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Home My WebLink About0401 BUCKSKIN PATH - Health m- I N- I 401 3uckskin Path _I 4 = 191-120 _ Centerville y QdbM ® NOL CH®'r30M MADE IN u.SA ESSELTE 0 0 ® 0 i No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZippYItatlon for Disposal �bpstrm Construction Permit Application for a Permit to Construct( ) Repair(611"U'pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location dress Lot No.�O� //vC/C�tGN- ��11 Owner's Name,Address,and Tel.No. F(dK /v / Assessor's Map/Parcel / 2 �/ l (�h 0 �° p, Installer's Name,Address,and Tel.No. Designer's Name,Address,ank Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building l�J-/ h�l No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) yy0 gpd Design flow provided Y5,5,-- gpd Plan Date & Number of sheets Revision Date Title Size of Septic Tank J�:_Xl�NC Type of S.A.S. lD 40A4 Description of Soil Natur of Repairs or Alterations(Answer when applicable) 11740 17 y .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. r Signed 1 � Date l5 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. �� Date Issued �( r _ _ • � 4 d ; tt a' { r No. r/ 7 7 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplicatlon for Bisposal 6pskm Construction Permit Application for a Permit to Construct( ) Repair(Prxupgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name Address,and Tel.No. �01�1'�1c w �C"fA J � Ass sor's M p�11�1 1 I �i1 r� Installer's Name,Address,and Tel.No. Designer's Name,Address,an4 Tel.No. 2 rJ 1 Type of Building: i Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other ,Type of Building ��/(�q'�►G No.of Persons Showers.( )%.Cafeteria Other Fixtures Design Flow(min.required) !/In gpd Design flow provided 1,k<-- � gpd Plan Date Number of sheets / Revision Date y Title )) Size of Septic Tank Type of S.A.S. 4:M_ r-4 )144 Description of Soil 4 Nature of Repairs or Alterations(Answer when applicable) 1e= i 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. Signed r f Date Application Approved by j ':�KJ �; 1's.� c �.1� �� Date ; _ .?v ` C/ Application Disapproved by ! Date for the following reasons Permit No. Date Issued /` )U ' G 1 _; --------------------------------------------------------------------------------------------------------------------------------------- - THE COMMONWEALTH OF MAS�ACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(d�<pgraded( ) Abandoned( )by at e k has been constructed in accordance c� with the provisions of Title 5 and the for Disposal System Construction Permit No.col`� A�� dated r y 1 Installer (� ��4� �' Designer . . T� YG r^ #bedrooms Approved design flow ! gpd The issuance of this permit shall not be c strued as a guarantee that the system will fu on as designed. DateT Inspector 4_3 C2. ---------------------------------------------------------------------------------------------------------------------------------------- No.,-?O/-I - 5 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS ]Disposal Opstem Construction Permit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. � f Provided:Construction must be completed within three years of the date of this permit. -� C Date Approved by as M od x 0 00 z LL N O w x M OA w (D O7 E Cl) L coj!"`f N 4 ,O R0000 ,.�' __ r co co co 00 co CD �j I Cl) 13�i�C 6Ce?S N 0 00 m j o e ��1 RD47 .r 00 m co gym_ co (D LO LO .D F aE m a� fN d a f9 E O V �C U N cn CL M O O O L 401 Buckskin Path ICS N.� Centerville, MA 02632 r,w The Buckskin Path home has always been a four bedroom house as long as the trust has owned this home from 2001 to present. The Olsen's purchased the home in 1997 and to the best of my knowledge was a four bedroom home. William H Porter Trustee, I Town of Barnstable �t r regulatory Services Thomas F. Geiler, Director ERLAPMN NUM. . ` Public Health Division rfo9.�a Thomas McKean, Director , 200 Main Street, Hyannis, MA 02601 : Office: 508-862-4644 Fax: 508-790-6304 .' r Date: IQ Sewage Permit# (9C)1cf r Assessor's Map/Parcel I Q I IZd Installer &Designer Certification Form Designer: y�� Installer: �1 ��1)ri Tr13 Address: Address: .0, 1 _r,,N+P(J)P * Ooq&? On q` l ,C-R n r -(-Nr was issued a permit to install a (date) (installer) septic system at `��3 X*Klb1'F Cf &MMU based on a design drawn by (address) AV I� ►�"10(� Qb dated �,C->� (designer) I ertify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system).but in accordance with State & Local R- '-(ions. Plan revision or certified as-built by designer to follow. Stripout (if r- cted and the soils were found satisfactory. P\VN OF�M4�� DAVI D D B. c= U�" MASOy (Installer's Signature) 9 No.1066 SST esi er s Signature) PLEASE RETURN TO BARNSTABLE PUBL,., fE OF COMPLIANCE WILL NOT BE ISSUED UN ri i ni,3 ryR1VI AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice forms\designercertitication fonn.doc TOWN O``F,,--BARNSTABLE JgCATION n1 13kaef1�� Qi'�l SEWAGE# 9� - S7 VILLAGE C(n fk (V`11e ASSESSOR'S MAP&PARCEL J 9/ - /, _ INSTALLER'S NAME&PHONE NO.'T),N 'A�(0,,0QTM( 9:6AD04,1 0, -'a SEPTIC TANK CAPACITY LEACHING FACILITY:(type) Cz1 Cy size) r� NO.OF BEDROOMS OWNER / IQ(��1CF 1 T o�'�- '� PERMIT DATE: !3-ao M COMPLIANCE DATE: kr,i Separation Distance Between the: /�("jt11�. (y+--rr&r 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 Bt_ ��$F. �3 qv 336 3 i y 27 3� qq No..... Fl�s...:�.....o._ ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diipoittl Workii Towitrur#ton Prrutit Application is hereby made for a Permit to Construct ( ) or Repair Ocj ) an Individual Sewage Disposal System at: ..................................................................:L7 Location-Address r Lot No. .... !.v c-t. ----------------`fll, ..... ��_ s z �.