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HomeMy WebLinkAbout0080 CAP'N JAC'S ROAD - Health 80 Cap n ac s Road i Centerville P r .. - A = 194 060 UPC 12534 y l II s No.Z�LOR HASTINGS, MN c:u.'�iY--._.. .:......v��__...-_..a. ....ate.. ...-u....:. '- cc No. /p Fee �? THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -`TOWN OF BARNSTABLE, MASSACHUSETTS es 4plitatloii for Vsposal .pstem Construction Permit Application for a Permit to Construct( ) Repair�4 Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 8© C_q 01/�Sp(°s JZo4-A Owner's Name,Address,and Tel.No.-)4 ;�) /n� ,#4, --- Assessor's Map/Parcel 11q't b o �`'� �- 5AM4 Installer's Name,Address,and Tel.No. /f f Cc,,ss,,"4. S r Designer's Name,Address,and Tel.No. C4.ul2 t �i--5 LL(- IN4,� o `y �,C.C Type of Building: _ Dwelling No.of Bedrooms Lot Size �il 000 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 o gpd Design flow provided gpd Plan Date -2S- Zo k Number of sheets ( Revision Date Title W Y mod)r 13 r C,.� / 7 Size of Septic Tank f 000 Type of S.A.S. 573?N Y Description of Soil Nature of Repairs or Alterations(Answer when applicable) i LC)DO go/ nl wtk 0 TD tV,; s�z,,' 44d o,' 4&(, 3co Lk,' j3i`. I!V-s z- Date last inspected: ?.eo.!e C( 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. G Signed Date -I ( ' - t Application Approved by Date g vo od t 1 Application Disapproved Date for the following reasons Permit No.Z01I- 2�q t Date Issued M 3411 No. Z�� Z I�J Fee "T l Q0"0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH'DIVISION "'T"OWN'OF BARNSTABLE, MASSACHUSETTS-.. - S appricatron for Misposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair 54 Upgrade'`( )-Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 8 Q CAP fl jAG'$ 'R,34,A Owner's Name,Address,and Tel.No. r- Assessor's Map/Parcel 10f Y l o 6zK4".; ('f �j67»t6 Installer's Name,Address,and Tel.No. /s') Co.4t .,wL Sr Designer's Name,Address,and Tel.No. CAIUw-'de e0Vjv ej LLC ��l� c a �.C.�N��. .,5 2srY W� " 4iu., !.A---Ph1. Type of Building: Dwelling No.of Bedrooms 3 Lot Size ?, 000 t- sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 d gpd Design flow provided ? S^S^. �• gpd s Plan Date -IS- - Zo l k Number of sheets 1 Revision Date Title cs r.ya-q N T✓3 c 'S _ Size of Septic Tank /ODO Type of S.A.S. STi%dr.`) (—,'d d Description of Soil Nature of Repairs or Alterations(Answer when applicable) 6J 1 t.< 1000 io/ ?)'►kA r, l dA o F (2 to) t. 3 co We d� r� �.l-L o' Date last inspected: 10—t. l Agreement: The undersigned agrees to ensure the construction an i d 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 A 11 Date ��1 Application Approved by Date ii ,7a ao ii Application Disapproved Date for the following reasons Permit No.Zp I — Z q 6 Date Issued ----------------------------------------------------------------_------------------------ --------------------------------- ---------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site ewage Disposal system Constructed( ) Repaired(X) Upgraded( ) Abandoned( )by •e 0i4cfAj,0tj L L C at t �o has been constructed in accordance with the provisions of Title 5 an the for Disposal System Construction Permit No.00II 1' Z q 4 dated Installer — /.?( L�. Designer #bedrooms Approved design flo T gpd The issuance oft is p rmit shall not be construed as a guarantee that the system w' fun ti as `esigne . Date 2 Inspector �✓ No. ZO( 1 —_Z�& Fee V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( 14 Upgrade( ) Abandon System located at0 5 IQ G s D A. 6.v►,M/u 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. _ I Provided:Construction must be completed within three years of the date of this permit. Date OV/3°IZ a,,, Approved by j, TOWN OF BARNSTABLE LOCATION CA 0 0? S A c.'S '(Zoqd SEWAGE# 2 O I 24 b VILLAGE ee4y�Vt,1 ((t ASSESSOR'S MAP&PARCEL (t (00 INSTALLER'S NAME&PHONE NO. C/1pCWi d (' tetai3 e-S L(—C- SEPTIC TANK CAPACITY 1000 LEACHING FACILITY:(type) 5Tww4.,s �;ocl QtiK�3 (size) t l•S A Z S NO.OF BEDROOMS OWNER 17 Ay tr S ^ k4t-r PERMIT DATE: 16 - 3 a 20 t I COMPLIANCE DATE: 9 l - Z 61 1 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility No N'OQ 1) 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 Q ,y i U—C A-a= ?• (�-d=19 Tu` 1�3_ 1� / A,i.lt"31,a� 0-4= A-7=3 9,3 t3-7,f-7,,?" All boor Drive 10 0* tot 06 3 06 107 Town of Barnstable Regulatory Services Thomas F. Geiler,Director BARNBCABLE : Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Otrice; 508-862-4644 Fax: 508-790.6304 Date: 9-2'11 Sewage Permit# Zola Z% Assessor's Mup/Parcel 60 Installer& Designer Certification Form Designer: SL Enntneeci,n Tv)C, Installer: Caec.�.{:ide. Cr1lerPris�S LAG -- Address: Z8.5y Ccanberry �li�hw Address: O 1 IC 7t.2 East wcre�,am� H A- 02.53$ �v\�`� VVI,4 On �f 30 << C.4 lw� 60y )c) was issued a permit to install a (date)septic system system at 8o Caen 3O'C'S tZ0Q4 based on a design drawn by (address) G �P19iv1eeri��C LTgnC, dated August 2512011 (designer) _ ✓ 1 certify that the septic system referenced above was installed substantially according to the design; which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. 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 Regulations. Plan revision or certified as-built by designer to follow. Stripout (if req i nspected and the soils were found satisfactory. h JOh!N L. � a CjjVR1:r1I;,L �(In. Iler's Signau e) Civil. No 41!