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HomeMy WebLinkAbout0006 BRALEY JENKINS ROAD - Health 6 BRALEY JENKINS7CENT:ERVILLE A=170-190 j i j r UPC 17534 Ng.2-15 COR KASTINGS.YN No. J Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplication for Migo!6al *pgtem Con5tructiou Permit Application.for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. h4 Owner's Name,Address,and Tel.No• gq /t/�j►f'�1�, vvvv�iii Ob t Assessor's Map/Parcel U bl i ,-g-Ak fro �®��►���vo�� installer's Name,Address,and Tel.Ne4jeb f Iu 1q Designer's Name,Address and Tel.N AV f/6 /11 ASOK) o l?/ Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder (Rq Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.requ' ed) 13 d gpd Design flow provided v gpd Plan Date d Number of sheets Revision Date /y —� Title Size of.Septic Tank /,900 COL 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 rd Health. c SignedA ° d ate —if— Application Approved by ate Application Disapproved by: Date for the following reasons kool Permit No. Date Issued b. No. � M� �. .," p Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 1 Zipplication for Mioont *pgtem (Con0truction Vermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. /„ A J Owner's Name,Address,and Tel.No. n// ;� , Assessor's Map/Parcel 1 170 bl J_ C., f f ✓!� r� � % Installer's Name,Address,and Tel.N�4�PO4) ��i' Designer's Name,Address and Tel.No.�/ V I b /y Aso t) Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder �11? Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided () gpd 7 Plan Date /Z 6 1)8 Number of sheets L Revision'D e -4& ' Title / Size of Septic Tank Type of S.A.S. 7 / A11.1 A Ai d- Description of Soil _ V / r Nature of Repairs or Alterations(Answer when applicable) ,01-46, J%.,ttr.,/a/VO 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 o At of Health Signed . t �' A ° d ate �� 1t — •'�� v y Application Approved by / ! Date Application Disapproved by: v W Date r' for the following reasons Permit No. "� Date Issued „l .� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (tbmpliance THIS IS TO CERTIFY,than the On-site pS�ew/yage Disposal System Constructed ( ) Repaired ( Upgraded ( ) Abandoned( y�by / `�//��j-MIS � /jr1,I ,rd� at 49 J / C 1/ � �;!V��/ S fe��_ 0�'"r,,A �1��been co structtee yd iinn�accordance Ws1- t-- C . r L/- - 1 ..! .l with the provisions of Title 5 and the for Disposal System Construction Permit No. dated - Installer Designer v ~ #bedrooms t Approved design flow gpd /1 The issuance of this A ermit sWallt lie construed as-a guarantee that the system-wil function as-designed.- � _r�/J� a O Date Insp ector. -- No. Fee-_���^—•---- THE MASSACHUSETTS OF COMMONWEALTH C PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Migo!goY �§pztem Cow6truction Vermit Permission is hereby granted t ))Co struct ( ) �R,.e/pa�ir ( / Cpgraden( ) andon ( ) System located, 119 A � \/L, � ! J ( �r 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: ConstLucIlion ��must be ompleted within three years of the date of thi ie it. Date �/h� _ Approved by /� Town Of Barnstable ME_r Regulatory Services Thomas F.Geiler,Director as ii�:sii►sILE. A 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: j A Zone \" Designer: 1J '�'`t Installer: A T-- Address: . � VV��� 1 Address: �OZ On '� r was issued a permit to install a �date) (installer) septic system at � YW� based on a design drawn' (address) "by dated (designer) ►'' I7 eerti fy that the Septic system referenced above was installed substantially according to ::lie design, which may include minor approved-changes such as lateA, relocation of the dll tribution box and/or septic tank. t. . I certifjx'that the septic system referenced above was inst d v►nth`n�a�o :changes ( �:e. greater than'l0' lateral relocation-of the SAS or any vertical; elocafion of any component of the sep6epystem)but in ae'cordance with State &Local_Reg nations. Plan revision of certified as-birlt`by designer to'follow. ZNy�FMgs (Installerh,Signature) 6• cGn MASON R, .No: 066 9FQ� P� _ • �sgNlTAa�Pd (D er s Signature} (Affix gner's Stamp Here) PLEASE RETURN TO BARNStAj iUE PUBLIC HEALTH DIVISION,. CERTIFICATE OF COAZLIANCE Wl u.1°NO E : SSUED JUN WTHI:=&iFORM AND" AS= BUILT CARD ARE RECEWED BY-4-THE.THE.BAIL. STABLIE PUBLIC HEA�LT$DIVISMW Q:LlealtidSeptic/Designer