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HomeMy WebLinkAbout0225 CAP'N LIJAH'S ROAD - Health 225 CAPT.LIJAS RD.',, CENTERVILLE A= - i ,Sj'n& �aa�cvtiF��� A/I UPC 12534 No.2-1_53LQR HASTINOY, YN ' Commonwealth of Massachusetts / -1,3! W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 225 Capin Lijah's Road Property Address Marjorie Watson Owner Owner's Name information is required for every Centerville Ma. 02632 06/08/2015 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �06/08/2015 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. ****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 QS the same or different conditions of use. vie t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °yr 225 Cap'n Lijah's Road Property Address Marjorie Watson Owner Owner's Name information is required for every Centerville Ma. 02632 06/08/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts 4 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •�' 225 Capin Lijah's Road Property Address Marjorie Watson Owner Owner's Name information is required for every Centerville Ma. 02632 06/08/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water I ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " 225 Cap'n Lijah's Road Property Address Marjorie Watson Owner Owner's Name information is required for every Centerville Ma. 02632 06/08/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 225 Capin Lijah's Road Property Address Marjorie Watson Owner Owner's Name information is required for every Centerville Ma. 02632 06/08/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,•°" 225 Cap'n Lijah's Road Property Address Marjorie Watson Owner Owner's Name information is required for every Centerville Ma. 02632 06/08/2015 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): '330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 225 Cap'n Lijah's Road Property Address Marjorie Watson Owner Owner's Name information is required for every Centerville Ma. 02632 06/08/2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: in 2014 93,000 gallons were used and in 2013 138,000 gallons were used Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Capin Lijah's Road Property Address Marjorie Watson Owner Owner's Name information is required for every Centerville Ma. 02632 06/08/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 225 Cap'n Lijah's Road Property Address Marjorie Watson Owner Owner's Name information is required for every Centerville Ma. 02632 06/08/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: septic tank was installed in 1981 and the leaching was installed on 07/03/2013 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 19"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 11" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Standard 1000 gallon septic tank < 1" Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 225 Cap'n Lijah's Road Property Address Marjorie Watson Owner Owner's Name information is required for every Centerville Ma. 02632 06/08/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 39" „ Scum thickness < 1 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Field Instruments Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank is structuraly sound and has a pvc tee on the discharge side of the tank. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 225 Capin Lijah's Road Property Address Marjorie Watson Owner Owner's Name information is required for every Centerville Ma. 02632 06/08/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 225 Cap'n Lijah's Road Property Address Marjorie Watson Owner Owner's Name information is required for every Centerville Ma. 02632 06/08/2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins•3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 225 Cap'n Lijah's Road Property Address Marjorie Watson Owner Owner's Name information is required for every Centerville Ma. 02632 06/08/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: one with infiltrators ❑ 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 part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts 4 Title 5 Official Ins pection spection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 225 Cap'n Lijah's Road Property Address Marjorie Watson Owner Owners Name information is required for every Centerville Ma. 02632 06/08/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form >ti Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 225 Ca 'n Li'ah's Road Property Address Marjorie Watson )wner Owner's Name nformation is Centerville Ma. 02632 06/08/2015 equired for every State Zip Code Date of Inspection )age. City/Town D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately , i I IM A if-�� 7c :Sins•3113 Title 5 Official Inspection Form;Subsurraoe Sewage Disposal System•Page 15 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 225 Capin Lijah's Road Property Address — Marjorie Watson Owner Owners Name information is required for every Centerville Ma. 02632 06/08/2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 13 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augured a hole at a lower elevation and shot it with a transit to show five plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I - Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 225 Capin Lijah's Road Property Address Marjorie Watson Owner Owner's Name information is required for every Centerville Ma. 02632 06/08/2015 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 No. C/ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS I01pplitation for !Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair Grade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.A2,5-(:�f K 4:!I C. j Owner's Name,Address,and Tel.No. Assessor's Map/Parcel d'ek rev V` cc. Installer's Name,Ad�res�and Tp�tj �j�p-r ��j Designer's Name,Address,and Tel.No. 1 6.> b Z — I-Y Type of Building: Dwelling No.of Bedrooms -- Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided y gpd Plan Date wU%3 Number of sheets ) Revision Date AIJA Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issue this Board of Health. St d- Date 7 Application Approved by Date VV Application Disapproved by Date for the following reasons Permit No. Date Issued NO. t Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS G application for Disposal 6pstetit Construction Permit; �1 � Application for a Permit to Construct( ) Repair Grade( ) Abandon( ) ❑Complete System ❑In ilvidual Components Location Address or Lot No.a,2S / K � 41 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel C�K i cV✓' �'�G ?J 10131 H 4Jr— 4J e d Installer's Name,Adllres and e��;T Ana, Designer's Name,Address,and Tel.No.✓" r1�VJ o� In_l (� 1, 3. (1 — �Y6 z S Type of Building: Dwelling No.of Bedrooms —3 Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) y Other Fixtures Design Flow(min.required) gpd Design flow provided V�1 gpd Plan Date ���, U%2 Number of sheets Revision Date �y Title Size of Septic Tank Type of S.A.S. Description of Soil i Nature of Repairs or Alterations(Answer when applicable) 1 Date last inspected: Agreement: 4 ` .. 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's of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issue this Board of Health. Sl ned % Date 7 Z Application Approved by �j.l/ Date 1 v Application Disapproved by Date for the following reasonsAl ^ r Permit No. Date Issued �` --------- TIC V COMMONWEALTH OF MASSACHUSETTS .• BARNSTABLE,MASSACHUSETTS Certificate Of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ,/Upgraded( ) Abandoned( )by i at ,2 Z has been con c e acc s with the provisions of Title 5 and the fo Disposal System Construction Permit No da ed Installer 4qr e-Ary ( �9�1 SG� Designer y� #bedrooms Approved design flow / gpd• The issuance of thi Xrmil III no e.construed as a guarantee that the system w 11 nctt'on as designed. O Date Inspector V --------------------- ----------- ----------------------------------------------------------------------------------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pstetn OnstrUttion Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon System located at G ( '�,2 H Te✓Y• 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. Provided:Construction in It be co plete Z ithin three years of the date of this permit. Date Approved by I ' FROM :down cape engineering inc FAX NO. :15083629880 Aug. 01 2013 03:57PM P2 �. l3 e�y •-n�lt??,Tlil� L�bD, .i�a�.�1�i1;.�i.�,N tG).r- .� n9Ar.^�. ��/ i"E!IlP31As: �gfiSi9�iI:��Q �'Ati�Il^sIIaD'G� •..�r�nur�•?.:'� ?.$r.o.atFot�:, IGl[a�][�r�:�au, d�iilt•,ea�El:ea�r w�Q� ��)I�hPILL�$9•fid''fi,,�Il�e$iI1Y1E�y�{� Q.1����. O flc,:: :U�•I CZ-�{��� 1'P:C: �i��• 7!IQ-ff3{)�G Date: D f sew9ge$'�¢mrnilt,;' u3 L /��1l�So:f�G: t� �f✓1 � ,P�GItG)11"E,.:i: Q., is8iied 4 permittn Tm l a _ (clue) septic sy8teln �t d�. {� G_/t,C! liaaed ctt,9 rlesi}? E dr�eVJuliy (adt�-esti) J0 1, k � �. A, �` , 1.1 daCeci l r Nrtify that. Lhc 8lsi:tiE3 systc-m.rdf£,.enrcd above; -,V,13 in,,E!tll.:cl ,.21.)8tan-(ially Cicrording to — thee ilc:,q i.pn, whic:}, ma) urlt?clls r_riiiinr aPT,rovt:cl ;:}Ja;r.��es LbCIL a.^ late}-al floe distri},ii.t.innbox_,radlo ;r�ti[:ya:r_ik: I r,('i i , tlL-it the sejrti(,. s, stem referencc4J above wee, ins",9ll.Pld with m4jor' �rrAtc'.E than 10' late-.-al rc.lc:c,,ti.nn,of the SAS ux ara_y verticLsl zr:lncatirn c l�arl'y coznt�c�nc._�t rur th:rptic ;,yst;.rn.) hUL iL arr;orrlaTice,NIA. statc"ati'; Load al plall iovisinn or rPlti he.El as'liililL by to lallo,7y. IT VANILLA s. CIVIIcis I KID..46bC2 eQ r ���SS�UNAL E<lG``• 91�?1ur' l;;flatlrF::l I -- (1�l Ll.d�j)[^E �i;r ti Stamp Ii-xc) .`,' r� )LT F, K �e��9 TYtY�! L'g WILL 1.2Ce`E' -Y,C 9 11NI , IL� i-O. A9. `CMS FUR-.1@{., �'�ND � .,i�?B1Z' C Afk�A !�_ E+4:�IlVll')DBY'ilf ,BP".FY.NSTABH EP'fTEt1',.KJvFIf►LTlf V11, [090q. 'if TK Y0�IT. n.r,,..•ul.rq...n;�ri l..�i,,,.,•crrri fr>Giml H'r,-n I-26-04.iibc oF� Town of Barnstable P# Department of Regulatory Services ' Public Health Division Date eexivarner8. �twas A 200 Main Street,Hyannis MA 02601 OV/3 Date Scheduled Time Fee Pd. 710 So ' Sui bility Assessment for Se Dispos Performed By: Witnessed By: p� LOCATION& GENERAL INFORMATSI�ON r Location Address ZZ J �q �i q� �� Owner's Name �1ewN1f°r `� . zzSS Car U Address S i de..