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HomeMy WebLinkAbout0336 CAP'N LIJAH'S ROAD - Health 336'Cap'n Lijah's Road' ` Centerville P A = 193 .107 h No. 4210 1/3 ORA Pendaflexe ;:4• 10% • No. / V ��`' Fee a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for Migooaf Op5tem Construction Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. C�!� l� wner's Name,Address and Tel.Nq. J 'ali Assessor'sMap/Parcel I i . `® CA9"N ` 1SA9 Rd Ce. C > 1ej Installer's Name,Address,and Tel.No. L a 51s signer's Name,Address and Tel.No. �"�(Ozi—(v j ko6ec-�' Po. bog. CC7 ^� AS� Eaeoo N Type of Building: Dwelling No.of Bedrooms Lot Size Csq.ft. Garbage Grinder( ) Other 'Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow '�.�,7 gallons. Plan Date 4 GL I I Number of sheets Revision Date Title Size of Septic Tank 1 000 Type of S.A.S. cc;') 04 Description of Soil Rkli D�-1 Zo"— ®JqMj SA Nature of Repairs or Alterations(Answer when applicable) l Q&fQ Q'130K Sod 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 C nd not to e e system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. / '� Date Issued No / 5 p. / r Fee Q U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC�HEALTH DIVISION -TOWPFBARNSTABLE, MASSACHUSETTS 01pprication for 33igpog t bpgtem Congtructton Permit Application for a�Permit to Construct O Repair( DN)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. tj,L Owner's Name,Address and Tel.N.q. Lo a, - C'et'j Ii�C ZZ RA4vM zAIjA �"1 ' Assessor's Map/Parcel f �N -S k RCP Q�0 S. r`' I `^,Al �t3 la _ G+� A t W ►/1 fC ej Installer's Name,Address,and Tel.No. 5 d� V S30 signer's Name,Address_and Tel.No. j�^���..Gj o Robe r r v >` �, G 2 Cv • ASS K)V C I Nee Type of Building: Dwelling No.of Bedrooms 3 Lot Size 150 0)_1 sq.ft. , Garbage Grinder( ) Other Type of Building No.of Persons " + Showers( /) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow,_ _- -©`�3 T��gallons. Plan Date 4/el I Number of sheets Revision Date Title Size of Septic Tank I coo Type of S.A.S. : W om d d't14P_.r_-S Description of Soil; A&H O rN zo"— 0 A A1,I S A 13 3_ Nature of Repairs or Alterations(Answer when applicable) 1 N 1 ®"bo l l SOO QC'110 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 nd not toe the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date •� r s. . Application Approvad'by Date Application Disapproved for the following reasons Permit No. f.� Date Issued / ,_t, ZZ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(Y_ Upgraded( ) Abandoned( )by Robe rr A _ oi>c- Cn SN C at C has been constructed in accordance with the provisions 4 Title 5 and the for Disposal System Construction Permit No.;j22S- 3 • dated Installer Designer The issuance of this pe , h}aid not b constxued as a guarantee that the system'-'will.fur�nctiofn�a deb gned. Date / -A H Inspector V V�.1�y'� U Nor.�K/�GI "' J? `/ — —— - Fee t THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ,x Migpogat *pgtem Congtructton Permit Permission is hereby granted to Construct( )i Repair O Upgrade( n)Abandon( ) System located at r A nJ c�e&.1 rP r-I/ l le and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date off this permit. �1 Date: %� / �— / Approvedby---._ t `r AFFIDAVIT I, OvIM7_� Av \�- Zn i n6) Do hereby swear that when we purchased the house at the following location, 33b C o �-d In the year of oo4 , It was a bedroom dwelling and is still used as such. date: date: �l �2YV���Y jZ01�1� Owners' signature Town of Barnstable nix Two Regulatory Services Richard V.Scali,Interim Director 9ASS Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer& Designer Certification Form Date: l U 1 Sewage Permit# ao 3§339 Assessor's Map\Parcel Designer: HbMAA j✓1(',(,�Lt j�E Installer: I`( �� �jU� U9 Address: 13 OX 11 b 3 Address: On (O(g�I 1 �;- �,016e,-rl & C)-V_q was issued a permit to install a (date) (installer) septic system at 33.6 CAPT. U JA N S P-0 based on a design drawn by (address) TH o M,4S / 1 c-UE t.L-A (''-E dated 9-2- 15 (designer) II 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. Strip out (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. Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the terms of t 1\A approval letters(if applicable) .