TANK CAPACITY LEACHING FACILITY:(type (size) (size) NO.OF BEDROOMS OWNER �G/, ii✓. PERMIT DATE: _" COMPLIANCE DATE: S � 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 l 0 ' r LA(Ir '�/46� \\ � rl X )�\ till i � 1 Town of Barnstable P V oFTME� - „IY' Department of Regulatory Services Public -MAW c Health Division Date �1K/7 rf2639. 200 Main Street,Hyannis MA 02601 IDate Scheduled Tune`_ Go_ Fee Pd. Soil Suitability Assessment or'Sewage Disposal % JF Performed By: _- . \ ;Witnessed By: LOCATION& GENERAL INFORMATION Location Address 5; " Owner's Name �C/ l V Cc�`rT Address Assessor's Map/Parcel: / - /�� D� mg Engineer's Name NEW CONSTRUCTION REPAIR Telephone# �-:is land Use • Slopes(%) Surface Stones Distances from: Open Water Bod \ Y ft Possible Wet Area Drinking Water Well ft Drainage Way ,, c ft'� .. Property Line', ft Other � ft SKETCH:(Street name,dimensions of lot,ex t locations of test,holes'&lierc tests,locate wetlands n Proximity' mximit to holes) ) IJ Parent material(geologic) r Depth to Bedrock t- Depth to Groundwater- Standing Water in Hole: Weeping from Pit Fpcc Estimated Seasonal High Groundwater DET + NATION FOR SEASONAL HIGH WATER TABLE Method Used: �-,Q/�• Depth Observed standing i, obs.hole: In. Depth to soil mottles,Depth to weeping from side of obs.hole: in, Index Well# Reading Date: Index Well level in, Groundwater Adjustment _ ft. Ad),thctor z Adj.Ciro ndwatei Level PERCOLATION TESL' batr 3 . -- µ Observation ,/ PZ ,e_e_ Hole# f rr Time at 4" Depth of Perc p G Time at 6" .e.. Start Pre-soak Time @ Time(9"-6") �1 End Pre-soak << 6 1 .Rate MinJlnch f*1 Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original:Public Health Division Observation Hole Data To Be Completed on Back----------- percolation test is to be conducted within 100, of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to.beginning. Q:ISEPCICIPERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. on i tenc % ravel b- 1Z" �zff Z?' �i lZ0' G fl`�� DEEP OBSERVATION HOLE LOG Hole# —Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. nsi to %Gravel) lob 2 I� G ! - Z GNU C/P X klb. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consiste cy. o Gravel A �w DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Mottling Structure,Stones,Boulders. Surface(in.) (USDA) (Munsell) g r Cons' en 1 _ F Flood Insurance Rate Man: / 1 � `Above SOO,year flood boundary No L— es ✓-__ Within 500 year boundary No_ _Yes Within 100 year flood boundary No____ Yes Y Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervlou a rial exist in all areas observed throughout the area proposed for the soil absorption system? �. . If not,1what is the depth of naturally,occurring pervious material? '. -. Certification I certify.that on /C f Z (date)I have passed the soil evaluator examination approved by the Department of Envir mental Protection and that the above analysis was performed by me consistent with the required training,exper'se a exp rien described in 310 CMR 15.017. v Signatu e � Date Q:\SBp nC�PERCFORM.DOC Town of Barnstable �pE7HE o. Regulatory Services Thomas.F. Geiler,Director 9�A ' •��' Public Health Division Thomas.McKean,Director 200 Main Street,.Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304. August 29, 2006. Mr Richard Dubin 1645 Falmouth Road Centerville,.MA 02632, ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located 96 Braley Jenksins.Road,Centerville,MA, was.last inspected On July 6th 2006. by,Michael Kellett, a certified septic.inspector for the.State of Massachusetts. The inspection of your septic system showed that your system has "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to.the.following: The leaching pit was full of sewage,"flooded with liquid 6" above the.lid." You have 30_days from the date of the of the system failure to bring the system in to compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department.. BARNSTABLE HE H DEPARTMENT omas A. McKean,.R.S., C.H.O. Agent of the Board of Health COMMONWEALTH OF MASSACHUSETTS s ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION y TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: q(, ,3-aj&1jv s Owner's Name: I ` Owner's Address: 16145' Fa. Date of Inspection: bt5 Name of Inspector: (pl se print) Company Name: yuy�haytl* Mailing Address: Telephone Number: t CERTIFICATION STATEMENT --; v personally inspected the sewage disposal system at this address and that the information reported I certify that I have pe so y p � P Y �. 