Certification'Fom, ;. I t R i Town of Barnstable. r# Department of RekWatory Services n . Date H Di P7 - ; Public ealth visioII Maiii'Stree4 Hyanni MA 02601 z %6J 2009 °$ ��FD µ1►'tA I . ` I r Date Scheduled Time Fee Pd. ,foil Suitability Assessment for Sewage Disposal Performed By: �`� \/t Witnessed By: AO1 i LQ ATION & GENERAL INFORMATION �m J� , } Location Address o r! Owner's Name T, tie Address Assessor's Map/Pnrcel: Engineer's Name7? � F 7i` NEW CONSTRU .,ON REPAIR Telephone# Land Use Slopes 09) ' Surface Stones ' / t ft Drinking Water Well ft Distances from: Open Water Body Possible Wee Area -f- � d ft • Drainage Way ft. Property Line �ft Other o ea C c_ V SIOTCH:(Street name,dimcnsiods'of lot.exact locations of test holes&Perc tests,locate wetlands in proximity es) C C. > I I . I i I i • Parent material(geologic) JrV 1"�'�c.c Depth to Bedrock Depth to Groundwater. Standing Water in Hole:' " o . i Weeping from Pit Face Estimated Seasonal iHigh Groundwater � DtTERMINAI TION FOR SEASONAL FII(�]E�'V�ATER TALE Method Used: In. In. Depth to salt mottles: � Depth dbse-ved standing in obs.hole: I in, Groundwater Adjustment Depth toiweeping from side of obs.hole: , (�etor - Adj.Groundwater l evel,.,e Index Well# Reading Date: Index Well level Add• ' PERCOLATION TEST Date Observation I I Time at 9" Hole# It ! 3'1 Time at 6" Depth of Perc ------^— Start Pre-soak Time.@ End Pre-soak hate MinJlnch '. Additional Testing Needed(YIN) Site Suitability Assessment 4 Site Passed Site Failed:___- — "+ om leted on Back-- Original:.Public H41th Division Observation Hole Data To BeBa P ***If Percola ibn testis to be conducted within 100' of wetland,,you must first notify the u ,-nnetahlP rAdservation Division at least one(1)wedk Prior to beginning. 9 1 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel g Z DEEP OBSERVATION HOLE LOG,- . Hole# Depth from Soil Horizon Soil Texture Soil Color Soil ' Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) r• DEEP OBSERVATION HOLE LOG Hole# Depth from' Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel)-- DEEP OBSERVATIONHOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, ,r r . Flood Insurance Rate Map: Above 500 year flood boundary No— Yes l Within 500 year boundary No V/ Yes Within 100 year flood boundary No ✓ Yes Depth of Naturally Occurring Pervious Material ' Does at least four feet of naturally occurring perv'outerial exist,in all areas,observed throughout the area proposed for the soil absorption system? If not,what is the depth of n turally occurring pery ous material? Certification �. I certify that on (date)I have passed the soil evaluator examina(ion approved by the Department of Environ 6ntall Protection and that the above analysis vras'performed by me consistent with the required training,exper' e and x eri nee described in 3.10 CMR•15.017. Signature V Date 7 Zt 7008 Q:\SEPTIMERCFORM.DOC 1 IKE Town of Barnstable Barnstable partment i e'ca�i Regulatory Services De BAMSTABLE, 6 . Public Health Division i39gp. `� m ArE°r"as A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO June 4, 2008 ,Joe Slominsky 6 Braley Jenkins Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 6 Braley Jenkins Road, Centerville, MA was last inspected on May 23, 2008, by Brad J. White, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Back up of sewage into facility or system component due to 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. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE OARD OF HEALTH in McKea , R.S., Cl�� Agent of the Board of Health CERTIFIED MAIL#7006 2150 0002 1041 9709 Q:\SEPTIC\Letters Septic Inspection Failures\6 Braley Jenkins.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 Braley Jenkins Road Property Address Joe Slominsky t ! I q y Owner Owner's Name information Centerville MA 05/23/08 required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Brad J. White cursor-do not Name of Inspector use the return key. Bluewater Company Name 350 Main Street Company Address West Yarmouth MA 02673 City/Town State Zip Code (508)775-2800 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 F sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Tit 5(310 CMR 15.000). The system: Passes ❑ Conditionally Passes ® Fails cJ Needs Further Evaluation by the Local Approving Authority N ` L 05/23/08 bisector's Signvspector Date ` The system 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. SlominskyT-5.