-07 esigner's Signatur (A 'ix Irsig ei S mp Here) PLEASE RETURN O BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL HOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. c�.\olli�t IixglstJuslynurcerliliianion Iirm.CluC DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistenj_:y_%Qmvei) ®- b - " F7/ >oYr SA - - y 2--13 2 G H S 2.5 Y 4A -5 o;6,5 raved DEEP OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture Soil Color, ,( Soil Other Surface(in.) T (USDA) (Munsell) Mottling (Structure,Stones,Boulders. nnsi's en %Grave b-V 2 B LS joYr /6 y213 2- c }9S 2_.S r 6 5-fib s l ' DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. C itec Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Co1or Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. _...._—Flood Insurance Rate Map:_ -_ Above 500 year flood boundary No_ Yes _- Within 500 year boundary No_Z Yes Within too year flood boundary No_✓ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? �2S If not,what is the depth of naturally occurring pervious material? Certification I certify that on /�'27"9`1 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,expertise nd exp nce described in 310 CMR 15.017. Signature Date15�6/ Q:\.S.EPTICVERCFORM.DOC Town of Barnstable P#_ 13 Department of Re I n p gulatory Services Public Health Division Date 200 Main Street,Hyannis MA 02601 Date Scheduled Time v Fee Pd. Foil Suitability Assessment for Sewage Disposal Performed By:_Ht6� eime.i��t , C--1 GSE Witnessed By: ,08 LOCATION& GENERAL INFORMATION Location Address O Gae N :YAC/S: (nA A � a Owner's Name" QG I`Y_ Ce Y ,C t %�k a C Address ?O G' 4p� 73—,q(.i S Assessor's Map/Parcel: l t l 6®rod / Engineer's Name C' W 671(W,D.,tle, jc,e-g54ve.rrrv, NEW CONSTRUC TION 6 REPAIR V/ Telephone# ���' ?7 —$$1 i. 50 8-273 6 3 7 7 Land Use S t[4e 44k4 ih5 Slopes(%) 3-7 Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well --I—ft Drainage Way ft Property Line ^~' 1 q ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) see 4t -4 Qlqq Parent material(geologic) 0 U t t*j0k► Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater 7 1 3 2103 S DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Drr'eCk 6V.etU-ktt4A 7j32 Depth Observed standing in obs.hole: _ in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# — Reading Date: — Index Well level Adj.factor. Adj.Groundwater Level PERCOLATION TEST bate d-2y-u Time to 1h Observation Hole# Time at 9" Depth of Perc2 -(OO Time at 6" ^ Start Pre-soak Time @ /0:05Ah — Time(9"-0) End Pre-soak Rate MinJinch Z 2 Site Suitability Assessment: Site Passed `J4 S Site Failed: v Additional Testing Needed(Y/N) IV Original: Public Health Division Observation Hole Data To Be Completed on Back---------- ***If 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:\SEPTIC\PERCFORM.DOC �U C 7 7 738' 45-f' 0" i9 S V V o N Do m b 0 ....-....._................... Sd"Pd *11-1-4 f0-7' � Pd.Pd OD N � � N iV13'-11' PdiPd 00 rd"Pd (�/� ..... NS V1c p 3-0'� 1110' 23'-10' 37'-10' :a Lh n + V + Nx ly) 4'-6' 6'4' 4'40" —1610• zo•.rd aao 4 8' 7-1f' 9=5' b 4 7-f0' 22 0* ad.ad N I I I 5'-2' 3'-1" 3'-0' S'-0"— ,r I I 1 I I I Vb NO !MaWl, r .�•r-x t`��. ,� fi ��'� ,�� f - r Vk � y,�: -'�s( i t e F�c�. � w,F x�k°I �,� siF ✓ j -rk �� ':L��:,. -��, _ tat wy{. � 'A '� .. •zaz ? d J g f 4f ,�y t �,� a�, r ,� t 'ar t w : f. } YA s , cr r - r -I s v wwwwwwasmv *5 Won t .� f.FC`f'.ti�}4✓�'. i �Y�r. S� :S{( ( 1 -X6 } s• r# x - a d V -U t son MAy. f.r 6 x?h r:;,tx ,s,- < z''• m• 3 �� 1 v�.:iy 'm�:C4A ?&���fe✓.1-_'6�Gr7".i�3.3.f�Y)`�"k:�!'��J 4� �� r...:t 5� �Y L� sr �ryE• n•x I- F' �". COMMONWEALTH OF MASSACHUSETTS RECEIVED EXECUTIVE OFFICE OF ENVIRONMENTAL AFF DEPARTMENT OF ENVIRONMENTAL PROTE TION ' JUL 2 5 2002 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A P CERTIFICATION A (� flC` S Property Address: 80 Captain Jacks Road Centerville Owner's Name: Diane Cameron Owner's Address: Date of Inspection: 7/6/2002 Name of Inspector: (please print) Kevin J.Sullivan Company Name: —Ready Rooter q A- Mailing Address: P.O.Box 371P Sandwich,MA 02563 PARCEL :. Q)&rj Telephone Number: (508)888-6055 LOT CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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: asses Conditionally Passes Needs Further Evaluation by the Local Authority Fails Inspector's Signature: Date: 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 how the system will perform in the future under the same or different conditions of use. Page 2 of I 1 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 80 Captain Jacks Road Centerville Owner: Diane Cameron Date of Inspection: 7/6/2002 Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D C. System Passes: 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 sect to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by a Board of Health,will pass. Answer yes,no or not determined (Y,N,ND)in the for the followings tements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic (whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank fail is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as appmv by the Board of Health. "A metal septic tank will pass inspection if it is structurally d,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 ou r high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or even distribution box.Sys will pass inspection if(with approval of Board of Health): ken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required p ping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with