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 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails A W Inspector's Signature: A Date: 7 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address tow the system will perform in the future under the same or different j conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2ofII OFFICIAL INSPECTION FORM�NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 'T 6 ` v —S i Owner: t Date of Inspection:_ (04n 6 Inspection Summary: Check A,B,C,D or E/ALWAYS com all of Section D A. System Passes: I have-not found any informati which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exi .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 ne d to be replaced or repaired.The system,upon completion of the replacement or repair;as approved by th oard of Health;will pass. Answer yes,no or not determined(Y,N,ND)in the for the follow' statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or septic tank(whethermetal or not)is structurally unsound,exhibits substantial infiltration or exfiltration tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic s approved by the Board of Health. sound,not leaking and if a Certificate *A metal septic tank will pass inspection if it is s aurally ficate of Compliance indicating that the tank is less than 20 years of ' available. ND explain: Observation of sewage bac or break out or high static water level in the distribution box due to broken or ,settled or uneven distribution box. System will pass inspection if(with obstructed pipe(s)or due to a bro approval of Board of Health): broken pipe(s)are.repiaced obstruction is.removed distribution box is leveled or replaced ND explain: The sys required primping 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPEC 7F ION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _ K�Gg.0 f Owner: 4,t" Date of Inspection: 6 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determ' 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 R 15.303(1)(b)that the system is not functioning in a manner which will protect public health,sa y 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 wet d or a salt marsh 2. System will fail unless the Board of Health(an ublic Water Supplier, if any)determines that the system is functioning in a manner that protects t public health,safety and environment: _ The system has a septic tank and soil sorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a s ace water supply. _ The system has aseptic tank d SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a s tic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply li**. Method used to determine distance **This system pa es if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and vol ile organic compounds indicates that the well is free from pollution from that facility and the presence o ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criter' are triggered.A copy of the analysis must be attached to this form. 3. Othe 3 Page 4 of 11 OFFICIAL, INSPECTION FORA—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART.A CERTIFICATION(continued) Property Address: 9 � LL � Owner: T2 J I n Date of Inspection:7 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 QC' Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 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. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ v< 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_compoimils indicates that the well is free from-pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is.equal.to or less than 5.ppm,provided that no other:_.failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/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 demign flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems-in addition a criteria above) yes no the system is within 400 feet of face drinking water supply — the system is within 200 et of a tributary to a surface drinking water supply the system is loc d in a nitrogen sensitive area(Interim Wellhead Protection Area—MPA)or a mapped Zone II of a p is water supply well If you have answe d"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Sectio above the large system has failed.The owner or operator of any