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Braley Jenkins Road Property Address Joe Slominsky Owner Owner's Name information is required for Centerville MA 05/23/08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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. Answer yes, no or not determined (Y, N, ND) in the ❑ 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. ND Explain: ❑ 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 ❑ obstruction is removed SlominskyT-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 6 Braley Jenkins Road Property Address Joe Slominsky Owner Owner's Name information is required for Centerville MA 05/23/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(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 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. SlominskyT-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Braley Jenkins Road Property Address Joe Slominsky Owner Owner's Name information is required for Centerville MA 05/23/08 every page. Cityrrown State Zip Code. Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 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 ® El clogged 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 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. SlominskyT-5.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 • f I I Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments 6 Braley Jenkins Road Property Address Joe Slominsky Owner Owner's Name information is required for Centerville MA 05/23/08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. ❑ ® 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.6 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 fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board-of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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 I I 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. SlominskyT-5.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 6 Braley Jenkins Road Property Address Joe Slominsky Owner Owner's Name information is required for Centerville MA 05/23/08 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following:. Yes No ® ❑ 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) ® ❑ Was the facility or dwelling-inspected for signs of sewage back up? ® ❑ 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? ® ❑ 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)] SlominskyT-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System'Page 6 of 15 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 6 Braley Jenkins Road Property Address Joe Slominsky Owner Owner's Name information is required for Centerville MA 05/23/08 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): ur4VJ40%zi" Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Unknown Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes Z No Laundry system inspected? ®'Yes ❑ No Seasonal use?' ❑ Yes ® No �(p Zile C.-PP Water meter readings, if available (last 2 years usage (gpd)): D, . 200&*o Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial 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: Last date of occupancy/use: Date Other(describe): SlominskyT-5.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Braley Jenkins Road Property Address Joe Slominsky Owner Owner's Name information is required for Centerville MA 05/23/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (coot.) General Information Pumping Records: Source of information: System was pumped approx 1 year ago per owner 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 System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ No) 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): Approximate age of all components, date installed (if known)and source of information: Septic tank, distribution box and leaching pit dated 1986 and infiltrator upgraded in 1997. Were sewage odors detected when arriving at the site? Yes No 9 9 ❑ SlominskyT-5:doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 6 Braley Jenkins Road Property Address Joe Slominsky Owner Owner's Name information is required for