ap val of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 80 Captain Jacks Road Centerville Owner: Diane Cameron Date of Inspection: 7/6/2002 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation a Board of Health in order to determine if the system is failing to protect public health,safety or the environ nt. 1. System will pass unless Board of H determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a er which will protect public health,safety and the environment: Cesspool or pri 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 viroament: _The system has a septic tank and soil absorption system(SAS) 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 ' in a Zone 1 of a public water supply. _The system has a septic tank and SAS and the S is within 50 feet of a private water supply well. The system has a septic tank and SAS and SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to etermine distance "This system passes if the well wat alysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic corn indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen d 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: I Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 80 Captain Jacks Road Centerville Owner: Diane Cameron Date of Inspection: 7/6/2002 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ _�Z 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 — _jZ Static liquid level in the distribution box above outlet invert due to and 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. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis most be attached to this form.] .[0(Yes/No)The system Ulls. I have determined that one or more of the above 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 most serve a facility with a' esign flow of 10,000 gpd to 15,000 gpdL You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the teria above) yes no the system is within 400 feet of a surface drink' g water supply the system is within 200 feet of a tributary a surface drinking water supply the system is located in a nitrogen sen five area(Interim Wellhead Protection Area—IWPA)or a mapped Zone R of a public water supply we If you have answered`yes"to any qu . n in Section E the system is considered a significant threat,or answered "yes"in Section D above the large tow has failed.The owner or operator of any large system considered a significant threat under Section or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner uld contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: SO Captain Jacks Road Centerville Owner: Diane Cameron Date of Inspection: 7/6/2002 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 __._ —ZWere any of the system components pumped out in the previous two weeks? —Z_ Has the system received normal flows in the previous two week period? —ZHave 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) �e 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 than 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: Yes o Existing information.For example,a plan at the Board of Health. ____ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 80 Captain Jacks Road Centerville Owner: Diane Cameron Date of Inspection: 7/6/2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_:a Number of bedrooms(actual):_Q DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Q.2c.3 49 f, Number of current residents:a Does residence have a garbage grinder(yes or no):-)5,� Is laundry on a separate sewage system(yes or no):�cif yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):_4,to Water meter readings,if available(last 2 years usage(gpd)): �vcac�=, ( !5�A• ac xa 1 = tcii cpc1t Sump Pump(yes or no): n ep Last date of occupancy:i--rs`c%0,4N4 COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sg8,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present or no):_ Non-sanitary waste discharged to Title 5 system(yes or no):. Water meter readings,if availab . Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: �r+a�-s b �,r r �•.•�w� Was system pumped as partnspection(yes or no): n..Q5 If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPAOF 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 all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): sV I Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 80 Captain Jacks Road Centerville Owner: Diane Cameron Date of Inspection: 7/6/2002 BUILDING SEWER(locate on site plan) Depth below grade: --,Vp" Materials of construction:—cast iron_40 PVC other(explain): Distance from private water supply well or suction line: K j c:,4n Comments(on condition of joints,venting,evidence of leakage,etc.): is SEPTIC TANK: (locate on site plan) Depth below grade: Q,1�" Material of construction: 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: '?r Sludge depth: 3" Distance from the top of sludge to bottom of outlet tee or baffle: o?c=�r Scum thickness: Q Distance from top of scum to top of outlet tee or baffle: 7°' Distance from bottom of scum to bottom of outlet tee or bathe: /� N How were dimensions determined: T.a ywe;Sc.3.rGG. -.