large system considered a significant at under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. e system owner should contact the appropriate regional office of the Department. L = — Page 5of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B /ff°�I e/ CHECKLIST �y , Property Address: (b �'P JS Owner: Date of Inspection: 66 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 _I,-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) Was the facility or dwelling inspected for signs of sewage back up? q� Was the site inspected for signs of break out? o _ 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? _int_ Was the facility owner(and occupants if different from owner)provided with information on the proper maenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no 4 _ 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(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION �{ i f Property Address: '"A" �.t5 vi 'e Owner: U dl Date of Inspection: n'6 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): c9 Number of bedrooms(actual): �— DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: 0 Does residence have a Garbage grinder(yes or no): Is laundry on a separate sewage system (yes or no): [if yes separate inspection required] Laundry system inspected(Xes or no):V Seasonal use: (yes or no): N0 Water meter readings, if av ilable(last 2 years usage(gpd)):. Sump pump(yes or no): Last date of occupancy: 5/0 6 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 K ): gpd Basis of design flow(seats/ tc.): Grease trap present(yes or Industrial wasteholding s or no):— Non-sanitary waste dis arged to the Title 5 system(yes or no): Water meter reading if available: Last date of occup cy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box, soil absorption system Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of al components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 1111�7 6 Page 7 of 1 1 OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 f15 at Owner: , D( b l h Date of Inspection: BUILDING SEWER(locate on site plan) . Depth below grade: Materials of construction:_cast iron _Y40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: 9 (locate on site plan) Depth below grade: Material of construction: t concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance (yes or no):_(attach a copy of certificate) / Dimensions: rUUO�C,�r Sludge depth: (1 Distance from top of sludge to bottom of outlet tee or baffle:Q?Z. Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottoruR f outlet tee or filer How were dimensions determined: /'16GtSd/^ Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related outlet invert,evidence of leakage, etc.): V' jv,e GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal tberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to to outlet tee or baffle: Distance from bottom of scu o bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping commendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet inv , evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal rg ass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gall s/day Alarm present(yes or no): Alarm level: Alarm' working order(yes or no): Date of last pumping: Comments(condition o larm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of ox,etc. : e I„ t*f-- c PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no):. Alarms in working order(yes or no): Comments(note condition of p chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C S rYSTEM INFORMATION(continued) Property Address: Owner: )U�i VL Date of Inspection: 040 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches, number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): I nn aa r� to 6 46 k" vl,c..s b t S'V r/bs/� to i u 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 constructio . Indication of ground ter inflow(yes or no): Comments(note c dition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on sit plan) Materials of construc 'on: Dimensions: Depth of solids• Comments(. to condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I 9 f Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) Property Address: Q Owner° rL Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or be arks. Locate all wells within 100 feet.Locate where public water supply enters the building. 