# ' (Installer's Signature) (Designer's nature) (Affix y,,, . - amp Here) PLEASE RETURN TO BARNSTABLE PUBLIC. HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.. THANK YOU. Q:\Septic\Designer Certification Form Rev 8=14-13.doc TOWN OF BA�RlNSTABLE LOCATION 3,,�C ON � n k, "d SEWAGE# 1 s— r "VILLAGE Ce-P -TV 01-e- ASSESSOR'S MAP&PARCEL i q3 INSTALLER'S NAME&PHONE NO. R(J6e(-'r &04- CC7 . -"33-0534 SEPTIC TANK CAPACITY LEACHING FACILITY:(type4A Soo Cicd• ckfa ,(size) a.��� l�: V NO.OF BEDROOMS 3 OWNER k AY)A 21)I oE. PERMIT DATE: 011./) COMPLIANCE DATE: 1 Separation Distance Between the: j 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) iq Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) 1AI Feet FURNISHED BY ' � �i o D,rd `L► 42Z 17 !VIdU7 ` I 3 �ttts Town of Barnstable P# Department of Regulatory Services i Public Health Division Date sfl39 200 Main Street,Hyannis MA 02601 • ffi!t�� . Date Scheduled duo Tune Fee Pd. Soil Suitabili .Assessment 11 '' ,�/� ^^l i1' for Sew ge isposal Performed•By:. 1P6M p> /n C t E(.( QAJ Witnessed By: 6n,/ t LOCATION&GENERAL INFORMATION Location Address Owner's Name CAW RED AddressyQ � Assessor's Map/Pare 6 9 3J 1 a 7 T(,t�v!Engineer's Name � 1P, Li tL � . NEW CONSTRUCT t , . Telephone/k J Land Use- Flc J Slopes Surface Stones . Distances from: Open Water Body /p`r A $ possible Wet Area 11 ft Drinking Water Well Draiha a Way t B Y ft Property Line _ ft Other ft SIMUCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands 1!n proximity to holes) 115.7Z - 2 llq.pp' fAPi L_J JAH5 � Parent material(geologic) O 0T l(J/4s 04 Depth to Bedrock Depth to Orouudwater. Standing Water in Hole: Weeping fl•01n Pit Fnee_&Q Estimated Seasonal High Oroundwater Method Used: DE 'RMINATION FOR SEASONAL*HIGH WATER TABLE Depth Observed standing In obs.hole: In. Deptlt to spit mottles: Index Well De�th to weeping from side of obs,bole: Ill, Groundwater Adjustment i't. #I Reading Date.- Index Well levol__ A factor � corU Adj.Groundwater Level Observation PERCOLATION TEST bate Tim at 91, Depth of Pero _ ~ t Time at G" Start Pre-soak Time @WC/Q Time(9"-G") 6 � End Pre-soak FoP_c 15 M j/J Rate Mih./luch . < 2Nit/v dn/ . Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back---- ***If percolation test is to be conducted within 100 of Wetland, must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTIC\PERCPORM.DOC d /� DEEP-OBSERVATION HOLE LOG Bole# Depth from Soil Horizon Soil Texture Sdil Color Soil• Other Surface(in.) (USDA) (Munsell) Mottlin• g (Structure,Stones;Boulders. nsistency,%t3ri►yell 5� o � �5 1 ID 6 I.6D`. G M00-F1k'f 2.51 51orvo DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistencv.%Gravel) • i� SPN�j DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soli Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,S(ope9;Boulders, Consistency. 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 mtiterial exist in all areas observed throughout the area proposed for the soil absorption system? 4r_ 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 Env onmental Protection and that the above analysis was performed by me consistent with . the required Ira ning,expertise and a perience described in 10 CMR 15.00117. / Signature Date; Q:\58PTIC\PBRCF0RM.D0C CO OIL A- LTH OF APIASSACMUSIDIS ExEcuTm OFFicE of&A 0N�7 } DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED p0 1 (�!N 0 1 Z004 TOWN OF BARNSTABLE TIME .5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ��6 n �-..� `ci Raj MAR 1 -13 ' W MA PARCEL Owner's Name: inerk Ssr6etlt _ a� Owner's Address 'r ;,0T try tittle Date of Inspection: WCKI t �/ �j s Name of Inspector: pI print) M Ieho t l l�.ede T E Company Name: �� lc ti► ��( (,n ��oy.g Mailing Address: V.Q 1k, 81 L «, MA D36cd f Telephone Number: 328 —ASS- 7608 r j CERTIFICATION STATEMENT ; I ceradfy that I have personally inspected the seumge disposal system at th s address and that the information reported below is true.accurate and complete as of the time of the inspections.The inspection was performed based on my i training and experience in the proper function and maintenance of its site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR I5.000). The system: 7 Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Bate: 3 f 