--.r`� ..f-----�-�`-`�?--�?:- • Owncr Addres -7 C .,fi4h�4 Installer Address Type of Building Size Lot............................Sq. feet U .., Dwelling— No. of Bedrooms----__--_--�--------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ---------------- -------------- - - W Design Flow.................. ...............gallons per person per day. Total daily flow............. ...................gallons. WSeptic Tank—Liquid capacity/AP ..galIons Length-----------..... Width................ Diameter__.-- .......... Depth................ x Disposal Trench.—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No-----------4------ Diameter------lV_.__._. Depth below inlet.....�2___._____.. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ L14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ---------------------------------------------------------------------------------------•------------......................................................... 0 Description of Soil------------------------------•----•------------------------------------------..........---------------...---..._..----------------------......--------........_....... x U •--•-------------------------------•--------- ---------------------•----•--•----...------------------------------------------------------------•------------------------------------------------------- W ------------------------------------------------------------------------------------------------------------------------------------------- ------- -----------•---- UNature of Repairs or Al rations—Agver when applicable..___/ :_-_ !-, Q,tS !� ..... .C �. ....... tir .f ---------- ............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complianc as�een�issu b he board of health. Signed ........ --.--- � ------------------- --- Dace Application Approved By ................ a . .�...'fi ... ---- ----- ------- Application Disapproved for the following reafonf: ........................... .. ...................................................................................... ................ .............................................................. . ............... ...... . . ... . ...... ----.......----------------------------- Q Dace Permit No. -...._....} 71.......6.at-------------- _------ Issued ......................................................... Dace Fxs. ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE XpVttratuatt for Uhi-puiitti lVar1w Toutitrurttnrt lirrmit Application is hereby made for a Permit to Construct ( ) or Repair O an Individual Sewage Disposal System at: y0JUG��<SWC�n/ �i4 T7� CC. rI ivi�ti.c ..-----•---•-•-------•-------•----•-------------------------•-------••-•--•-•-•-•--•---••---.•--•- •---••••--•-••-----•-••••••--•....---•......--•-•----...•--...------•-----------•---------.....--- Location-_address or Lot No. .....---."...!.!�:.L ................................. .......................................................s rc Owner Addres a .�.� nn c �,�s;- -7 cow . kJA Icy skit .'" c L Installer Address Type of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms------------ ---------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) p' Other fixtures ...................................................... W Design Flow................: 5.---------------gallons per person per day. Total daily flow.............� �...._......._..__gallons. WSeptic Tank—Liquid capacity�PQy__gallons Length---------------- Width---------------- Diameter---------------- Depth----------------- x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.._______.-l.._._._ Diameter......ZU------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit---2t............... Depth to ground water........................ a ------•-•••------------------•----•••...-••••••••••-•-••--------•--•-•......----•-----•-••-•--...---......................................................... 0 Description of Soil........................................................................................................................................................................ V ............................................................•...........................................................••---------•------••••----------•----•--••-•------•-.........•-•-...••-•--...__. W U ------------------------ ....................................................------------------------------.-------------------.--------------------------•------- Nature of Repairs or Alterations—Answer when applicable.____/.N�-`.��N:-_._._.� �� '...._.....�.��Z�-...._. ...-T.4 1 7 _��.._!t� -......�� --- �L:Q�1 _.... �!..... � -_.%.�!4�---------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance/Ras been issued)by.ehe board of health. Signed .........1:.: / �cti`-"- ------------------------- G'J.