Centerville MA 05/23/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: --� feet " feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): ----d Building sewer appeared to be in good condition no evidence of leakage. Used camera to check all exterior piping with no visible issues found. Septic Tank(locate on site plan): --lam Depth below grader 3'-10"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: 8'X 4'-10"X 5' (1,000) 5„ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28" 311 Scum thickness 8" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Measured SlominskyT-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 6 Braley Jenkins Road Property Address Joe Slominsky Owner Owner's Name information is required for Centerville MA 05/23/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee and outlet baffle appear to be in good condition. No evidence of leakage in or out of tank. Inlet has a riser 6" below grade, while outlet is 46" below grade. 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 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): SlominskyT-5.doc•03/08 Title 5 Official Inspection Fork Subsurface-Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Braley Jenkins Road Property Address Joe Slominsky Owner Owners Name information is required for Centerville MA 05/23/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert +2 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.): -0, D-box is level. Line to leaching pit has speed leveler in it. Line to infiltrators is sitting in the line for more.than 3/4 of it. Ran camera to infiltrators, infiltrators are full, ran camera to pit, pit only had 2" from pipe to water. Box is 50" below grade Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No SlominskyT-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts. m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 6 Braley Jenkins Road Property Address Joe Slominsky Owner Owners Name information is required for Centerville MA 05/23/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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: Type. — �® leaching pits number: 1 @6'x6' ® leaching chambers number: 4 ❑ 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.): Soil is wet. System is in hydraulic failure. Vegetation is normal. No ponding. Infiltrators are overfull and leaching pit had been not used in approx 1.1 years and only had 2" of space available between pipe and liquid. System is in failure. SlominskyT-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 6 Braley Jenkins Road Property Address Joe Slominsky Owner Owners Name information is Centerville MA 05/23/08 required for every page. City/Town State Zip Code Date of Inspection D, System Information (cont.) 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 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.):` SlominskyT-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Braley Jenkins Road Property Address Joe Slominsky Owner Owner's Name information is Centerville MA 05/23/08 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage isposal System: Provide a sketch of the sewage disposal system including ties to at least two perm Went reference landmarks or benchmarks.,Locate all wells within 100 feet. Locate where public ateerr supply enters the building. G � - A v R i u G 1ni (-C-A P .,r z A- 2 13% I a SlominskyT-5.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 Braley Jenkins Road Property Address Joe Slominsky Owner Owner's Name information is required for Centerville MA 05/23/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 1 feeett . 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: 10/17/86 Date ❑ 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: Well A1W230/Zone D/Level 22.7'/Adjustment 2.9 x 12" = 34" You must describe how you established the high ground water elevation: Test hole from 1986 indicates no groundwater @ 12'. System is in failure and needs to be replaced. There is also a slope off to the right of the property on the roadway. System will need to be upgraded. SlominskyT-5.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 i i I _ .......... --n- -_ -.. . - - - _ - -- - - _ _ � ; I 1 r { _....... -- - - -- _ _. - _ ,. , I._. 