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 1 tD,iN3o � 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 3 5 u *"*"This report only describes conditions at the time of inspection and under the conditions of use at that time.This l ion does not address Itow the system will perform in the future under the same or different conditions of u :. ? t • s { Title 5 Inspection Form 611SP000 page I s pne2of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE D SPOSAL SYSTEM[INSPECTION FORM PART A +RTMCt+ TION. (continued) Property Address: 3s& ea ,rt •,a ,e q e+Ife Owner: Sc, % knell c Date of inspection' It 1 6 0 inspection Summary: Check A,B,C,D or E l ALWAYS complete an of Section D A.+,System Passes: R I have-not found any information which indicates that any of the failure criteria described in 310 CUR 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 mn the"Conditional Pass" need to be rephwed or repaired..The system,upon completion of the replacement or repairs as approv the Board of Health,will lass- Answer yes,no or not determined(Y,N ND)in the for the fd statements-if"rot determined"please explain. The septic tank is metal and over 20 years old*or tank(whether metal or not)is structurafly unsound,exhibits substantial infiltration or exliltration fai ire is imminent System will pass inspection if the existing tank is replaced with a complying seat c tank approved by the Board of Health. *A metal septic tank will pass inspection if it is sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old vailable. ND explain: Observation of sewage r brew out tr bigh state water level in the distribution box dare to broken or obstructed pipes)or due m a b settled or uneven demon box System will pass" if(whir approval of Board of health): broke npV*j a . obstriminnisTemoved distributim beat is.lewhxi or replaced ND explain: The s m required pumping more than 4 banes a year dale to broken or obstructed pq*s).The systeaa will grass" if(with approval of the Board Ofhealth): broken pipe(s)are replaced obstruction is reamved ND e late 2 Page 3 of 11 OFFICIAL P SPECTION FORM-NOT FOR VOLUNTARY ASSESSN`IEN'TS SUBSURFACE SEWAGE DISPOSAI.SYSTEM INSPEMON FORM PART A CERTIFICATION(continued) Property Address: 336 CAC;, e V a Owner:_ ���� Date of Inspection: l6.lo Y C. Further Evaluation is Required by the Board of Realth: Conditions exist which require further evaluation by the Board of Health in order to determine i e system is failing to protect public Health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CM 5_303(lXb)that the system is not functioning in a manner which will protect public health,safety d the environment. Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetl r a salt marsh 2. System will fail unless the Board of Health(and c Water Supplier,if any)determines that the system is functioning in a manner that protects the lac health,safety and environment _ The system has a septic tank and soil n system7(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a saes water supply. The system has a septic tank and S and the SAS is within a Zone I of a pubic water supply. _ The system has a septic tank d SAS and the SAS is within 50 feet of a private water supply welt_ The system has a septic k 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' the well water analysis,performed at a DEP certified laboratory,for coliforrn bacteria and volatile rganic compounds indicates that the well is free£►om pollution from that facility and the presence of onia nitrogen and nitrate nitrogen is equal to or Less than;ppm,provided that no other failure criteria triggered A copy of the analysis merit be attached to this forme. 3. Othe . 