�ev�/ Assessor's Map/Parcel: 1 q 3 — 19 I Engineer's Name 0,,1-_ Ciao NEW CONSTRUCTION REPAIR Telephone# 96 2^ S P `t Land Use Slopes(%) — 6 Surface Stones Distances from: Open Water Body ' — ft Possible Wet Area ® ft Drinking Water Well ft D inage Way ft Property Line Z Z ft Other 1�60 1 13 ft SKETCH"(Street name,dimensions of lot, x ocations of test holes&perc tests,locate wetlands in proximity to holes) i V� to - —V) et =..-... F. V / Q Parent material(geologic) (/tom De p to Bedrock Depth to Groundwater. Standing Water in Hole: eeping from Pit Face "— Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: r__�__W in. Depth to soil mottles: Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level „ Adj.factor,,,,,.,,e,..— Adj.Groundwater Level,, PERCOLATION TEST Date T1me j Observation Hole# Time at 9" Depth of Perc Time at 6" Start Pre-soak Time @ 11i a) Time(9"-6") End Pre-soak / gM1N Rate Min./Inch L 6/ W I v J Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) 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:\SEPTICVERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones,,Boulders. onssr tency.%t3ravel) �z��z� G ems• z,s�r`b — DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) _Mottling (Structure,Stones,Boulders. Consistency,% /2_14-,D Z,STyl6 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ConsistencZ DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stories,Boulders. Con ' ten Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No= Yes Within 100 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? If not,what is the depth of naturally occurring pervious material? Certification I certify that on / (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 and experience described in 310 CMR 15.017. Signature OCr- - Date JZb3 Q:wEp r1C1PERCFORM.DOC TOWN OF BARNSTABLE LOCATION SEWAGE# ,PA/3 VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&.PHONE NO. SEPTIC TANK CAPACITY 0o a LEACHING FACILITY:(type) VO "%Cj\ i4k(size) NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: 7L3/A3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac fac' ' ) Feet FURNISHED BY ►� �? Zg � !� � 32 COMMONWEALTH OF MABSACHUSETTSLo ExEcUTIVE OFFICE OF .ENVIRONMENTAL AFFAIRS 'y'9 Y DzPARTxcNT or ENiV IGNMENTAL PBOTDC"I ON r 7 ONE T+lYrER STREET, SOMNf MA 02106 (617) 2s1 -MW 11014 Opp .. Tsitfil!COZZ Al CIZO PAUL CE'MUCCt ;b'k 'Ia E.'fTR.U>® � _ 1 10E haiRwAtiE DEPOS"SiYpTM MPECn=Pt Gor■oi�rimar PASST A t'il'flICA?IOM PAWWW AOftW. dTe? Cu. �.! i�IJ ase owe of carte a� C-�hCa,c� C. i L.c Ai/ of Ourrr: C ov r'fr �..of taarearar � �r� D NMI of I�Nnc Ploolos p As l ear a DO spa brrpagtsr pawrarrt is ti.yl0 all TIC i 1=70 M 1i.d�q NAIL Name: r t h�eCt CCU 5 Mawa A� S S Ca Vt Sdgftm M omb r: — — l om; that 1 have pesanWy Inapectad'Ae sawapa disposal system at No adilre"rind that the Infanyrathon reported below is any n.a made. sed a outlets as of the time of Mapecdon. The inspection was performed based on my tralalnp and experience in to proper 11 wilon oriel maUMwonoe of on-aft sawepw rEoposal Sly-two Tha system:. Y— Paseaw r� CurOrmapy Paean _ Moak Pwdw E+aluwilon IV the local Ap w*q AullwAty Palls leapaaaa�a plOtwaac /u arle s The S pow. lrtopeatsr shell submit a o"if of INS inapectlon report to the Alprawlmp Authority(sowd of Hooldr or DER1wMMr tfrht r(itN Uryr of oearissino We Mopeotion. if to systen,is a shored system or has a.doolpn flaw of 10.000 ppd or Vassar.the irapeotor and tilts *Ws m s,t.rar shsA atdwA the rapert to the approprIeW ropional office of the DepairlmartlefErevironmentei Protoction. The oAOtnd should to ssi it to Orr etretwm owner and espies eew to the barer,it appilesble. en4the*Wow sw0wlty. MMM AND COMKIRM t revised 9/2/9e frarl.ilt t*Polio an a«n'rr P"r t S L4MPJNFACIII SWAM OUPOSAL OYSTM 1111111PECTIM P MO1 PART A 1� nn�nC�I�A��IMrlrllrr� emir. 1`�C l70^il�e� sees" l cc WWWn=sussO M CMA A. At C, N a A. w.»pip 111-i 6— 1 have not famd any Informsliten which InAcates that aly of the lain conditions described in 310 CMR 16.303 wnhrt. Any falkrs ceflab net svab clod we bnlaNN below. IL sWTir 4 O 11OrAUV pewssih One ar acts opum on, iponat>s a described In the"Conditiennd poem"sac need to be replaced or rspoirod. The elirislni,span cowepleMon of the esplpoeernnt car repair.as approved by the Road of .will pass. hedloots yse,no,or not doom Maw d(Y.PI,or RD). Describe bads of fors In di Instances. If"not deternMned",explahi vs•hp not. The sapde talk is nwrld.unless terse owner or has troubled the system Irlspaotar wRh a copy of a Coritllcsls�s!' Catnpienes Wifteohalp inandad that the W* InOded within twenty(20l ysors prier to tlw date of tire lkit,pet:tlon:or One saptls tack6 wholtar or not metal.Is at .asructeadly unsound,shows substantial kvftaden or orrlllemlien,or taut falwo is Irunnhant. 