9 r , ...... . i : ;I : i ' I 1 -- -- I� f f _ I I f 1 I 1 i I I - - - - I i I I I I �r r - I ( I 1 I • I , I I ! I I I I I I Ix I IN � : I ..{_........... ......,�/YYV'{.�..4(... .' _._......... .. 1 .._._ :.""�W/^ vY_`•• � .. 0 .•_"•"Y��/V�Y'. _. ,. ...i..._.._ ...__i._.._,...�.--- I , i f I ' I ' i rPATI 1 f I r i I o I r f t ... ___.._._..' I 1 �° 1J : �_ _.i,NA.IC�TIo►.D_;-__®F_..__.�Rcz.cy ' �,,y4T'� I 1 i � r I , I I- : -.I -- - __. r r I Ne rpm Town of Barnstable op7 P��o regulatory Services ■umnABLE, : Thomas F. Geiler, Director ATED �A Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction,Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. Q:\SEPTIC\Disclaimer Private Septic[nspections.DOC TOWN OF BARNSTABLE LOCATION b/ 40. SEWAGE # —35 VILLAGE CP- S'SESSOR' T INSTALLER'S NAME&PHONE NO. 000eJ), , /'bh� �—Od SEPTIC TANK CAPACITY 16L;V ('741le"I LEACHING FACILITY: (type�o7 �dD �4f.eWf,f rWc&J (size)07 ?t 1 NO. OF BEDROOMS .3 BUILDER 01 QW7T 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 or � 1w g p No. � �✓ Feed THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MAS CHUSETTS 01ppricatiou for &.5pozat *pztem Conotruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components ti Location Address or of No. 7 + Owner's Name,Address and Tel.No. G 0 j �l Assessor's Map/Parcel / O Inst er's Name,Address,and Tel.No. 7 7 49 Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 13 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1 1..__P Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been.issued y t is Board o e lth. Signed. Date Application Approved b p Date a — — Application Disapproved for the following reasons Perm it No. Date Issued — �' No. / . : Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASS CHUSETTS 'Application for Mie;paar *p5tem Conotruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or t No. Owner's Name,Address andTel.No. 6 % Assessor's Map/Parcel 9 e.�tc,• o Inst is 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 No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Aepairs or Alterations-(Answer when applicable) �•� L4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board o-He lth. Signed f . ` "' Date Application Approved b Date { Application Disapproved for the following reasons Permit No. Date Issued 4 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CER IFY, that he qn-`site Sewage Disposal System Constructed( )Repaired (Upgraded( ) Abandoned( )by at aa,.been constru ted in accordance with to provisions of Title 5� and a for Disposal System Construction Permit No. ' %� dated �rr,.� '' � . Installer Designer The issuance of this Sm- t shall not be construed as a guarantee that the system will function as designed. Date Inspector F 8 — No. 97�,7"�� --------------- ---------Fee �^✓�z/ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwi! poe;al *p5tem Construction Permit Permission is hereby granted to Construct( )Repair(Upgrade Abandon( ) System located at (v �'� rti-� .� and as described in to above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and to following local provisions or special conditions. Provided:Construction must be completed within three years of the date of th' i . Date: °�' Approved � ' �% NOTICE: This Form is to be used for the Repair of Failed Septic Systems Only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL NVOItKS CONSTRUCTION PEIINIFF(WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated , concerning the property located at eets all of the following criteria: There are no wetlands within 300 feet of the proposed septic system v• There are no private wells within 150 feet of the proposed septic system �• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed `• There are no variances requested or needed. SIGNED 14 DATE: _ g— q—7 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. p,} no I TOWN OF BARNSTABLE LOCATION SEWAGE # 7 7 VILLAGE` ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ,l D7rU LEACHING FACILITY: (type) e (size) C Y- -a - / NO.OF BEDROOMS I? BUILDER:OR OWNER PERMITDATE: Y- S- `l 7 COMPLIANCE DATE: R II. 72 Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 ,44, 0 5 T' TOWN OF BARNSTA.BLE J410 LOC TON �— SEWAGE # Vf!.LAGE_ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1 D71-0 LEACHING FAC1L1TY: (type) (size) NO.OF BEDROOMS I? BUILDER OR OWNERt PERMIT DATE: g— COMPLIANCE DATE: Il• 72 Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 " �3 0 M - TOWN OF BARNSTABLE LOCATION \ o _ �c, g�o�\e� Je��.