3 ge4ofll OMCIAL INSPECTION DORM--NOS FOR VOLUNTARY ASSESSAIENTS SUBSPACE SEWAGE DOP09ALSYSTEM INSPEC`f'ION FORM P T.A- CERTMCATION(continued) Property Address: S3` C LPL•��t� s oa U- Owner. SCE tc c Date of bispection:4 j_l O D. Systems Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for nit 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 m the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid cuts in cesspool is less than b"glow invert or available volume is less than%day flow Required pumping more than 4 times m the last year NOT due to clogged or obstructed pipe(s)_Neuter of times pumped Any portion of the SAS,cesspool or privy is below higt ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a sine water Supply. Any portion of a cesspool or privy is wi a Zone 1 of a public well_ Any portion of a cesspool or privy is within 50 feet of private water supply well_ Any portion of a cesspool or prissy is less tun 100 feet but greater than 50 fixi from a private way supply well with no acceptable water quality a maiys s.f this system passes If the well water performed at a DEP certifiml laboratory,for cafferm bacteria and volatile organkcowpewKU indicates that the well is free from-pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equaf to-or less than 5 ppnn,proved that no other failure criteria /� are triggered.A copy of the analysis most be a ma to this for AJ 6 (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,tbeZefore the system fads.The system owner should contact the Bid 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 a designs flow of 10,0M gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the g ('ire following criteria apply to large systenzns in to the criteria above) yes no the system is within 400 feet of cc&inking water supply _ the system is within 200 of a tributary to a surface drinking water supply _ the system is i in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone H of a pub' water supply well If you have anew es"to any question in Section E the system is a significant threat,or answered "Yes"in Section above the large system has faded.The owner or operator of any large system considered a significant under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The em owner should contact the appropriate regional office of the Department_ A Page 5 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART R CHECKLIST Property Address: -6 C `Owner: C-e 4•► ptwS V`c V I ,P Date of Inspection: ql� o" Check if the following have been scone You must indicate"yes"or"no"as to each of the following: Yes Io 5 _ 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 mood? _j( Have large volumes of water been'introduced to the system recently of as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as NIA) 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? T _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and deptta of scum'-' Was the facility owner(and occupants if different from owner)provided with information on the proper tenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based o Yes no -y _ Existing information.For example,a plan at the Board of Ham. Ly _ Determined in the field(if any of the bilure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CNa 15-302(3)(b)) 5 Pane 6 of 11 63 OFFICIAL jNSPECTION FORM—NOT FOR't OLU-N'TARY .ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: C t Owner: tA'h I Date of inspection: b 04f FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design)_ Number of bedrooms(astral): DESIGN flow based on 3 10 CMR 15.203(for example: i 10 gpd x A of bedrooms): $3 a Number of current residents: c? Does residence have a garbage grinder(yes or no): MV Is laundry on a separate sewage system(yes or no): Na [if yes separate inspection required) Laundry system inspected(yes or no):A)0 Seasonal use:(yes or no): Aid Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):0Q Last date of occupancy: 7Cy!'tV0* COMMERCIALtIND€TSTRIAL Type of establishment Design flow(based on 310 CMR I5.03): Basis of design flow(seatsfpersonslsgft,etc.): Grease trap present(yes or Industrial waste holding tank present or no):_ Non-sanitary waste discharged to itle 5 system(yes or no):_ Water meter readings,if avail e: Last date of occupancy/use- OTHER(describe)° GENERAL INFORMATION Pumping Records NO n �� Source of inforniatior- 1 y t , � Was systems pumped as part of the inspection(yes or no):NU If yes,volume pumped:____gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of I co nents,date install (if kno )and source of information: a �� .