'nosy Boni wo pass It the existing septic tank Is replaced whh a EMI sipintc tent as appeaved by tfnr saaKl of lMdlh. $swage beci or break high etselc wets!W W obsocnel In the distribution box M dos to broken ar enIM�O n�00sd pilneda) ar dw to s broken.as or unarm sat ibwon box. The spew YA pass Inspection if(wkh approval gel!111im Ilbenf,al lledtinl. k.w p4Wal are popMeed Mpieuv n Is removed Aewbldan Ma M Waled or roplaead 7a000 Pis more don 14ner 4innnee 0 year do*to broken or obseluobd plpefe). The eysMkn Irdil pslM (wM approval of.ths,seed of"now. _ bi ptpslel we apbeed alns�tnatiann ko ronnawd revised 9/2/9 Q fJ1de i sf ll 0sC $T ION r SEWAGE PERMIT NO. V I L t'Ad E � IN'STA,LLLER'SR NAME i ADDRESS BUILDER 0 OWNER r DATE PERMIT ISSUED DAT E COMPLIANCE ISSUEDr *"` �� rr t _.._ op ` t r INAM111FACE SEw"E OMPOSAL STI"m ONFWTION FORM ►DATA CEIIfll1'.AT1ON Maasltlrlma Pempl PW A/OaM: Osnhtw: Dow of bumoodw C. 1IAMMI1 INALUATION M MOME30 SY THE DOAMID OF HEALTH: CondMons exist wtrloh require Mather eveluedon by dw bawd of Mfedth in order to detannita If the system Is falkwil>,ta pt c uct I MI pbro heofre,adsty wmd ttea wimironmerd. 11? S`ifSTM WALL PASS WMASS 114A 1D OF HEALTH DETER N ACC0l1DAMCE tIIIMTIM 310 CMM119.302 111M rNAT'Ir M.WrIWnW M NOV •o A MIWM l VOGON WILL P110TECT THE PNOM HEALTH AND SAFETY AND TIME WWKM 1vT:' Ceseposf or pivy to%within 50 feat of surfmw wetw Cesspool or privy Is emithin 60 feet of a bwdarinE verstowd wedwW or a soft nwsn. 74: $TOM tVLL FAL ISMS!T WE SOAIID OF HEALTH UM PUKJC INATBt SWPLISL OF ANY)DET191ME1111110S T U 1'MII::911,811131111111 is PjMgWNM MN A MA�VMIAT PIIOTVM THE PUKX HEALTHI AND SAFETY AND THE iSIV M101MWIR: The eyaeam has a egn1c taMt end soil sbsofpMen systwn MIS)and the SAS is wttMn 100 last of a surhe•s wailer @apply ar vrbmwy to a eurfam worse supply. The syatam has a segoic tank whl ease absor"on system semi to SAS Is whhin a Zone I of a public wMw snrppil,,wmil1. The aystam has a s"mia m*earl ear ebmption system semi*a SAS is wkMn 50 teat of a prlveN wallet mipsirlr seer. The eyeewn he>s a aelOio tw*and sail af»orp" system armf Ow SAS is less there 100 feet but SO feat or mcwt tram o phm"weew sWpiy 10reN,unlaas a was wale►wnlysis for w9dorm beetede and voleMe eryarde congMnls k4411=00 that On war is free dram poiklion from*hat fatilty wed*a peesnso of anernoNa Nerarrm end rlltrass nivoy" is ogPB1 to w limsm Ow Mi ppm. Methel imW to deterMrn d)otanea loopaoirhholMee ant VIM. bi OTMMSR revised 9/2/98 ftV3of11 I SUBSURFACE SEWAGE DIEPOM SYSTEM MPECTWN FORM PART A CERPMICATIOM 1mnWanQ *moor. Owenr: 0861 of CO 1 t k OD D. SYSTtM FAIT" -. You rmet"cote efthor"Yee"or"No" to each of the following: ® I have determined that one or more of the following failure conditions axis a described In 310 CMR 15.303. Thu beuii:for this determination Is)dentifled bsll:,w. The gowd of Health should be cent ad to determine what will be necessary tr,con nct the fail ire. Ye No Backup of sewage in/~babav r system compona us to an overloaded or clogged SAS or cesspool. _ Dlachargs or pondin! effluent to the surfac the ground or surface waters due to an overloaded or::9119 d Sik$,;r cesspool. ® _ Static squid level in tion above oub9at Invert rive to an overloaded a clogged SAS or eassiwrol. _ Liquid depth In csssn i"below Invert or available volume is Iasa than 1/2 day flow. Requirad pumping mtimes in the lest year NO dus to clogged or obstructed pipe(*). Number of times puu Any portion of theion System,cesepoel or privy is below the high groundwater elevation. ZFALS- You of cesspool or privy Is within 100 feat of o surface water eupply or tributary to a surface vrater:+upply. of a ess:rpoc9 or privy is within a Zone l of•public veep. of a cos+ipool or privy is within 50 feet of a private water supply wall. of a cesiupool or privy is less•than 100 feet but grater then 60 feet from a Privet*water*ujgl);a ell with rm: ater quidity analysis. If the well he@ been analyzed to be acceptable, attach copy of well wibter a tNy*is for teria, velatiis organic compounds, ammonle nitrogen and nitrate nitrogen. E. I►A M You must Indlcdto alther "Yes"or"No" to each of the following: The following criteria apply to large systems in addition to the elite ibove: The system some a facility with a design flow of 10,000 or greeter(Large System)and tore►system is a signif earrt hreswt to public health and safety and the environment becouse one or a of the following conditions exist: Yes No the system Is within-100 feet of rface drinking water supply the system Is within;100 Of a tributary to a surface drinking water supply tho syatam Is located I a nitrogen sensitive was(Intwlm Wuphead Protection Area:IWPA)or a mopped:Cate'l of a pubic water supply well) The owner or operator of any such stem shell upgrade the systom In aecordowe with 310 CMR 16.304(2). Pies"consutt gee iDesi reilioiul efflce of the Dgwvnom far fu Information. revised 9/2/98 PW4of11 E OSURFACE SEWAGE D{BPOM SYSTEM INSPECT"FORM PART 0 CHECKLIST ��r: �1�h0.