��,SEWAGE # G^ 1 VILLAGE ASSESSOR'S MAP LOT 5INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY (j b U G,CUc. �U EACHING FACILITY:(type) (size) (D �NO. OF BEDROOMS 3 PRIVATE WELL OR WATE \ i BUILDER OR OWNER O S DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No t/ 37 act s f • F coc.�- • L No...................... YmB ...... THE COMMONWEALTH OF MA,S*SACH11SETTS / BOAR® OF HEALTH 0 �i Apphration for 11ifiVasFal Works Tonstrnrtion Famit Application is hereby made for a Permit to Construct ( ! or Repair ( ) an Individual Sewage Disposal System at: !•(�, `�po7l j p� ---------� -- "= •. .....�'t.N�..- ---- ---------- Location o-V � � o. ...... ... f ���e�.........�. G ner I1�� n Address a .. ..... ... .........................................................G� f ?T :E:f....--•---. C Installer �-� Address Type of Building ���JJJ Size Lot.. S feet Dwelling—No. of Bedroom ............. ......... ...............Expansion Attic ( Garbage Grinder�( - p114 Other—Type g No. of persons.._._... ______________ Showers (� Cafeterias'Other—T e of Building - - dOther fixtures�....................................................................................................................................................... W Design Flow.................. . ------gallons per person per day. Total daily flow.._......_=�........... ._.._...._._gallons. WSeptic Tank—Liquid capacity_/ggggallons Length E...�:.... Width.`�_..l._.........._ Diameter________________ Depth_.,!5...l= x Disposal Trench—No. ......... ......... Width.................... Total Length.....................Total leaching area........ _..;,,sq. ft. Seepage Pit No....__.._�._______-- Diameter.......f�.�.__ Depth below inlet_. f ._�.. Total leaching area.__�`�..t«�`...sq. ft. Z Other Distribution box (� Dosing to '-' Percolation Test Results Performed by.--..� . . -------- Date...,/.��. a Test Pit No. 1........_..�inutes 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........................ O f_...... . . - -------------------------- ------ -----------•-- Description of Soil------...... 1 E 1 w' �- `� v x --------•----------------------•---•-•--•-•••--•--•----•• 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 TITI U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the bo d health. Signed �� .5-/Z 2/... . Application Approved By---••----•-•--•••---•------•-------_.•.... . 1110. 11 il� Date Application Disapproved for the following reasons--------------------------------•------------------------------•--•--------------•--....-•-•---•---........------ -•-------...--••----......--••---•-------------------------•--......------------.._...----------------------------------------------------•------------------------------------------------------------ Date PermitNo..... ----------------------- Issued....................................................... No............ .� ;�a. $ F.R$............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH P Appliration for Disposal Works Tontrurtion Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: L—(5 f3Ci4 cJC�(�Q CA-)'s >a�e JS T f' 04 r �t Z .... W caner , 4 Z l � , AddressG ...Aw W ....1. =.. ------ •- ------- Installer f Address ' Type of Building Size Lot_-- ©d.33..Sq. feet Dwelling—No.�of Bedrooms_____ ._.......•._•--------------------•Expansion Attic ()` Garbage Grinder aOther—Type of Ruilding .1 ..a_'Y''_� No. of persons.........______________ Showers (—) — Cafeteria(—) dOther fixtures .........................•-•--•--••------•----- ---•---------------------------------------------------•----------------••---------............--•• W Design Flow.................. -->.........gallons per person per day. Total daily flow........_ -- _—'i. ..____._.....gallons. W Septic Tank—Liquid capacity.l.� gallons Length �.4?.��. Width_'-./"_­Diameter................ Depth..:... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........_�.____-__- Diameter.__..._1_�. Depth below inlet...3r_ .. Total leaching area..2`.9-..?...sq. ft. Z Other Distribution box ( V)'' Dosing tank-(-)-' / Percolation Test Results Performed by.__...____.'