*L,,Z � '�0' ;e. Comments(on pumping recommendations,Inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete metal,fi/lass polyethylene other ("plain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee r baffle: Distance from bottom of scum to bottom of et tee or bate: Date of last pumping: Comments(on pumping recommenda' ns,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence eakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 80 Captain Jacks Road Centerville Owner: Diane Cameron Date of Inspection: 7/6/2002 TIGHT or HOLDING TANK: (tank must be pumped at time of inspecti ocate on site plan) Depth below grade: Material of construction: concrete_metal fiberglass ethylene _ other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working er(yes or no): Date of last pumping: Comments(condition of alarm and t switches,etc.): DISTRIBUTION BOX:-aZ(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pum amber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 80 Captain Jacks Road Centerville Owner: Diane Cameron Date of Inspection: 7/6/2002 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type _j/Ieaching 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.): CESSPOOLS: (cesspool must be pumped as art 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(y or no): Comments(note condition of soil,Aligns 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 hydraul' failure,level of ponding,condition of vegetation,etc.): l Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 80 Captain Jacks Road Centerville Owner: Diane Cameron Date of Inspection: 7/6/2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. G .pf t"rar� O 67 �� &o Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 80 Captain Jacks Road Centerville Owner: Diane Cameron Date of Inspection: 7/6/2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water L/Z 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 the local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USOS database-explain: You must describe how you established the high ground water elevation: /✓O i/Chl o 414TG%1- 7:h/ RI�1"te4'I rS w 1'T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION 80 Captain Jac's Road Property Address:West B �— Address of Owner: ^ an, (if different) c;? '<< a Date of Inspection:2/22/2000 Inspected by: James Holler ti01 ? y O I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 1�5�'000) 00 / Company Name:Holler& Son Construction LLC Mailing Address:P. O.Box 702,Marstons Mills,Ma 02648 Telephone: (508)420-0280 I l CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: 19 Passe§ ❑Conditionally Passes Needs Further Evaluation by the Local Approving Authority ❑Fails Inspectors Signature Date: 2�Z_3 i DO The system inspector shall sub Zit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D. A) SYSTEM PASSES: ®1 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: Comments:Soil absorption system not evaluated due to mature landscape plantings,system was located within a cluster of rhododendrons. B) SYSTEM CONDITIONALLY PASSES: ❑One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. ❑The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (Continued) Property Address:80 Captain Jac's Road,West Barnstable Owner:Mr.F.Baumann Date of Inspection:2/22/2000 B) SYSTEM CONDITIONALLY PASSES (continued) ❑Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: ❑ broken pipe(s)are replaced ❑ obstruction is removed ❑distribution box is leveled 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 DETERMINES 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 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ❑The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. ❑The system has a septic tank and soil absorption system and the SAS is with 50 feet of a private water supply well. ❑The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:80 Captain Jac's Road,West Barnstable Owner:Mr.F.Baumann Date of Inspection:2/22/2000 D) SYSTEM FAILS You must indicate either"Yes"or"No"as to each of the following: ❑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 15.304.determine what will be necessary to correct the failure. 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. ❑ ❑ 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. ❑ ❑ Any portion of a cesspool or privy is with 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 with 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: You must indicate either "Yes"or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: ❑ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No ❑ ❑ 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 11 of a public water supply well. The owner or operator of any such system shall bring the 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 Property Address:80 Captain Jac's Road,West Barnstable Owner:Mr.F.Baumann Date of Inspection:2/22/2000 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health. ® ❑ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ❑ ® 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. ® ❑ The system does not receive non-sanitary or industrial waste flow. ® ❑ The site was inspected for signs'of breakout. All system components,excluding the Soil Absorption System,have been located on the site. ® ❑ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of bates or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location or the Soil Absorption System on the site has been determined based on: ® ❑ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. ❑ ® Existing information,Ex.Plan at BOH. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property address:80 Captain Jac's Road,West Barnstable Owner:Mr.F.Baumann Date of Inspection:2/22/2000 FLOW CONDITIONS RESIDENTIAL Design flow: 110 gpd/bedroom for SAS Number of bedroo�s/idents: ,L Number of currentI Garbage Grinder:No Laundry connected to system:Yes Seasonal use:No Water meter readings,if available (last 2 years usage in gpd):Not available Sump pump:No Last date of occupancy:Current COMMERCIAL /INDUSTRIAL Type of establishment Design flow: gpd Grease trap present: Industrial Waste holding tank present: Non-sanitary waste discharged to the Title 5 system Water meter readings,if available Last date of occupancy OTHER:(describe) GENERAL INFORMATION PUMPING RECORDS and source Owner System pumped as part of inspection No Volume pumped-N/A Reason for pumping:N/A TYPE OF SYSTEM ®Septic tank/distribution box/soil absorption system ❑Single cesspool ❑Overflow cesspool ❑Privy ❑Shared system(y/n)(if yes,attach previous inspection records,if any) ❑I/A Technology etc.Copy of up to date contract? Other APPROXIMATE AGE of all components,date installed(if known)and source of information: 1984 Sewer odors detected when arriving at the site:No I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (Continued) Property Address:80 Captain Jac's Road,West Barnstable Owner:Mr.F.Baumann Date of inspection:2/22/2000 BUILDING SEWER (Locate on site plan) Depth below grade 20 inches Material of construction❑Cast Iron®40 PVC❑other Distance from private water supply well or suction lineN/A Diameter 4 inch Comments:(condition of joints,venting,evidence of leakage,etc.) No problems noted SEPTIC TANK (locate on site plan) Depth below grade 24 inches Material of construction®concrete❑metal❑Fiberglass❑Polyethylene❑other If metal list age is age confirmed by certificate of compliance Dimensions: 1000 gal Sludge depth: 18 inches Distance from top of sludge to bottom of tee or baffle 30 Scum thickness 2 inches Distance from top of scum to top of outlet tee or baffle 1 inch Comments:None GREASE TRAP (locate on site plan) Depth below grade Material of construction❑concrete❑metal❑Fiberglass❑Polyethylene❑other Dimensions Scum thickness Distance from top of scum to top of outlet tee or baffle Date of last pumping 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 leak,etc.) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (Continued) Property Address:80 Captain Jac's Road,West Barnstable Owner.Mr.F.Baumann Date of Inspection:2/22/2000 TIGHT OR HOLDING TANK:❑(Tank must be pumped prior to,or at time,of inspection) (locate on site plan) Depth below grade: Material of construction: ❑concrete[I metal❑Fiberglass E]Polyethylene❑other(explain) Dimensions: Capacity: gallons Design flow: GPD Alarm level: Alarm working?❑yes❑no Date of previous pumping Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:Zero Comments(note if level,and distribution is equal,evidence of leaks or solids carryover,etc.) Level and no solids evident PUMP CHAMBER:❑ (locate on site plan) Pumps in working order: (yes or no) Alarms in working order:(yes or no) Comments:(note condition of pump chamber,pumps,and appurtenances,etc.) eN � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(Continued) Property Address:80 Captain Jac's Road,West Barnstable Owner:Mr.F.Baumann Date of Inspection:2/22/2000 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 1,estimated as 1000 gal pit leaching chambers,number leaching galleries,number leaching trenches,number&length leaching fields,number&dimensions overflow cesspool,number: Alterative system: Name of technology Comments:(note condition of soil,signs of hydraulic failure,ponding,vegetation,etc.) No indication of ponding,or hydraulic failure CESSPOOLS:❑ (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 Material of construction Indication of ground water inflow(must be pumped as part of inspection) Comments:(note condition of soil,signs of hydraulic failure,ponding,and vegetation,etc.) PRIVY❑ (locate on site plan) Materials of construction: Dimensions Depth of solids Comments:(note condition of soil,signs of hydraulic failure,ponding,vegetation etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(Continued) Property Address:80 Captain Jac's Road,West Barnstable Owner:Mr.F.Baumann Date of Inspection:2/22/2000 SKETCH OF SEWAGE DISPOSAL SYSTEM Include ties to at least two permanent references,or benchmarks,locate wells within 100'and where public water supply enters house. Ai Z D I 2- 2— 3 31-7 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (Continued) Property Address:80 Captain Jac's Road,West Barnstable Owner:Mr.F.Baumann Date of Inspection:2/22/2000 Depth to Groundwater 68 feet Please indicate all the methods used to determine High Groundwater Elevation: ❑ observed from design plans on record ❑ observation of site(abutting property,observation hole,basement sump) ❑ determine it from local conditions ® check with local Board of Health ® check FEMA maps ❑ check pumping records ❑ check local excavators,installers ® use USGS data Describe in your own works how you established the High Groundwater Elevation. (Must be completed) .................._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 7_7_�.0UP.n............OF........n::B.Q%.A s. .. Appliration for Bispnsal Works Tons rnrtiun Frrutit Application is hereb made for a Permit p Construct or Repair ( ) an Individual Sewage Disposal System at: ( C `) z � ►� _ 9Y GW\ \�T o ration-Ad�dr`es � l 1 pr Lot No. 1` a� . �1-�1r1 .S T .... .......... ... - =....................................... W l ' Owner Ad ress Installer Address O�O Type of Building Size Lot_ ________________________Sq. feet Dwelling—No. of Bedrooms.........................................Expansion Attic (0)'3 Garbage Grinder (&_�© p-, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ............................................. W Design Flow.........IN. ..........................gallons per person per day. Total daily flow__-_____2.3_o............