� ®waesr: Dsse of InapaeMan: s f 1 t t l oo Check tf the following have been done:Ifou must Indicate either"Yes" or "No" as to each of the following; Yea No Y— — Pumping information was provided by the owner,occupant,or Board of Health. _ None of the system components hove been pumped for at hws*t two weeks end the system has been readvirq normal Isow rates during that period. large volumes of water have not Ibsen introduced Into the system recently or sa part M this Inspection. — As bunt plans have Mean obtained and examined. Note if they are not available with NIA. T — The facility or dweliinll was inspected for signs of saws#*beckrtp, _ The system does not receive non sanitary or industrial waste flow, _ The sit®was inspectai-i for signs of breakout. _ AN system cornponews,excluding the Sol Absorption System,have been located on the site. r The septic tank manhrdes were uncovered,opened,and the Interior of the septic tank was inspected for concfi7tLm of brM+n or We,material of ccprotructlon, dimensions,depth of liquid„depth of sludge,depth of scum. The size and location of the Soft Absorption System on the sit*has been determined based on: _ Wating InfamuMon. Por example. Plan at B.O.M. r Determined in the flel:l Of any of the failure criteria related to Part C is at Issue,approximation of distance is wwi cceptal:del Q1 fb.30#t9lib)' _ The facility owner(and occuper a, If different from ownw)were provided with information on the proper ntatnti,nMC* of subsurface Disposal 11 yatema. rev:Lsed 9/2/98 ilegaseril JUBSURFACE ISMA0E DOSPOSAL INVSTEM IMPECTKM FORM PART C SrSTEfid MromAhTm o Dom)of l FLOW COND11 am MEEM Design f w: L ,S.p.d.la.� Miember of badrooms : (lumber of bedrooms(setudi? Total DESION ftwn Nurrdtar of current►esidante 1lertnge p(nder(yea or no): �LG Laundry(separeb systam) )yes all no)V: If yea,@operate Inspection required , Lowkkv system inspeotsd1l"s or no) cy )50 Ssesonsi use(yee or no):�+ tCl Wabrr meter reading*,if a��r�p ppe(lest VNO yosr's usage tgpol: Sump Pump fyse or_nol:-L Oast dote of ocoupsncy: T"m of eitabNehment: _-�! / Design flow: and( Based an 19.203) .' Seelo of design flow Gros"trep present:(yes or no),_ Industrlel Waste Holding Tank prssant:I'ye r no)� Non•aanita dry waste echargsd to the e S system:(yes or no),_„ Water meter readings.It evellabie: Last date of occupancy: OTOOMR:(Describe) `.eat data of Doaupan �- ON1AL N1ORMd1TION FIJlAfiNO i s�so�ueoe o�infroe��+�adign: (Z Yu�. : System pun VW me part of IneOioationc lye*or of If yes, volume pumped: gallons Reason for pumping: TVPIPF STOTM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) Of(Fes,attach previous Inspection records,If any) 11A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of 0 EP Approval Other APPP OXNAATE AGE of all components. fete Installed(Of known)and source of information: Oa�tl!L4)C2 Seirsee odere detested when arriving at the site:(yes or no) revised 9/2/98 Per 6 of 11 i i USSWACE SEWAGE DwiPOSAL SYSTEM MdtPECU M FORM PART C SYSITEp wro w"THM 1aarMr0" Dam of : 't tit a® Nftl=o s~* (t.oclite on aft ptsn) n Depoh below Orede:� Material of construction:_,cast iron x, 40 PVC,._other (expialn) Dlstsnce frop privets water supply well or suction Ono Dlsmefer Cona*ronts:(ccnddon of joints, venting, evidence of leakage,etc.) Poevio on site plan) r� Do"%below Vmdo: Material of construction:X Conerets_,;meld_Pitwoless „Polyethylent_other(sxploin) If tank is metal,Ist cgs_, I Is age corr'ientetl by Cartificats of Compliance (yes/No) Dimenellm sue"depth: Distance from top of�rludoo to bottom o'outlet toe or baffle. Scary~thickness: AR 1r Distainco from top of scum to top of outl rt too or beffle: � r Distance*an botunm of soum ott to borr of outlet toe beff e: 'tow d monsians were dete►minod: t'P Comments: (reemnmendatlen for pumping, con `on of Net and outlet less or ba"as,depth eLf fould le I in moll n to outlet Inert,strucr,:ur;J integrity. evidence of leakage.K o :.lt •_- ' e. s c► .,1.� ._. .L _....,. QIIwISAAE .�. (ioome on Wee plan) Depth,below prok:l. � Material of construction:_concrete_metal`Wbergisas ! t;fhylww—4wwr(exploin) DbtrarWone: --' gem ddaknm- Distanco tram top of soum to top of outlet too e: Dlstarme from bottom of scurry to bottom of too or baffle: Does of loot PumphV: Comments: (recornmendstlon for pumping, dltion of Inlet and outlet two or baffles, depth of liquid level in Weldon to outlet Invert,stmalisrrl Integrity, evidence of kukage,etc.) revised 9/2`98 hr7of11 SUUURPACE SEWAGE D1SP►O"L WrSTUA NSPECT1ON RMN PART C IVB M!lIPOIeMAT10114ownli esdl PONT. Doss of btsP ,ML >i q t ` `e TOW OR HOM O TANK: (Teti It must be pumped prior to, or at time of,inspection) (kaoeso an ake plan) Depth below Srade:o Material of construction:_concrete-metal_Rbe a_Polyethyiene_otherlexplain) Dreensions: Capeoity: !ice 00, Design flew: oellons/ Alarm rve prese Ahrm)svW: Alan n workle!;order:Yes No_ Dasu of prevbua Cor wens: (condition of Net ,condition of alarm and float awteehes,etc.) D1d1'! 1 vex:.g llocnb an un pion) •De plft of"level above outlet invert: Commons: lr+oto If I"Jpd distMV'�on Is&wet,widence of solids Barr ,ver,evi of I kepe into or out ofqq x, etc.) _ _ Iva KsO&ti ie JtL °fir .=tQ IA,* 1r�L.L'1�. l�o `SN$ .gx-�r .._.