_.....:�_�------------------------------------------- Date-_. __.__. .__......__.__..__.....____. Test Pit No. I.... �.. '__minutes per inch Depth of Test Pit. /..-...... Depth to ground water........1__- _�_ (Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ N ..--•-----•----•-- ........................----..............----=....................................................................................... Description of Soil------------ '� t' '; s............................................. .......... - --------------------------•-•---------•--- U --•----•------•--•--------•-••-------------•-----------------------------•----------------------------------------------------- W UNature of Repairs or Alterations—Answer when applicable._.....................................................:........................................ ...................................... .. ----------------------------------------------------------------------------------------------------------------------------•---••------••-•----• Agreement: \�C The undersigne agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beep issued by the bow�"d o health. `� % C - s--12 21,P-4 Signed\'' __r.�r'1,,, C Application Approved By __..-.. 1 Hate PPPP -----•-------------------- _r_ -----------•• ------...... ' r2 G 1 Date Application Disapproved for the following reasons ----------------------------------------------------•--------------------•----•------•-• -•-----------•-••-' ............................................•------•---------•---------------'------•--------------=----------•------•---•••-----••--------------------•-----------•--•--------•-------•----•-•...... Date PermitNo......................................................... Issued....................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -�,� � ...........J.. ! .........OF....... h ;.5....../G........%-�..%........................... Tnr#ifirab of ontpliFanrr THIS IS TO C RTIFY, That, the Individual Sewage Disposal System consVucted (1/ ) or Repaired ( ) 4� Installer at-•-.. Q..1.L., ......... L L.�� jC ✓v1C15.....lT ✓(C C. has been installed in accordance with the provisions of TITLF_, 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 -••------•----------- THE COMMONWEALTH OF MASSAC}�HUSETTS BOARD OF HEAL%.. ' :. � G No ...................•••••. U r-- FEE........................ Disposal / orks �. ntrnrtion Vrrmit 1 ;Permission �` �� �, i hereby granted ..".���..:: ............. �' � VA---.....----I................ to Constru or Repair an Individual Sewage Disposal System Street as shown on the application for Disposal Works Construction Permit Dated......:�-1_.Y:v_ .. .51_-_---- ---------------------------------------•---Boar o Heal-- •-th -- . - - .....-•---- DATE.............. l ------.......----------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Date: Oulu TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: BUSINESS LOCATION: G B Poi MAILINGADDRESS: -AM Mail To: TELEPHONE NUMBER: "! a Board of Health Town of Barnstable CONTACT PERSON: P.O. Box 534 EMERGENCY CONTACT fELEPHONE NUMBER: Hyannis, MA 02601 TYPEOFBUSINESS: Does your firm store any of the topic or hazardous materials listed below, either for sale or for you own use? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes i Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS - _ - . r . 777 ee SOIL LOG ' DATE: d 1 1_9� WITNESSED B Y: <D A/4 ®,V Z3. 0. H. L - - z Tamer r� � s v c r3raxrsR , I , sir,i a - 0 0 L 7- Z7 V `1 Q 14 9d O ,.. N C 0 U.mil Tt=� � 5' pQ 4 , �, ?� .. a :p' v. TOPOF MANHOLES AND CO BUILT WtTHIN �`�. E L E ty .,.•- i2" OF FINISHED GRADE . ` FOUNDATION T`- M I N. 2� SLOPE `1 �9 � L . '�" filNISHED 6 R A D E o a a4, CAST t RC1 4,. P Y P� MR Y..•�•+` • '.O�w!'..n. �:�,.. •• V \r SC -•MV I C SGH. 40 P ITCH I FT. 2�LEvEI , .. ---�.. ,•✓✓ 4 MtN 2 LAYER ��/, ~ . r,`• PITCH :4+ "+ `8#1 ,_ I/2" PEASTONE a Iry f� S_3.uv ,5"2,7 F a I / T. t7 - C3o T INVERT (� f C)C� t N V E,R T~ D I ST. :i� `a; GALLON INVE RT o,» } '?' � "•* , :. INVERT BOX ,D SEPTIC TANK 30 n= p ��r 4 zCY�.: 3,4 ► i I�2uD i A.; � ... .,. ,..,.....•....: ►•.•` INVERT � �• Ep .�.IJ `U �A `WASHED STONE !? INVERT .; jp w dta"O ALL AROUND . :•.°. MIN. GARB `t --�.