_......gallons. WSeptic Tank—Liquid capacity.k0'9 .gallons Length................ Width................ 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 ( ) Dosing, tank ( Percolation Test Results Performed by.... _ :___ ..,....d_.. -............. Date_. ' a ."'- - ........... 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.................... Depth to ground water........................ Ri •-------•----------------------------------------------------------------------••• 0 Description of Soil-----_.Q-.a....... v.... - - -- ->..................... . _. U ---------------•----------------------- - -a...---- '�__.QL!a. ...------......j(�-��W e ---------�------ . ��S-------- W U VNature 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 iITLL 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 board of health. Application Approved By. --•- - ®trJ-�' Date Application Disapproved r t following reasons:................................................................................................................ .....................................Date ............ PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD DOE HEALTH ---- —-o ........_OF.......�.�,LcJ1 r�.�..�:..���.►............................ Apptiration for Disposal Works Tonstrairtinn jJrrmit Application is hereby made for a Permit to Construct (d/) or Repair ( ) an Individual Sewage Disposal System at: >--�--- --------------- nor---L--o------- e Location-Address �3, a Owner J 1 .A4dress Installer Address Type of Building Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms.............................................Expansion Attic Garbage Grinder NP aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ..W Design Flow........>>. ...........................gallons per person per day. Total daily flow-_-____ v....................gallons. WSeptic Tank—Liquid capacityk�P O..gallons Length................ Width................ 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 ( ) Dosing tank ( ) aPercolation Test Results Performed by._._ ._ ____ .____ ... '``":.............. Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 •-•--•------•-----------------••--•-...................-•- ----- ...i.....----------- ---------------------- ..------------- •------------------- .-.. Description of Soil....... .......-==l ?Gt n"• .... .. --._... � ' ------------ ------------------------- x � \3 CJ jj 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 TITiZ 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 board of health. C s_ - igned._. Cltr'Y z3x.)- ......•--------•------------ ................ Application Approved By_ ._.. 4" Date Application Disapproved or a following reasons----------------------------••--------------------------------------------------------------------------•-••---•- -------------------------------------•-------------•-----------------------------•-------•----------•------•----•---•------------••---•------------••-•--.............................................. Date PermitNo......................................................... IssuedL....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH : : ?^............OF................... A .......................... wrr#iliratr of ToutpliFanrr THIS IS TO-CERTIFY That the Individual Sewage Disposal System constructed (I�or Repaired ( ) by...... :9: U C,(\.A) V7 r•u s ----•-.......•••--------------••-••----•-----•••-•---••------•--••-•••--•---•-------•---•---••-•--...............---•--......_..._ nstal ler has been installed in accordance wit the provisions of T j f The State Sanitary ?__-i s scr ed in the application for Disposal Works Construction Permit No. "._3 ................ dated___ ._..._._.__.__... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................... � ..�y.....................••..._.. Inspector..................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r �.� O3 ..--- _0 No. /.. .. FEE........................ _ Disposal Works Tnnstrurtilan rumit Permission is hereby granted.......Q.vkm' _-' .............. --n�-5--...................................................................... to Construct ( t. 6r�Repair ( ) an Individual Sewage Disposal S te� C.,!:? ---------------- ---- U 1 Street as shown on the application for Disposal Works Construction Permit No ............ Dated.......................................... .................... ..... --•-••-- ------------------•------- ,,�� �DATE--------L ' :iy.J' �............................................. Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON IN- S E.�Tt G T AW W-.o 3 30' )L. SDP/.w1# qPj 6-G W ' • u K «x, �c�. s�911G .,..�-; 1 , I I ►, �` :�' .9 Dtu �p �", •� Q F-- i •T� '� Tip! ' .' ; , •r• ' : 11P _.� �� '(,T�',1-it..., } A%Z 000 4 kuowl 1 .. 1 :'..-1 ._... •i , 'r'.1• i. ( 1 1 , � 1 .�� �.�•..�'.,� Lam,.-p•4• I]At � C. .16 Nu ONAt I � qN0 5,I1�d�u... .. . 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V.J v ¢�c.►sr� Q� ��� �,�,ev�oec ( ► TN1S QLb�.1 S �1DT $ASED AU 1.0 I WMEuT otTE:�V11 ► [ AA A.�`a� . . 