13 J Page I I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-I�^NFORMATION (continued) Property Address: q 7 Q v�v.(LS �Q Owner: Date of Inspection: p SITE EXAM Slope ►Y . Surface water 00 Check cellar(JO Shallow wells V" Estimated depth to ground water 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) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevyation: pD 1� 2 C Cyc aS�74_4' 11 l T. No....... .:? Fimx.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � f 197-3 .......... ...........oF.....- Appliration for Disposal Works Tnntrnrtiun Prrmit Application is hereby made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal System at: fi{ 5' 49 ..................__.... ...........�1 Ac.s �l ---------.........zuv' - ... ..................................... LE-8 Location-Addresses^ or Lot No. Owner •s���j.� f�� ress a ..... ,.. =. _ ":rl.................... .... �.....------ Installer t Address w Type of Building 1 /j d0 c7 Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder Other—Type a ype of Building ..�.�.�_S .1�_..___! 'No. of persons........... �_..._._..._. Showers (—�•_' Cafeteria' '- Otherfixtures ..........-••-••••••-••-•••••-•.........-••••••-••••••-_....-••-••-•••••-•--•••••-••--•••••••-••••••--••-••-•••........--•••••............•-•-• w Design Flow...........................457 .....gallons per person per da�. Total daily flow...........a.4A... ...............gallons. .W Septic Tank—Liquid'capacityL�°. ®gallons Length. ........... Width.._..`®"Diameter................ Depth_-S`...Vi x Disposal Trench—No. .................... Width.................... Total Length.............. _Total leaching area....................sq. ft. Seepage Pit No...........t....... Diameter....... Depth below inlet....2e.......... Total leaching area...�'ISsq. ft. z Other Distribution box (P-r- Dosing tank '-' Percolation Test Results Performed b ......... �Y................. Date.... - Test Pit No. 1....—...?-.minutes per inch Depth of Test Pit...... ........ Depth to ground water....1__________________ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........... -_-----.-_--. 9 •--------------------------•••••••-••...............-••••••••••..........•.._...... ... --------- ------ O Description of Soil..........1'1_� -.......................................................�5 '� Al �� L"..�_ca.�'f�__._..� _l_�.�.✓�L x w UNature of Repairs or Alterations—Answer when applicable............................................................................................... .•-•••-......-••••-•••• •------ ----•----------•••--------------------------------------------- Agreement: The undi agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI'I LEa 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the b ar of health. Signed........- •-•.� L . ---•--.....-•-•- Application Approved B Date Date Application Disapproved for the following reasons:---•-•-• --•••-••••-•••••-•••••••.....-•--•-•-----••-•--.......--•- -:•• •-•••-••-•••......•---- • . ••-•-••••••••-••••••--•••-•-...••••-•-•---•---••••-•....-••- QQ Date Permit-No........C1.4!•- -- ................... Issued_....................................................... Date 6 PT. No....................... T�� Fi$.............................. THE COMMONWEALTH OF MASSACHUSETTS �y- BOARD OF HEALTH �� "� '3 2_3 .......1<510 F......t3/4 f: ./J. -"4 6............. L C Appltration for Uiiposal Mirkii Tonitrurtion ramit Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewagft?tposal System at: _ Q(p / — Location;�ddcess or Lot No. .....o E4 u`'`" ----.../ ............................ .. .. .... ..._Z.1 Z...-- - Owner }f�� % Y` � Address � ^n . ll..�'----- -------------- Installer Ta a � '[�� Address Type of Building t i Size Lot..... 6-0.------------Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic -(—� Garbage Grinder �---� HE'S. ) a Other—Type of Building ____________________________ No. of persons.............___------------ Showers (-')�— Cafeteria ( ) 04 Other fixtures ---••----------------------------------------------------•---•---------•----•-----------------•--•--------------- W Design Flow............................................gallons per person per day. Total daily flow..........................................._gallonss..; WSeptic Tank—Liquid capacityf '"'gallons Length.. ._.__ ._._ Width__.1_.."'._ Diameter................ Depth............ x Disposal Trench—No..................... Width.................... Total Length.__...�...�__.-Total leaching area....._-�.�..sq. ft. Seepage Pit No._..._._...�_...... Diameter......./.. ...�.. Depth below inlet................... Total leaching area..................sq. ft. Z Other Distribution box ( Y)'•r Dosing tank'(� i W Percolation Test Results Performed by...... ----------��---e----------•----------- Date.----------/_.__.�- ----zr Test Pit No. I.....-..._---_.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........................ P4 --------•-----------------------•----•-------------•---- ---•-----------.....-•----........----....---...•---•-----....-----........._.... . O Description of Soil f?'� rn........................................................................................................................... 5.. .\/ "—:"x � " Cs 1� / �-> i t --I J F7G.- x -----•---------•---------------------•-•----•-----._......_.----•- U ---•-------------------------------------------•---.................----------------------------------------------------------------•--- W --------------------------------------------........------------------------------------------------------------------------------------------------------•-------------------•--••-------------------. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ....................... ....................... -------•-•--------........--------------------------------------------------------•---------------------------------------.....---- Agreement: cam` The undersigagC e s o install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT?2 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance Signedhas be sued by the-board of health. _ - -/4-)1Zu,, e� j .L_". ./" !(y. C3 Date Application Approved BY-------------------------•---------------. -------- ......... ......... .............. - --- Date Application Disapproved for the following reasons:--------•-----••---------------------------••......----------•-----•----------•----------------•-•------....... ----•-•••------------------------••-•----•-••--•...-----------•-•---------...•-------........---------•---•------••--•--•---------•----. Date PermitNo......................................................... Issued-................................... Date THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH .........ICJ..�!?�,.14...............OF....... . .IC ................................... Trrtif iratr of Tontplianrr THIS IS,TO CERT FY, That the Individual Sewage Disposal System constructed (-for Repaired ( ) by------------------ ti 'r ------....A. ............ -'tea' 1�.................... / _ (�Q Installer at---------------r--1._.�..'.-•------ 2�� 1�!_N. ��1�......-•-- CTG .�d( has been installed in accordance with the provisions of TITLE. 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated..........................__.................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................... ....................----- Inspector......�........a.... ... ............... I-Ir - ; 3 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ac a FEE........................ Disposal Works Tonitnution famit ���� ��f . C71 Permission i hereby granted...... _.. �3 - . Ito Construct ) or air ( . ) n•pdiv� 1C ewage&sp `:V 14 t G-V t (� at .... ............... ... .................%...1� Street " r6 as shown on the application for Disposal Vorks Construction Permit No________________ ___ �te�._........._.._...... ---------------- ---------------.--- DATE.......�_ . ___�..�. _.� . oar of health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS " - -- - _ TOWN OF BARNSTABLE ,�-`-R � - t -5e�.\Q; it 1�J-,- t; LOCATION c'� ��� ���►,�,�y SEWXGE # (6 6 S / r7/- VILLAGE ASSESSOR'S MAP & LOT AJA C INSTALLER'S NAME & PHONE NO. (0 SEPTIC TANK CAPACITY \ 0©U ax ' a LEACHING FACILITY:(type) Q \"-v (size) Q t�NO. OF BEDROOMS .-� PRIVATE WELL OR UB�,IC WATER fl BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: •- �! - 7 VARIANCE GRANTED: Yes No „/ � F c o�'� � tea` 3 \, 6, a � �, 3� S0I L LOG f DATE: 4., 7 2 813 WITNESSED BY, + . CD4_n. Pot , 2 5vt3 Ca/L 55'L/ers ho7"> , e-1' at G P r)V E'4. NZN yQ l4 f MrD,Uri 0 l - ,• TA�,I piS d, MANHOLES AND COVER TO SE ' BUILT WITHIN I' 7 a ELEV.-TOP of •'`: ,-'- - 12" OF FINISHED GRADE . w� i a FOUNDATION �'.rt�•,RG °°%f F ,•• ' ' .,.