-� 'r"f' .: C _j C7:; ELEV. BOTTOM GRINDER -- ----_CI' ! •°••'t _ , of- PIT t r 1 2 PROFILE OF GROUND WATER TABLE BELOW -�� DISPOSAL SYSTEM SAN ITAR � DES OSA �f NOT TO SCALE DESIGN DATA BEDROOMS ------�8 t� (T � P O A CONSTRUCTION OF SAN ARTY D ( S S L DESIGN FLOW �330 GAL ./DAY SYSTEM SHALL CONFORM TO MASS. LE AC H RATE MI �/ ENVIRONMENTAL CODE , TlTL. E V REVISED7- 1 - 77� N.! ( NCH ANb E TOWN OF ' - L PROPOSED LEACH CAPACITY : THE O W HEALTH REGULATIONS. p SEPTIC TANK] DiSTRtf3UT ( ON BOX AND LEACHING PiTTO BE OF RE`I NFORC,EO CONCRETE - ' M [ N. CONCRET,E :ST'R'ENGTH • 3000 PSI GAL/DAY ; MIN. STEEL • STRENGTH 20�000pS H 10 DES'IG,N LOADING • DRIVEWAYS N .OTTO ZE LOCATED OVER SYSTE M UNLESS`'H- 20 DESIGN L`O'ADING IS USED. : • ALL PIPES AND FITTINGSTO BE WATERTIGHT AND TO BE OF CAST IRON OIL , SCH`ED ,40 P.V.C.' SITE P' L A N S HOWI ["G PROPOSED CONSTRUCTION SH.JoF �SHS LEGEND. L dcar , ON: F O R Z. `,3 E"Z-' -- ,oz Z,. I,�' " "` A P P R O V E D 19 � r SCALE: .�i' = C� DATE : � f / BOAR D OF HEALTH BUILDING SETBACK REGULATIONS PER TI NG CONTOUR __-1 R E F E .R E N C E, BU LD EXiS 6 �G� _•23 � 3� G BUILDING INSPECTOR OR BU ( LDI`•NGP'G . " `C7v, �� PROPOSED CONTOUR 16 DATE AGENT COMMISSIONER . m , EXISTING SPOT, EL.EVATION 17. 6 FRONT SETBACK B AC K 11,11', l N. FRO E �,+ v,°• '°ems , , MIN. SIDE SETBACK PROPOSED WATER SERVICE W c TEST HOLE LOCATION 1 MIN. REAR SETBACK clvn:� � � No. 2?433 R . b ff R� �+or �FGty1'EF�® _ ' PROFESSIONALL- N , Y A. D SURVE ORS a ENGINEERS 15 8;6. M A I N S T"R E T RT -.�- E E. EAST DENN ( S . M ,4SS. 02841 G • C ,.� , - ASSESSORS MAP : */7/ PARCEL : TEST HOLE LOGS NOTES: FLOOD ZONE: SO I L EVALUATOR : (xj C DII.1 M)0 iA V-*A >( REFERENCE: , �•,try �� /tee WITNESS : ` DW�� DATE• 1) The installation shall comply with Title V and Town of Barnstable Board of Health Regulations. PEPERCOLAT ION' RATE : ..� Z tj " - - ' 5 J 2) The installer shall verify the location of utilities, sewer inverts and septic _ �� ._ ! •57` components prior to installation and setting base elevations. TH- I � TN-2 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first A Wj" J+ Lo,q, y � two feet out of the d-box to the leaching shall be level. 4) This plan is not to be utilized for property line determination nor any other purpose other than the proposed system installation. l"� �Caa ,� � �f 5) All septic components must meet Title V specifications. LOCATION MAP - t � �r �-( �j �� `"'� S�t�� 6) Parking shall not be constructed over H10 septic components. 9 3 7) The property is bounded by property corners and property lines. P P Y P p Y �MJW. '6" ql&?, 8) The property owner shall review design considerations to approve of total ValW design flow and number of bedrooms to be considered for design. Receipt - `67t '� _ �#►" ALE of payment for the plan and installation based on the plan shall be deemed r�s, ) I b t- approval of the design flow by the owner. 1� 9) The existing leaching or cesspools shall be pumped and filled with material 4-�, ' per Title V abandonment procedures. Those within the proposed SAS shall I ' / ►�lD t�rcp,Wv1 `� r�,, be removed along with contaminated soil and replaced with clean sand er Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the ''r �` Cc► water line shall be sleeved with 4 inch SCH 40 PVC with SEPTIC SYSTEM DESIGN t ends grouted if applicable. The proposed SAS is being installed below the water service pP � P P g line. The line is to be sleeved as aforementioned and maintained in place. FLOW ESTIMATE 11) If a garbage grinder exists it is to be removed and is the responsibility of the > owner to ensure such. ` I ILA BEDROOMS AT (D GAL/DAY/BEDROOM - GAL/DAY 12)The installer is to take caution in excavation around the as line. � g 13)The installer shall verify the location, quantity and elevation of the sewer SEPTIC TANK _..�u,..._ lines exiting the dwelling prior to the installation. y GAL/DAY x 2 DAYS GAL USE tbOD GALLON SEPTIC TANK SOIL ABSORPTION SYSTEM Y 1 a 2. t1 4 s .� SIDE AREA: X 3 -I- 2� X2X I) BOTTOM AREA: Z '�tt SEPT I C_ SYSTEM SECT I ON 409 or- rov ►an►�c�( ►p to a' , dF .�/ ' �'r'a�Tnw off, tt,-r>�2 1 3� � 0 . i DO(� GAL C` �! v .F: SEPTIC TANK l.►'Lv .0 1or _- DAVID 0CID aYa 4? its . FSITE AND SEWAGE PLAN LOCATION : PREPARED FOR : zZw SCALE*ZLo DAVID B . MASON DATE: DBC ENVIRONMENAL DESIGNS w Z DATE HEALTH AGENT EAST SANDWICH . MA ( 508 ) 833- 2177