5�1iCvC( 4 TOG- oFF'S4'T; •SNOuL� LICIT USe ApPLAr-AwIr �I y To 'D�.Tcr_mi►.1L 1 � -DT Llu . �' 5.IZ,�,k t,t.l.• LOCATION OF RMC3RERTY LINES MAY NOT BE ACCURATE STANDARDLEGEND NOTE:not all symbols will appear on a mop GOLF COURSE FAIRWAY - EDGE OF DECIDUOUS TREES EDGE OF BRUSH ORCHARD OR NURSERY \ v—P—V—v EDGE OF CONIFEROUS TREES MARSH AREA ( . . .— C EDGE OF WATER �/ AP I / _ _ _ = DIRT ROAD O DRIVEWAY I -E--PARKING LOT !+1 �-- PAVED ROAD - \� — — DRAINAGE DITCH ` .. t — — — — - PATH/TRAIL PARCEL LINE** MAP 19 MAP -< ---MAP# 0 21-�--PARCEL NUMBER #367 F—HOUSE NUMBER O2 FOOT CONTOUR LINE O �� to 10 FOOT CONTOUR LINE l Elevation based on NGVD29 >/4.9 SPOT ELEVATION STONEWALL AP 19 - - FENCE 6 RETAINING WALL r RAIL ROAD TRACK 8 API STONE JETTY (�> SWIMMING POOL - O PORCH/DECK 1] BUILDING/STRUCTURE DOCK/PIER HYDRANT 6 VALVE O MANHOLE 194 0 POST 0" FLAG POLE T O W N O F B A R N S T A B L E G E O G R A P H I C I N F O R M A T I O N S Y S T E M S U N I T o SIGN a STORM DRAIN M PRINTED SCALE:IN FEET *NOTE:This map is an enlargement of a **NOTE:The parcel lines are only graphic representations DATA SOURCES: Planimetrics(man-made features)were interpreted from 1995 aerial photographs by The James 1°=100'scale map and may NOT meet of property boundaries.They are not true locations,and W.Sewall Company.Topography and vegetation were interpreted from 1989 credal photographs by GEOD 0 UTILITY POLE TOWER '" q ` 0 20 40 National Map Accuracy Standards at this do not represent actual relationships to physical objects Corporation.Planimetda,topography,and vegetation were mapped to meet National Map Accuracy Standords i INCH=40 FEET* enlarged scale. on the map. at o scale of V=100'. Parcel lines were digitized from FY2005 Town of Barnstable Assessor's tax maps. ¢ LIGHT POLE o ELECTRIC BOX f L0CATI 1� SEWAG (EVE MI N0. L oF*:/ VILLAGE INST A LLER'S NAME i ADDRESS d U I L D E R 0 OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED - .�r�f &,4xA f r� PROPOSED VENT WITH CHARCOAL T.O.F. EL.= 121 .0'± INISH GRADE OVER D-BOX= 121 .2'± o FILTER TO ABOVE GRADE FINISHED GRADE OVER BIODIFFUSERS = 120,50' - 121 .13' GENERAL NOTES fPROVIDE EXTENSION RISER 4 /o SCHEDULE 40 PVC MIN. SLOPE 1 SLOPE @ 2% MIN. WITH COVER OVER INLET& REMOVABLE WATER-TIGHT COVER OVER 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION OUTLET TO WITHIN 6"OF F.G. RISER TO WITHIN 6"OF FINISHED GRADE INSPECTION PORT WITH ACCESS BOX TO METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL FINISH GRADE WITHIN 3"OF F.G. (ONE PER OUTER ROW) @ FND. EL.= 120.0'± F.G. OVER TANK EL. = 120.7'± 5"DIA. OUTLET(s) CODE AND ANY APPLICABLE LOCAL RULES. j } 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. EXISTING 4" PROPOSED 4 SEE NOTE 21 SEE NOTE 21 3.5' MAX. 4.0'MAX TOP OF SAS/B.O. = 117.13' 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL SEWER PIPE PVC SEWER PIPE SYSTEM UNLESS OTHERWISE NOTED. -- ---_- i -�� 3" DROP MAX " " PROVIDE WATERTIGHT 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN -� 6 3 2" DROP MIN 3 9 L = 10'± JOINTS (TYP.) ELEVATION = 117.13' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A MIN.SLOPE�tq7 10" 4" PVC IN FROM MIER MIENuffig AMN dj j1.1V Q 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF 14" �-*1 17.Z'± SEPTIC TANK O 4" PVC OUT TO (TYP.) t 113. THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. i LEACHING FACILITY 0.90' 10.75"(TYP) o CONTRACTOR TO PROVIDE , + 5. SLOPE ALL SOLID PIPE AT 1.0 /a MINIMUM. SPECIFIED DROP BETWEEN ! " " INLET AND OUTLET CONTRACTOR CONTRACTOR SHALL , 12 6 116.70' -115.80' /laid flat 2.875'(34.5")--I 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. SHALL VERIFY SIZE 48" VERIFY CONDITION OF OUTLET TEE 117.00 MIN. 116.83 ( (TYP.) 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK GAS BAFFLE 6" AND CONDITION OF EXISTING TEES 5'0�CRUSHED STONE (TYP.) 5' MIN. 11.5' FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS EXISTING SEPTIC AND REPLACE AS OVER MECHANICALLY REQ'D NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH TANK NECESSARY COMPACTED BASE 25.0' AND DESIGN ENGINEER. 5 OUTLET DISTRIBUTION BOX (TYP.) 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM OF 60.00' ESTABLISHED TO BE INSTALLED ON A LEVEL STABLE GROUND WATER ELEV.= < 109.50' BIODIFFUSERS (END VIEW) ON A HYDRANT BONNET BOLT AS SHOWN ON PLAN. BASE. FIRST TWO FEET OF OUTLET 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION EXISTING 1,000 GALLON CONCRETE SEPTIC TANK PIPES TO BE LAID LEVEL. BIODIFFUSERS (PROFILE) THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT CROSS SECTION VIEW (BY ADVANCED DRAINAGE SYSTEMS, INC.) 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES TO THE DESIGN ENGINEER. *CONTRACTOR TO VERIFY EXISTING ELEVATION PRIOR SEPTIC TANK PROFILL DISTRIBUTION BOX DETAIL (H-20) ARC 36HC (#3616BD) BIODIFFUSERS (H-20) 10. ALL HE DE GNENGHERE IPEENTERSANDEXITSCONC. STRUCTURESSHALLBEMADEWATERTIGHT. TO ANY WORK & NOTIFY ENGINEER IF DIFFERENT. NOT TO SCALE NOT TO SCALE NOT TO SCALE - 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING TEST PIT DATA REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM * w �R$ d PERC NO. 13387 APPROPRIATE AUTHORITY. a INSPECTOR: Donald Desmarais, R.S. 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS / o o LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE EVALUATOR: Michael Pimentel, E.I.T. THEY SHALL WITHSTAND H-20 LOADING. C.S.E. APPROVAL DATE: Oct. 1999 L ark �/ ► � �" DATE: Au ust 24, 201113. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. B.B. �� " t�►Q , ! g60.00' o TEST PIT#: 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE M.S.L. f �„ '• •• MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. I� \ ELEV TOP= 120.50 REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, ply ' AT ELEV WATER= < 109.50' FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). PROPOSED TOTAL 20 ARC 36HC (#3616BD) U.P 15 cO 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN BIODIFFUSERS (H-20) IN A FIELD CONFIGURATION DiNiw l I • PERC RATE _ <2 min./inch SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. Hiw / 1 0 • - DEPTH OF PERC= 42"-60" G I�WIRE o O ,.. 16. PROPOSED PROJECT IS LOCATED WITHIN: 0-'' 2 LOCUS TEXTURAL CLASS: 1 ASSESSORS MAP 194 PARCEL 60 S aiNiw /��° / P 2, 120x5'TP1 °� / ZONE : M �N SPG �OVCI oiKiw 1215 _ OWNER OF RECORD: DAVID D. & SHARON L. MINEHART 121--e o / o ADDRESS: 80 CAP,N JAC S ROAD a G l50 �� l M o �-� ` p 6" Fill 120.00' CENTERVILLE, MA 02632 v IJbI1C A Loamy Sand ME/ \ �.a>TIlt� f1$ 8„ 10Yr 3/1 119.83' PROPOSED 4" PVC VENT PIPE; +� FEMA FLOOD ZONE C 12 -- .� I/ I f EXACT LOCATION PER OWNER - u ~ Loamy Sand COMMUNITY PANEL# 250001 0015 C B 10Yr 5/6 A 17. DEED REFERENCE: BOOK 15431, PAGE 191 / °' ��--EXISTING LEACHING PIT & SPOILS TO BE REMOVED & •` �. 42" 117.00' `��+ A 18. PLAN REFERENCE: P.B. 379, PG. 70 G o REPLACED WITH CLEAN COARSE SAND PER 310 CMR 15.255(3) • . Perc / z �3x� g/ . 1�• `! 60. 115.50' 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. PROPOSED H-20 DISTRIBUTION BOX y LK / ,�� -� - �.VdP` 0/ ✓ PROPOSED INSPECTION PORT ' p 12 1 °, 111 J ^h WITH ACCESS BOX (TYP OF 2) r•� • Ave • 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY \ *• * ,� 0Med. to Coarsc Sand FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY #80 �116 r • . C 2.5Y 6/6 FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. EXISTING , 4 • , • ° EXIST. 1,000 GALLON SEPTIC TANK MAP 194 + . • • r\ (5/a gravel) 3-BEDROOM 21. IN ACCORDANCE WITH 310 CMR 15.401 -15.405,THE FOLLOWING LOCAL UPGRADE TO BE UTILIZED IN THIS DESIGN—-" DWELLING 2 - APPROVALS ARE REQUESTED FROM 310 CMR 15.221 (7): PARCEL 59 (1.) A 1.0'WAIVER(3.0'-4.0') FOR THE MAXIMUM COVER OVER THE LEACHING SYSTEM. TOF = 121.0'± L PLAN (2•) A 0.5'WAIVER (3.0'-4.5') FOR THE MAXIMUM COVER OVER THE DISTRIBUTION BOX. 01% OCUS ks SCALE: 1" = 1000' 132" 109.50' 2 a01. No Mottling,Weeping or Standing Observed V1. MAP 194 DESIGN DATA TEST PIT DATA LEGEND PARCEL 60 / PERC NO. 13387 15,000 S.F.± GROUNDWATER INSPECTOR: Donald Desmarais, R.S. 50x0 EXISTING SPOT GRADE i PROTECTION MAP 194 OVERLAY DISTRICT NUMBER OF BEDROOMS (DESIGN) 3 EVALUATOR: Michael Pimentel, E.I.T. - -- 50 -- EXISTING CONTOUR PARCEL 61 C.S.E. APPROVAL DATE: Oct. 1999 DESIGN FLOW 110 GAL/DAY/BEDROOM 50 PROPOSED SPOT GRADE DATE: August 24, 2011 TOTAL DESIGN FLOW 330 GAUDAY �TEST PIT#: 2 PROPOSED CONTOUR DESIGN FLOW X 200 % = 660 GAL/DAY ELEV TOP= 120.50' G/H/W EXISTING OVERHEAD UTILITIES N6p,0 2$ SWING-TIES SCALE: 1"=20' USE EXISTING 1,000 GALLON SEPTIC TANK �Og• ELEV WATER= <109.50 - GAS --- -- - EXISTING GAS LINE . DESCRIPTION HC-1 HC-2 PERC RATE = W �V' EXISTING WATER LINE MAP 194 BIODIFFUSER CORNER(1) 36.6' 41.6' DEPTH OF PERC= TEST PIT LOCATION PARCEL 62 BIODIFFUSER CORNER(2) 44.8' 50.3' INSTALL 20 - ARC 36HC (#361613D) BIODIFFUSERS (H-20) Ik � TEXTURAL CLASS: 1 BIODIFFUSER CORNER(3) 63.5' 40.7' O EXISTING 1,000 GALLON SEPTIC TANK BIODIFFUSER CORNER(4) 58.0' 29.3' SYSTEM CAPACITY - (TOTAL L.F. OF BIOS)(4.8 SF/LF)(0.74 GPD/SQ.FT.)=GPD 0" 120.50' PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE (100.0')(4.8 SF/LF)(0.74 GAUSQ.FT.)= 355.2 GAL. LEACHING/DAY 6" Fill 120.00' A Loamy Sand ❑ PROPOSED H-20 DISTRIBUTION BOX 8" 10Yr 3/1 119.83' TOTALS: 0 PROPOSED ARC 36HC (#3616BD)BIODIFFUSER(H-20) 0 193 TOTAL NUMBER OF BIODIFFUSERS: 20 B Loamy Sand 3) TOTAL NUMBER OF COUPLINGS: 0 10Yr 5/6 TOTAL LEACHING AREA: 480.0 42" 117.00' (2 TOTAL LEACHING CAPACITY: 355.2 REV. DATE BY APP'D. DESCRIPTION 4) PROPOSED SEPTIC SYSTEM UPGRADE L NOTE: PREPARED FOR: (1 EFFECTIVE LEACHING AREA OF 4.80 SF/LF OBTAINED FROM THE C Med.t2 Coarse arse Sand CAPEWIDE ENTERPRISES DEPARTMENT OF ENVIRONMENTAL PROTECTION APPROVAL LETTER 6/6 "MODIFIED CERTIFICATION FOR GENERAL USE" ISSUED TO ADVANCED (5%gravel) N HC-2-� DRAINAGE SYSTEMS, INC. ON OCTOBER 3, 2003 (LAST MODIFIED ". JANUARY 11, 2011). TRANSMITTAL NUMBER=W000052. LOCATED AT 80 CAP'N JAC'S ROAD NOTES: CENTERVILLE, MA 02632 HC-1 -- - --- 1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF EACH #80 132" SCALE: 1 INCH = 20 FT. DATE: AUGUST 25, 2011 EXISTING 109.50' /11�1! 0 10 20 40 80 FEET SEPTIC SYSTEM COMPONENT. 3-BEDROOM No Mottling, Weeping or Standing Observed w� ss9 ;�or r�lq ,2.) CONTRACTOR CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF THE DWELLING ___ _ _ oaf cti��. TOF = 121.0'± r JOHN PREPARED BY: PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY WITH TEST PIT DATA RESERVED FOR BOARD OF HEALTH USE CHURCH LJ . JC ENGINEERING, INC. SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL BOARD OF HEALTH IF NO.l 1L' 2854 CRANBERRY HIGHWAY SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. ST EAST WAREHAM MA 02538 3.) A PORTION OF THE PROPERTY IS LOCATED WITHIN THE GROUNDWATER SITE � 508.273.0377 PROTECTION OVERLAY DISTRICT(SEE PLAN ABOVE). V(T E PLAN SCALE: 1" =20' Drawn By: MCP Designed By:MCP Checked By:JLC JOB No.2049