---- P,J&rem OV G1 p11MP CKUN (locate on alto plan) Pumps In wet Ing order:(Yea or No)-- Ale""In workwq order(Yea or Ne)__ Corwrteerte: (note•oond dal of pump chamber.condtd of pumps and appurtenances,etc.) revised 9/2/98 Page lair ll RUSSIJRFACE SEdvAGE DISPOSAL SYSTEM WSPECTM FORM PART C SYSTEM iIOP01IIIIIIIATION fammOnmeQl Dow of boopeasm OW A§SOMWM STOM WASI:-& (locate on sits plan,If posdble:excaysti�ci n not required,location may be approximated by non-intrusive methods) of nai located,sxpkdn: Type. g pies.ewmbw: femahhng daanbers,numbw:_,_ l ing$so 1-s,number.,-. lemehf�lg Immoltes,rumba, lanifth: Issoflkq fld/s,f*nnbw,dimm Wons: ovwlrow cesspool.numbw:_•_ Akerfndve aystann: Moms,of Technology; Comrnentm: (note condition of i!,signs s o�ahy�drw fmilu► ,Tavel of pending, dwnp soN,condki'4not a ti on. etc,! k P (locate an oft plan) Number are eofnflgwadom 'Imoi-top of Nduld to WM Invert. apdu of solids lava: Dimsnwefts of cesspool: materials of ceomouedw►: bmIcadon of droundwstw; Inflow Icesspool must b rd as part of inspection) Commefnb: Incto condition of , signs of hydrwllo fallum. level of ponding,condition of vegetation, etc.) FRM': (loons an eke pk ml Mateffsle of owwNucdon: __ Olmensfone: Dpth of ao", Comtvents: 11,00, Qnofo,wndkbn of call, signs of h foilun, level of pondhp, con will tlan of tiger tlen, stc.l revised 9/2/96 Ps®e9oftt ILMURFACE SEWAGE DUWOSAI S1rSTM NSpECTM FORM PART C SYSTEM MFOOONATMol Ioa dnwe owrssr: *,A Hof 4 t(t� SKETCH OF SEWAGE ONPOSAL SM SE: include tlos to at!oast two permanent reference landmarks or bonchmaks fixate aN weRs wMMn tO0'(Locab where pubac water supply oanes into houso) o . 1 ?7 8 ad revised 9/2/98 Kar10of11 11USStIVACE SEWAGE DISPOSAL SYSTEM NSPECT1011 FORM PART C SY8TTW MIPOISMATM 6eentitated) Owvz Daft of mopeadmie Lt too NRCt Report nan+a Soil Type— TVOcal depth to groundwater_ USOf Date wobWw visited Obsavetlon Wells chocked Chem wow depth: Shallow Moderate _!gyp SITE EXAM Slope Surface water Check Caller Shallow wells EstimHtod Depth to Groundwater Fail Plaeso Indicate M the methods wood to determine High Groundwater Elevation: Obtained from Design Plane on record Observed Site(Abw4ting property,abservation hole,besentent sump ate.1 Detemoned from Wool canditions Chocked with local Board of health r Chocked FEMA Maps Checked pumping records Chocked local excavators,Ineeallem Used USOP Date Daseribe hdw you established the High Groundwoter Elevation. (JIM be completed) t OwtereS_04- �- C eo-c, t 0- rev _sed 9/2/98 .11aru _Yee a Fms.. ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. Xe-�.................... App irFation for Biiposal Workii T.mstrurtion ramit Application is hereby made for a Permit to Construct ()() or Repair ( ) an Individual Sewage Disposal System at .......... ...Ll. .r ....._... ��....... ............ on-Addres o t 60 ..,/ V, Ownez Address yA� --------••.............. --------------- --•----•---•-------•-----------------------------•------_./..(�` r Installer Address Q Type of Building Size Lot_�6Q4�._Sq. feet U Dwelling—No. of Bedrooms................................. -Expansion ttic ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons.........(P---------------- Showers ( ) — Cafeteria (�J 04 Other fi ture ------------•--- W - Design Flow.............. ............................ allons per person per day. Total daily flow........ ................._------gallons. WSeptic Tank—Liquid capacity/A4. allons Length.............•.. Width---------------- Diameter................ Depth................ x Disposal Trench—No..................... Width...___.________.. Total Length............. --___ Total leaching area....................sq. ft. Seepage Pit No...../----------- Diameter.,oW........... Depth below inlet..... ........... Total leaching area.2,i.'v7__.s . ft. Other Distribution box ( ) Dosing t nk ( ) �, �oa% 49ec Z Percolation Test Results Performed by._._7�bl"Y-2,�......... ..... Date_._..._._4�� �_.._ . ,4 Test Pit No. 1-----4------minutes per inch Depth of Test Pit.... ... p B..... Depth to ground wa er______.11��..__. f1.� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------- ----34, - #---- ---- -•--...---•- O Description of Soil.................b.-�-34 -- ...: /[a - ---- -- -- --- --- W -------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------- ......................... UNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with p -TT-1 7 5 of the State Sanitary Code— The undersigned further a rees not to place the system in the provisions of i 1.:!.;.. operation until a Certificate of Compliance has��issuedby,the board of 1 _.� Signed. = f'[, --�-- �_ .. d ....... / Application Approved By...... � �,�A... CzG� �..............•......__..._ .., Date Application Disapproved for the following reasons:.............................................................................................. ................. ----•-••--.....••---••------••-----••-•----•----•------•-•--••••••---•-----------•••••••-••••-----•---------•-•--•••--•-•--••••-•------•---------•------•---••--------- ------------------------------- Date PermitNo......................................................... Issued_....................................................... Date N(9 ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 9��•!/: ................OF........... .. 1 .-S7 7;4.U ............ Appfiratiun for Ui4puual Work.6 Tomilrurtion Prrutit Application is hereby made for a Permit to Construct (,Y) or Repair ( ) an Individual Sewage Disposal System at: t -Address of trov 15 Owner Address a - ' !'