�.../�y... Dare Application Approved B � ;- ---4�=--- .-�^' ,�� . ... ...................................... PP PP rove Y - - - Dare �. Application Disapproved for the following reasons- --------------------------------------------------------- ---------------------------------------------------- -------- ........... .......................................................................... ..................:..----------...-------------------------------------------------------------------- ............................ Date Permit No. .. .� /....-....�-a<a..0 ....................._. Issued - ......................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE V Ertifirate d 0Lii2jili ncie THIS IS TO CERTIFY hat the Individual Sewage Disposal System constructed ( ) or Repaired ((< ) � ------rVvG/Ct-0crU�---------c - _ _ . -by .............................................- a - ----In}taller .^� '/ ��J/ _-..__........ .... ..................-.............._............_........_........................................- has been installed in accordance with the provisions of TITLE 5 of The State_Environmental Code as described in the application for Disposal Works Construction Permit No. ..__tv..-....(�. �'-------- dated .............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....... /... .`-- - ..... --------- Inspector.. .' . ... ........... , THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.....c��.'..(,b FEE... Dispnstt1 Workii Tanntrurtivit "rrmit Gi ot.u,� r_&•�.t•s c_7784tI Permission is hereby granted.................... .......... ---�----••--- --••-......._.................... to Construct ( ) or Repair (x) an Individual Sewage Disposal System atNo........................................................ 1-----s� -'�-� ....... Street q as shown on the application for Disposal Works Construction Permit No..�y_... __ Dated--------`_O__-1)..:_ .f/...... ........................................Hoar -• -�-•--•••.....-•--•............................... C% f Health DATE............... `-°---I -� �,/ FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS �/. TOWN OF BARNSTABLE LOCATION 7�� '�jj}� SEWAGE # VILLAGE� jC�l�///C� ASSESSOR'S_ MAP & LOT INSTALLER'S NAME & PHONE NO 6/`Y�IUY�`1 SEPTIC TANK CAPACITY Qd LEACHING FACILITY:(t �w 11x) (size) (3 NO. OF BEDROOMS- PRIVATE WELL OR UBLIC�WATE� BUILDER OR�QWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: G VARIANCE GRANTED: Yes No 4 _ ,� a _ . ,. . � / � � : . e' : .�;=�.. �,,. �Y, `b ° -40 e �y�y BORTOLOTTI CONSTRUCTION, INC. °FAsy��F 9j 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-771-9399 508-428-8926 FAX: 508-428-9399 Z i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: - Date of Inspection: 7 Inspec is Name: Vwqtrs Name and Address: CERTIFICATION STATEMENT! I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal/�stems. The System: I L Passes Conditionally Passes Needs Further Ev ation By a al Aproving Authority Fails inspector's Signature. Date: The System Inspector shall submit copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY* A)SY M PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - 1 - C* MV, y�v C� �► INSPECTION FORM � DISPOSAL SYSTEM 1NSP (. SUBSURFACE SEWAGE S +►` PART A CERTIFICATION (cotilinued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERM INES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. i with a Zon e I of a public i tank and soil absorption system ands p The system has a septic a rp y water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and.the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well. The owner or operator of any such system shall bring tl►e system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done:' !-,- Pumping information was requested of the owner,occupant, and Board of Health. None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. �GThe system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. V All system components,excluding the Soil Absorption System, have been located on site. _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees, material of construction,.dimensions,depth of liquid,' jpth of sludge,depth of scum. The size and location of the Soil,Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- SUBSURFACE'SEWAGE DISPOSALSYSTEM INSPECTION FORM PART B CHECKLIST(continued) y The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RFSIDENTLALo Design Flow: Aal allons Number of Bedrooms: Number of Current Residents:_ Garbage Grinder: Z41C110L Laundry Connected To Systcirr/Z/za Seasonal Use:z Water Meter Readi s,if ailable: Last Date of Occupancy:�, it— COMM .R LALIIND ST L4 L.: Alb Type of Establishment: Design Flow: aallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings, If Available: Last Date of Occupancy: OTHER: ,Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 1 System Pumped as part of inspection:JC ' If yes,volume pu ed: gallons Reason for pumping: TYPE' F SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): PROXIMATE AGE of all com ent date installed(if known)and s urce of information: /0 4 Se age odors deiecWd when arriving M the site: ,, 