•� `. ,-- AA 1 N. 2,-.' SLOPE r2 l" / t� } ' f1N ►SHED , GRADE t n e 4 CAST tR0 , . 4 0 OR ., :.•• 4 PVC SC IST - PVC SCH. 40 °„;, P iTCH i ,q:` FT. � 2'i_EV£L: rr MIN. , ?-" LAYER �' :.� tat: _._L.._ ,.. _._�� .✓ �°•r 10 •�` i��rr 12" PE----w- , ' ` r p• PITCH _ / �� " ,.•., • :e f- CTtQ•�� ASTONE ; . iFL ! ©fl '� �.: 1- n to INVERT 5"` GALLON INVERT DtS'C. v INVERT SOX a17 ,31 I I/2 DtA, SE PTtC TANK v'3.4 " .D 5 a t''�. WASH LdT r48 INVERT .,p � V UZ). .. ED $TONE 3 ----- -- , �2' p+_ INVERT n' p w dpa` ALL AROUND . 4C3C7 .�� �12f'•%� �� '•'p; r , � _ r, � s ��' � W dw� GAR AGE f a p". _ _ o o: EL.EV. SOT T0M - - � �� - - :®�� MtN. GRINDER -" of PIT j C , 1 f, �3c�T: C T, HOL ELEV. Vim_ ` PROFILE OF GROUND WATER TABLE Z30r4ONA S A N I `I•' ARY DISPOSAL SYSTEM NOT TO ` SCALE DESIGN DATA P AL � BEDROOMS CONSTRUCTION OF SANITARY DIS OS DESIGN FLOW- ,33t5 GAL./DAY SYSTEM SHALL CONFORM TO MASS. LEACH RATE • MIN./INCH E N V I RONME NTAL CODE TITLE V (REVISED 7- 1 - 77� AN D THE TOWN OF r2 r 04 PROPOSED LEACH CAPACITY ' HEALTH REGULATIONS. o SEPTIC TANK, DISTRIBUTION BOX AND LEACHING PITTO BE OF REINFORCED CONCRETE : ' -F" GAL. DAY MIN: CONCRETE STRENGTH 3000 PSI MIN. STEEL STRENGTH 2O,OOOPSI H 10 DESIGN `LOADING DRIVEWAYS ,NOTTO ' BE LOCATED OVER SYSTEM UNLESS H • P- 0 DESIGN LOADING IS USED. ALLPIPES AND FITTINGSTO BE WATERTIGHTAND TO BE OF CAST IRON OR , SCHED '40 P.V. C. S [ T E �.. S MOWING PROPOSE D CONSTRUCTI .® N SN.�oF t SHS L .aCATI C3N� ,_ - LEGEND „ FOR " " , . y'. 1 f�. APPROVED I9 " SCALE DATE _, -- BOARD , 0F HEALTH BUILDING SETBACK ' REGULATIONS PER EXISTI NG CONTOUR 16 REFER £ N C E �- v < ,� f YG,�^/ .8 .3<5� BUILDING INSPECTOR OR BU LD PROPOSED CONTOUR 16 DATE AGENT ' COMMISSIONER . - M �t N. FRONT SETBACK EXISTING .SPOT ELEVATION 17. 6 PROPOSED WATER SERVICE itN M c /4 R �� MIN. SIDE SETBACK �. ,. Ait LOC AT I O N . TEST HOLE' MIN. REAR SETBACK l O Cl�'t1. Na 27= R O '�" i N � a Y INEERS _ 'PROFESSIONAL LAND SURVE ORS: 8 ,ENG ' r I W T, M A I586 MAIN' . ST`REE. RTE. 6A EAST DE NN S SS, 4264 (� \J i - A r , .. y ASSESSORS MAP: , -- TEST HOLE LOGS PARCEL: I Q� .�- NOTES: FLOOD ZONE: �� �pPUGiA- SOIL EVALUATOR: ---- WITNESS: T REFERENCE: mil' 1) The installation shall comply with Title V and Town of Barnstable Board of Health REFER 'I� ''jt� I �Z-�_ DATE: -- �` ; ,. Regulations. 1J PERCOLAT I ON RATE: ,.G.Z. ZL1 2) -The installer shall verify the location of utilities,sewer inverts and septic components prior to installation and setting base elevations �l " t` -j, I�Qu q -•�*t• l� �j 3) All gravity septic piping to be 4 inch Sch:40 PVC at 1I8 per foot.The first two feet out of the TH- 1 TH-2 d-box to the leaching shall be level. �.1 4 This plan is not to be utilized.for property line determination nor any other purpose other than Z ii t7 the proposed system installation. 5) All septic components must meet Title V specifications. Lt 6 Paricing shall not be constructed over HI0 septic components. 7) The property is bounded by property comers and property lines. J,' 1 8) The property owner shall review design considerations to approve of total design flow and LOCATION M A P J,�-- number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material per Title V C1 abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean washed sand per Title V specs. �'✓ I1 10) System components to be 10 feet from water line. Sewer lines crossing the water line shall be d 1 ! sleeved with 4 inch SCH 40 PVC with ends grouted if applicable. O �} 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure I� 1 such. ---- 12) The installer is to take caution in excavation around the gas line if applicable. . `T M` -DES I GN SEPT L �. SYSTEM FLOW ESTIMATE ; /OC7.O C� �. BEDROOMS AT, GAL/DAY/BEDROOM • GAL/DAY ## i t SEPTIC TANK ; GAL/DAY x 2 DAYS -.,C�GAL USE = GALLON SEPTIC TANK(CIS ! t28�a� h4t�EQL t� 1,40 AtLk S IL ABSORPTION SYSTEM 15 V SIDE AREA: <Z Z� '— - L3': �{ x , '7 r /D�f, Z y , 9� �p c, I. BOTTOM AREA: f��`Ti PS ��srEp ,� / to &O SEPTIC SYSTEM SECTION y aQ 1 ti'M , c, ,� NiAo r ra'Mq44. elm, oC ft t �« r % 4 D-sox 5�, 1 tl --- I b � �' GAL SEPTIC TANK X /3 �w ? 74DI) ,r N Lo SITE AND SEWAGE PLAN +� . LOCAT i ON: °I L o PREPARED FOR �"t p 1L P C " SCALE: — o I DAV I D $ . MASONt'RS DATE. o v D$C ENVIRONMENTAL DESIGNS W DATE HEALTH AGENT EAST SANDWICH`. MA � ( 508} 833-2I77