=.��t -•------•-------------------------•-----.......- -•-•---------------- ............. Installer Address d Type of Building *Wwr" Size Lot_ 6.4 TSq. feet Dwelling—No. of Bedrooms_-- ..__'. eidc ! ---------------Expansionttic ( ) Garbage Grinder (-'*f Other—Type of Building _______....... No. of persons......... ._............... Showers — Cafeteria QI Other fixtures,...._ W ;Design Flow............. ___or. per person per day. Total daily flow__._..... .....................gallons. WSeptic Tank—Liquid capacit AP-_ � 'allons Length................ Width................ Diameter................ Depth................ Disposal Trench No. .................... Width... Total Length..............---___ Total leaching area... ._...._..sq. ft. 3 Seepage Pit No . ............ Diameter.,�4.......... Depth below inlet_....4............ Total leach-n area. D�_...s ft. _ Z ,-Other Distribution box ( ) Dosing nk ( ) �. r A7 '-' Percolation Test Results Performed b .... ____. e ..._. Date. ......__. Y � ,.a Test Pit No. I...............minutes per inch Depth of Test Pit... ........ Depth to ground wa er....... t�... .. rZq Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................ -••----------•------••-----•-------•-•-------------•---- D Description of Soil "' .- W UNature of Repairs or Alterations—Answer when applicable..................................................................:............................ ---------------- .........................................................................................................------------------------------------------------------------......•••--.-•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of-TT LE,p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee ''fed by the bo- f Si ned-:.._ .......... ----- .... .�' I ate Application Approved By.. 1 � _ ...... --•- - .......... � Date Application Disapproved for the following reasons:...........:............:.:..:...:..: :. .. .................•--•--•--••----------------•--------------------------------•----------•------------------•-••--•--•-----•-----•••--•--••••-•--••••----------•--------•-••-•----------....••---------- Date PermitNo........................................----------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACLHUSETTS BOARD OF HEALTH OF....... �Pr ...................... Tnrtifirtttr of Gout fi�anrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY.................................................................................................................................................................................................... Installer at................................................................................... ........................•---------------------------------------------------------------------__...------------------ has been installed in accordance with the provisions of TITIZ j of The State.Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �..� 8� 1 DATE-•---•-•-•--------•----------••---•--•..............°� .. ,ev Inspector -- - - -- --•-- -----------------------------•--..-.-.•-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,w�. 7 .........OF......."" ram, / r................................... �' No ..,. �...... FEE....,,, .............. Disposal Workii Ionotrudion rranit Permission is hereby granted------..c'-------� ' ' to Construct or Repair ( ) an Individual Se rags Disposal System at No.- ^ e. �---------- ------ e 7_1 a �. Street as shown on the application for Disposal Works Construction Permit No--------------------- Dated.......................................... B .rd of Health DATE _ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS t s �1 3 1 ' f SOT 4-�S Q s THOMAS q�ti O KELLL'Y �' .p Mo.l11i0 y /STS NAJ_E� V OF THOM" U �0/1TER��pp T4 J " �O.su 'THOMAS E. KELLEY CO. .410 MNOINEERS—SURVEYORS 346 LONG POND DRIVE /pi /1� ti SOUTH YARMOUTH,MASS. 026" O LOCATION C° NTE ✓.�44� . .!'7i�J. • C SCALD /.�_ �. . . . DATE .O.//8/. . . PLAN REFERENCE . ... ,� .4.T. . . i� : . .... .. Boo �2 ES�SHOWN AT THE C. 191z L E"S�`� 5 Y,-42^1 AF. N PLAN IS LOCATED 0 E GROUND H DATE . . .. . . . .f Lij�6R PETITIONER; REGISTERED LAND SU o/-2 TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS 4' CAST IRON ��nrnam; PIPE (OR 12 MAX. 12"MAX. EQUIV.)- MIN. 4"ORANGEBURG(OR EQUIV.) "�' PITCH I/4"PER. PIPE- MIN. LEACH PITCH 1/4"PER.FT. PIT ,e PRECAST N V �tT o 14 LEACH I N G `•e EL. INV RT INV RT o . a•; PIT OR o,. SEPTIC" TANK EL. SBS DIST. EL�.�GI. ' : >_ EQUIV. ,e INVERT / BOX �- "' IDDQ GAL. IEVER INVERT ww „ 3/4 TO 1 V2 EL. a.' �� WASHED • , w \:. gip•, STONE 31 DI�A: o �•,o PROF) LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE >F . e X f I L LOG WITNESSED BY DATE ..�C .Z. O l:.' TIME.��,FM. . 4� ��AGa41 BOARD OF HEALTH r TEST HO� I TEST HOLE 2 " /- m s �; . ENGINEER ti ELEV.:¢R•Z.. . . . ELEV. .. .. . . . . . . ° -So/L DESIGN DATA .Saa 3o`�t;4S:7� NUMBER OF BEDROOMS Th�TZ 9 TOTAL ESTIMATED FLOW ,��... .`GALLONS DAY �5.. BOTTOM LEACHING AREA p..S� SQ FT./PIT SIDE LEACHING AREA . .