9f) - -4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grader Material of Construction: concrete metal. FRP_Other r (explain) _ Dimisions: . Sludge Depth: 02 Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: 36 � Distance from bottom of scum to bottom of outlet tee or baffle; Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid 1 , in rel n to outlfflt invert,structural integrity,evide ce of leakage,etc.) ' OOd ,I GREASE TRAP: Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage, etc.). TIGHT OR HOLDING TANK F Depth Below Grade: Material of Construction:_concrete_metal FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX. Depth of liquid level abov outlet invert: Comments: (note if toeljand distribution is equal,evide solids carrypver,evidence of 1 ge into or out ol box,etc.) PUMP CHAMBER: C N. Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) _g_ 14- SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits, number: Leaching chambers,`number:` Leaching galleries,number: Leaching trenches,number,length: Leaching fields, number,dimensions: Overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failWq level of ndin ,cmiditionof vegetation, CESSPOOLS: 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(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: _ Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (confirmed) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include des to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. 2 q5 o _ DEPTH TO GROUNDWATER: Depth to groundwater: Pq Feet Method of Detennination7 r Ap 'roxima on: e4.0y1P 5 -7- TOWN OF ARNSTABLE LOCAT?JN `7O/ SEWAGE VIT LAGE O_&/ �/ ,0 ASSESS O 'S MAP & LOT 42-O USPtc7012SNAME&PHONE NO. o� SEPTIC TANK CAPACITY 000 LEACHING FACILITY: (type) ��J (size) /oyO NO.OF BEDROOMS- BUILDER OWNER PERMITDATE: COMPLIAN DATE: 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 o �3' ASSESSORS MAP : installation shall com l with the State Environmental Code Title V and Town of l . TEST HOLE LOGS 1) T�,e comply PARCEL- I ,( Board of Health Regulations. FLOOD ZONE! SOIL EVALUATOR: 1 L7 2) The septic system as proposed on this plan shall not be installed until a licensed town installer _ , WITNESS : ! receives approval and an installation permit from the applicable town. REFERENCE: rJ /�,�' DATE: \13 1 M 3) Prior to installation, the installer shall verify the location of utilities sewer inverts sewer lines PERCOLAT I O RA E and existing septic components prior to installation. 4) All gravity sewer,piping into be 4 inch schedule 40 PVC at 1/8" per coot. The first 2 feet out of --- - Zv !-- ZP-- -- ---- the distribution box shall be level. All piping connections to be glued. w 5) This septic design plan is not to be utilized for property line determination or for any other JLL , � Lb �i� �d �3 purpose other than the proposed septic system installation. yu/� 6) All Title V components are to meet Title V specifications. �Y I l0 G 7 Parkin shall be prohibited over Title V components unless components are H2O loaded. � ) g LOCATION MAP ! / i/" !!nn 8) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Leaching and cesspool(s)and contaminated soils within the removed and replaced with clean sand per Title V specifications. (,� �► .�� proposed SAS shall bee p p 9) Septic components are to be 10' from a water service line.Sewer lines crossing a water line shall be sleeved with an appropriately sized schedule 40 PVC with ends j grouted/ The water service f/ J M1111M line or the septic line can be sleeved with the sleeve being a distance of 10 on both sides of crossing the line. 10) If a garbage grinder exists in the structure, it is to be removed if the septic system is not . l j designed to accommodate a garbage grinder. C 11) The installer is responsible for care of excavation around all utilities on the property and SEPT I C ` SYSTEM DES I GN protecting the structural integrity of all structures during the installation process of the septic system. IJ i FLOW ESTIMATE 12) This plan only represents that a septic system can be installed on the property meeting Title V �.. requirements. ; BEDROOMS AT I L GAL/DAY/BEDROOM - GAL/DAY 13) The property owner shall review design criteria to approve the total number of bedrooms and �. design flow: Installation of the septic system as proposed and receipt of payment for the design SEPTIC TANK shall be deemed approval of the design criteria by the property owner or agent of. - GAL/DAY x 2 , DAYS GAL 14) The Validity of this plan shall expire with the expiration of the town installation permit issued for �0 this plan or the validity of this plan shall expire on the expiration of the Certificate of Compliance _ USE 1C00 GALLON SEPT i C TANK C � issued for the installation of the proposed system on this plan. ru-In. 9509P FUN-,SYSTE Ul _r SIDE AREA i X X ,1 112 7 BOTTOM 'AREA i g SEPTIC S M SE CT1 ON Y SY E!!9A NV - ---------- ,, ��r/�- � Ln F I C�qS � 5Jf� L_1 2,.pF 9 fit► , 5� n , 'vim Cs=c�fiefIIl ° -� �., �`� ►` IFS `.� puj SEPTIC TANK �F (N nn�. SITE AND SEWAGE PLAN DAViD B. -A PA C) MASONLOCATION : V v No.10 G C PREPARED FOR : M o )J SCALE' W DAV I D B . MASON,RS DATE: 1 o DBC ENVIRONMENTAL DESIGNS _ ! t 1 , I DATE HEALTH AGENT l � is