� 8. . .'SQ FL/ PIT s l� GARBAGE DISPOSAL / /J/L?. . .(50%'_AREA:.I NCR EASE) TOTA L LEACHING. AR/E,A,,,�T.v.7 0 SQ.FT , PERCOLATION-;;RATE��JJ/!�'�fl _ ;MIN/INCH . :LEACHING AREA PER PERCOLATIONr RATE. . SQ.FT ' &l�WATER ENCOUNTERED `NUMBER .OF'LEACHING PITS , � �:5� /�/'� 41 APPROVED . . . . . . . BOARD OF HEALTH f si DATE . . . . . : . . . . . .. . . . h ', , ,I •. AGENT OR-INSPECTOR } K` s �jtkOFMd9 9 zit t .� 02 THOt S r MAS E.KELLEY:CO Li THO v 60 O ENGINEERS—SURVEYORS o 'A �, �Q /STEP �tr. 346 LONG;POND DRIVE. ONAL \ ` �,V PETITIONER SOU I H YAR1vfOU TH,MASS.:• ssl dab NIP 5 l ALL SYSTEM COMPONENTS SHALL BE SYSTEM PROFILE MARKED WITH MAGNETIC TAPE OR PROVIDE MIN 20" DIAM WATERTIGHT (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. NOTES a �, ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 1. DATUM IS APPROX. NGVD 2" PEASTONE OR GEOTEXTILE PROVIDE INSPECTION PORTS TO \ TOP FOUND. EL. 68.5' FILTER FABRIC OVER STONE WITHIN 3" OF FINISH GRADE 2, MUNICIPAL WATER IS EXISTING 2% SLOPE REQUIRED OVER SYSTEM MINIMUM .75' OF COVER OVER PRECAST 68.0'- 68.5' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. Stye PRECAST H-10 °k Locu RISERS (TYP.) 2'0 4"OSCH40 PVC 4. DESIGN LOADING FOR ALL PROPOSED PRECAST 0 on S . - 67.0' ZUNITS TO BE AASHO H-10 Three i EXISTING " P LEVEL 1ST 2' S 5' � ,� PIPES 6 . 5. PIPE JOINTS TO BE MADE WATERTIGHT. �o 10 14 9Sh/� y ** TEE 6. CONSTR U..."\ CTION RUCTION DEACCORDANCEa• � •O TEE SEPTIC TAN TAILS TO BE IN* o Locu 65.6t 65.06' WITH 310 CMR 15.000 (TITLE 5.) o� Qo \ GAS BAFFLE::: °��°�9°�°�° �c c o k�00 0.92' 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND 65.25' 65.08' 64.16' NOT TO BE USED FOR LOT LINE STAKING OR ANY } 6" MIN. SUMP OTHER PURPOSE. 12" MIN. INT. DIM. 16 H-20 HIGH CAPACITY INFILTRATORS 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. or �� (NO STONE PROPOSED) o 6" CRUSHED STONE OR MECHANICAL 9. COMPONENTS NOT TO BE BACKFILLED OR C COMPACTION. (15.221 [2]) CONCEALED WITHOUT INSPECTION BY BOARD OF p�a po �o a 5.46' HEALTH AND PERMISSION OBTAINED FROM BOARD s ( 1 % SLOPE) ( 1 % SLOPE) OF HEALTH. EXIST. D' BOX 4' LEACHING ' 10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS MAP FOUNDATION- SEPTIC TANK 35 FACILITY . CALLING DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION OF ALL UNDERGROUND & *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT BOTTOM TH 1 EL 58.7' OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF NOT TO SCALE UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE WORK. PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM WITH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE ASSESSORS MAP 193 PARCEL 131 CONDITIONS IF NOT SUITABLE 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED LEACHING FACILITY. 12. EXISTING LEACHING FACILITY SHALL BE PUMPED D AND REMOVED OR PUMPED AND FILLED WITH CLEAN I V SAND. 99- EXISTING CONTOUR SYSTEM DESIGN. X 99.1 EXIST. SPOT ELEV. 99 PROPOSED CONTOUR GARBAGE DISPOSER IS NOT ALLOWED DESIGN FLOW: 3 BEDROOMS © 110 GPD = 330 GPD 6 99 PROPOSED SPOT EL. S), TH1 USE A 330 GPD DESIGN FLOW TEST HOLE Y d SEPTIC TANK: 330 GPD (2) = 660 2� SLOPE OF GROUND � �O RE-USE EXISTING SEPTIC TANK** UTILITY POLE / LEACHING: FIRE HYDRANT 4.73 SF/LF x 6.25' LENGTH = 29.56 SF PER NOTE: NOT ALL SYMBOLS MAY APPEAR IN oRnwlNc HIGH CAPACITY INFILTRATOR UNIT 330 CAPE AND VINEYARD EASEMENT � REQ'D PD/0.74 GPD/SF = 445.9 SF LEACHING TEST HOLE LOGS �910 PROVIDE 38' OF 40 MIL LINER AT 445.9 SF/29.56 SF/UNIT = 15.1 UNITS ENGINEER: ARNE H. OJALA, PE, SE // x 5 5' FF SAS IN AE SHOWN.ATOLEVATION s5R5A BOTTOM AT P THEREFORE, USE GRAVELLESS SYSTEM OF (16 DONNA MIORANDI, RS // 7 5 EL. 61.5' H-20 HIGH CAPACITY UNITS IN FIELD ) WITNESS: 77 CONFIGURATION OF 2 ROWS OF 5 UNITS & 1 ROW DATE: 7/1/13 / x 8 / �� OF 6 UNITS � PERC. RATE _ < 2 MIN/INCH � 70 DECK / 16 UNITS x 29.5 SF = 472 SF > 445.9 SF CLASS I SOILS P# 14069 GARAGE 99 ^ 64 472 SF (0.74) = 349 GPD (OK) 7x 69.12 1 ELEV. z ELEV. x 6X 2 x 26 1 G A APPROVED DATE BOARD OF HEALTH MA O» O» 68.7' 6I .1 APPROVED 68.41 69.2 �.w EXIST. DWELL. 8 3 " 12 �g a 68.27 TO? FNDN. = EL. 68.5' x 68.88 H �8. 68.05 FI LL FILL \� 68. 18 OA 2 I �QF .48 G/� 67.83 TITLE 5 SITE PLAN 6pp 6 9 OF 37' 6 / Bw Bw 7), SL SL .96, 68. 8 0. 225 CAFN LIJAH'S RD. 12" 2.5Y 7/6 68.2' 12„ 2.5Y 7/6 67.7' s . 3 O *-67 6x1DMH7.21 CENTERVILLE O x 67.71 7.00 6 c9s x 67.50 ��/ 5^ SEWER LINE MUST BE PREPARED FOR C C G�' li'y� J� / X 76.81 SLEEVED FOR 10' EITHER PERC (, Iz� .52 66.9 SIDE OF CROSSING OF HICKEY CONSTRUCTION/ 8 J DMH WATERLINE WATSON 66.63 X 67.15 MS MS ��� `6 61 BENCHMARK: USE CATCH BASIN AT ti^'�� 69 ELEVATION 66.6' JULY 1, 2013 � 4SN h, .s. Zs X 6 .68 6 / / ^t f^ dq �vy� 9C OPQ 2.5Y 6 6 2.5Y 6 6 a � _ S• '�' �o DANIEL ti� ,� 98 .14 66.88 (D6.75 off 508-362-4541 d f. its DMH ��y��JALA �� ( fax 508-362-9880 Oa ~t downcope.com 120" �Fss , r a� 67.15 �/ 59.2 58.7' r' c ; ; R fir` own cQPe eng%Weer%ag %IIc ' 120 ,� s4� °. �w �r E s. 1 P civil engineers NO GROUNDWATER ENCOUNTERED v R_ J Scale: 1"= 20' land surveyors r 939 Main Street ( R to 6A) 3- 134 DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 0 10 20 30 40 50 FEET