� . Were sewage actors detected when arriving at the site(yes or no):"_� Peae ofll OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SIBSU11kACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORTM, PART C SYSTEM INFORMATION(continued) Property Address • GtA Vt � Owner. •tNb Date of Inspection 4 t Q O t BUELDING SEWER(locate on site plan) . Depth below grade: 3 Materials of construction:—cast iron Y 44 PVC_other(explain): Distance from private water supply well or suction line: Continents(on condition of joints,venting,evidence of leakage etc.): SEPTIC TANK: e( (locate on site plan) Depth below grade rt_Material of construction:-concrete metal`ftbez;lass^polyethylene __other(explain) If tank is metal list age:V Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) / Dimensions: 60170 CA Sludge depth:i P W v Distance from top of said,e to bottom of outlet tee or baffle: 3V Scum thickness: ; 0 Distance from top of scum to top of outlet tee or baffle:_ ' __ _ Distance from bottom of scum to bottom of outlet tee or baffle: 15� How were dimensions determined:_Me is ui-tad Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as relate to out)et invert,evid €ence o leakage,etc.}: ``� CL ov l Sov dl 'F t t M c Cc rrtfX t GREASE TRAP:____(locate on site plan) Depth below grade:J Material of construction: concrete_metal fi �ass polyethylene other (explain): Dimensions: Scum thickness: Distance from top oXtoof et tee or baffle: Distance from bottotn of outlet tee or baffle: Date of last pumpingComments(on pumpions,inlet and outlet tee or baffle condition,structural integrity,liquid levels 3s related to outlet roeakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT OR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM, INSPECTION FORM PART G SYSTEM]INFORMATION(continued) Property address:--Z I -.-c�hs (Owner: Date of Inspection: 14 04 TIGHT Z'or HOLDING TANK: (tank must be time of inspection)(locate on site ) Depth below grade: Maternal Of construction: CflllGrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: alions Design Flow: Gall `day Alarm present(yes or no): Alarm level: Alarm' orking order(yes or no): late of last pumping: Comments(condition of and float switches,etc,): DISTRIBUTION BOX: o./- (if present must be openWocate on site plan) Depth of liquid level above outlet invert EV'U/r 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(ves or n€i)-. Alarms in working order(yes or no): Comments(note conditionof porn ber,condition►of pumps and appurtenances,etc_): R Page of 11 OFFICIAL SPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Ca .� ��`►� �R� e•. ,r U Owner: S G 6'e s Hate of Inspection: 4 .CX 10 SOIL ABSORPTION SYSTEM(SAS): Gate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,nurnber: leaching chambers,number: leaching galleries,number_ leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number innovative/alternative system Typeiname of technology: Comments(rote condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): c CESSPOOLS: (cesspool must be pumped as part o ionj locate on site plan) Number and configuration: Depth—top of liquid to inlet invert Depth of solids laver: Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of groundwater' ow(yes or no): Comments(note conditio 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 cord' on of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.). 9 Page 10 of t l OFFIICL4L INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM EVF DI TIGN(continued) Property Address:-�3jk _ C ( Owner. c7. Gt De Date ofInspection: _ 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_ f a . �(f r • Page It of l l OFFICES INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Wt, C � 4.. k.,,g Owner: 6,& • Bate of Inspection: l L be( SITE EXAM Slope ie"-4 Surface water kM Check cellar &P.5 Shallow wells rJ 8 Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan rev-sewed: Observed site(abutting proms/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: xS my-g,—cS k *.K a le x a� , �A � 11 � 6 - No .:3 ....... Frs..........................._. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ........ ................................OF...............-.................._.....------------------------------.................... 3 r Appliratiou for Uhipvii al Workii C owitrurtinat Prrmit Application is'hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst '%at% . ��........................ ....................... - . Loca(y�}�•Ad ess //� r Lot I�/,�. [��� _... .:. ...................... ^7 Z `... Address a -•-• ... ......................................... ............. f.....-••••- .orf"_.=••---•......-----•----••... Installer Address Q Type of Building Size Lot_ram.°`z_ .Sq. feet Dwelling—No. of Bedrooms.-----••--.i� ---------------------------Expansion Attic ( ) Garbage Grinder p., Other—Type of Building ... ..... No. of persons............................ Showers ( ) — Cafeteria ( } p" Other fixtures __________________________________ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length_•_-___-____•._- Width................ Diameter---------------- Depth................ 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.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit______-___-__-.__._. Depth to ground water....................... Test Pit No. 2................minutes per inch Depth of Test Pit____-__---_-____•_.- Depth to ground water........................ a --------------------------------------------- •------------------------- ------•-•---.----•--•--•---- -------------- ------------------------------------- ...... ODescription of Soil--------------------------------•----•-•-----•--•--....----•---•------•-----•--------------------•-------------------------------------------...-------•-••-•----•----- x 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 TITE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued byrd of health. Si ne .._ / �3_. ApplicationApproved By.--•--- ----------•--- -----------------------------•--------•---•--......-•---------... ..•--.. ---------- Date Application Disapprove for he following reasons:---------•----••--------------------•------------------------------••---------•-•----------------•---........•-- •------------------•-----••-•-------•-••------•--------------------------••--••--•--•--•---------------.....-•------••-------•--••----------------------------------------•--------•--------------------- Date PermitNo......................................................... .................. No"_ ....... _ Fni3.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. ... ...... .............O F.......................................................................................... Appliratiou for 11hipmFal Works C outitrurtiou ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst at:, p Loca Ad f ess /_ W (j Own .... Address ........................... Installer Address Q Type of Building Size Lot. �1._ °`'_ ..Sq. feet V Dwelling—No. of Bedrooms........... -............................Expansion Attic ( ) Garbage Grinder Other—Type of Building ... _ft_^.5:...... No. of persons.............................Showers ( ) — Cafeteria { ) Otherfixtures -----------•-----------------------•--••---•-•-•-- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............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.......................................................................... Date........................................ Test Pit No. l................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........................ �. -----------------------------------•----•--------------------------------•-•---•--••--••--•..._.............................................................. 0 Description of Soil......................................................................................................................................................................... x U .........................................................................----••--•••-....•-••-•--........•---------•-••••••-----•-•--•--------------•••--••----••--•----••-•----••---•--•--•--•-••••... 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 TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued by the,bbooaid of health. Signed ..... ... ! � ........... /—_ ........ f D Application Approved By. 1%'' ti- -=". ....................... Date Application Disapproved for he following reasons:............................................................................................................. ---------------------------•------•-•--------•---•-•--------•----•-------......_............••--------••....--•---•. Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............I..........................OF.................................................................................... Trr if irFate of Toutplittttrr T S C ,TT!i Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.... ----• ---------•-------------------------------------------- •------------- at.. �'� ........ a....---------------------- ------------------------- has been installed in acco, ante with,t'"' provisions of TITLE 5 of The State Sanitary Code, s d cribed in the application for Disposal Works Con` action Permit No._ .�-""_ _. ............... d. ed__-. r. _._ .................. THE ISSU NC OF THIS CERTIFICATE SHALL NOT BE CONSTR AS A GUARANTEE THAT THE SYSTEM 1 F CTION SATISFACTORY. DATE...._.. ..!Z� (/2 . -•-QZ...•-•-•--•.............•-------•-----••--------.... Inspector....-- -•-• -•----•-----------------------------------...-• ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CJ?_2 ' ..........................................OF..................................................................................... V No.._ ._.... ?........ FEE....... ............. fit�at��ttr�i�n rr�ti� Permissionis h .eby grant .. ------ • •. •-------------•--.----••-----•......••-••--••---•-•-•••--••._..._................._........-•.................... to Constru or Re r -, Indi_ uaall S gage Disposal System at ¢ . ---•---- ------••--•--•••---------•--........................................... •.....,................... ,,. Street as shown on the application or Dispos orks Construction Permit No... .......... ..: Da d ::'- . Board of Health DATE.................... - •-----------•-••----•------------•-- FORM 1255 HOBBS a WARREN. INC., PUBLISHERS 1. 0CATION SEWAGE PERMIT NO. CCU 14,h Is lid CIL V1'LLAGE ' 4 ---), I-e Y.v I I f � I N S T A LLER'S NAME ADDRESS d U I l D E R OR OWNER y P r-t-e --� DATE PERMIT ISSUED c�- 3 1 DATE COMPLIANCE ISSUED ��� . t P . � I _, I �' �' c5 l y 3� C._, • SEWAGE PERMIT NO. j I. flCDlTION �a�) S W�3 _. VILLAGE t -f I I [Y.vI I I )cr, tq-, I NSTALLER'S NAME ADDRESS �° � ►� s' 7 B U I L D E R OR OWNER DATE PERMIT ISSUED 1 Zb DATE COMPLIANCE ISSUED /1 J ,y ` 1. •y. -Y 1 M•.+Y-w,•+Mw,r.q-rl.+n+!• ww..rrrrwrwreY,e-Y wMwwM.-...1,••..wtf-^•Yn•vNwaw.r YsItWYM1N / ft o� 77 i.7z 4- 77 C.. V Al J .�`st v C, 7- 4 IVi /J�f�,a-�I�"��/ �1�� �r7.3 1,4,�� CzFe fS / ` 7`� A�/ •F»A' GJ . Sw'"ff aG.:X�7• a a Rl , i f��six�x .GG le 20 l000 At 41 W / I �'�'9 C r / �- ��'. N e �7 .�Jt1 S / ,S. • � ...__� � i � I��' .........,..� .iiRrw�.n.,r. 14- A)"oO S �. ate• . „ `. . Ot 51 J ( .... � �' ' _ .`, ,/�C"1_ �tee. 77 • /l. . [ `� „ r' . '��'�� "s" a t �.q j I CERTIFY THAT THIS PLAN. SHOWS Tr!jf ACTUAL LOCATION OF THE STRUCTURE ON THE LAND AND FLAN OF THAT IT CONFORMS WITH THE e - IN 'may. r BY-LAWS. OF THE TC3 .MASS_V OWNED BY v� t € too, S � It of was,f, of Miss\ o IQ . `p FRANK ti�'t � � FRANK COMERY,". 12 BRUNER LAME 0 _. ..-�.--+ c .,;- FRANC �' NG732 y.' cai GONERY CENTERVICLE, M1AS$. 02632 - �� �� 4 REGISTERED ENGINEER &,LAND SURVEYOR ! ',.I � / ��•� �I'd 1��= l/Y p zeMM.,,ff SCALE 1 IN =Zo- I`T: t/a�'7 12, d . } KEY: 5� EXISTING CONTOUR: ---- SEPTIC SYSTEM DESIGN SEPTIC SYSTEM SECTION p PROPOSED CONTOUR: ............. 2"PEASTONE OR FILTER FABRIC OP EXISTING SPOT ELEVATION: 25.5 FLOW ESTIMATE: PROPOSED SPOT ELEVATION: 5.5 85.04 COVERS WITHIN 6" 3/4"-1 1/2" t © 3 BEDROOMS AT 110 GAL/DAY= 330 GAL/DAY OF FINISHED GRADE WASHED STONE N Q TEST HOLE:� TOP OF . FOUNDATION m "'�m'�^ -�� n% m a INSPECTION PORT UTILITY POLE: ELEV.=79.5 = SEPTIC TANK: F,„, r\^ \ \ 2 FENCE LINE: Q HYDRANT:-6- 330 GAL(DAY x 2 DAYS= 660 GAL O'O U RETAINING WALL: ® g2,7g COVER 3'MAX, <gti'Qy LOCUS USE 1500 GALLON SEPTIC TANK ELEV. a (1'MIN) a 1.7 LEACHING AREA: (EXISTING) ELEV, USE 2-500 GALLON CHAMBERS 8.5'x 4.8'x 2'EFF.DEPTH WITH 82.0 $1 E LE ( ) ELEV. ELEV. 76.5 LOCATION MAP ELEV. D-BOX H H ELEV. LOT 21 (15,012 SF) a 4'OF STONE ALL AROUND (25'x 12.8'x 2'DEEP) (6"STONE UNDER) 4' 4' ASSESSORS MAP:193 PARCEL:107 1000 GAL 25'x 12.8' PLAN BOOK:277, PAGE:98 SIDE AREA: (25'+12.8')x 2 x 2=151 SF (0.74)=112 GAUDAY SEPTIC TANK TEE SIZES: (TO BE CONFIRMED) 78 5 2-500 GALLON CHAMBERS WITH BOTTOM AREA: 25'x 12.8'=320 SF (0.74)=237 GAL/DAY INLET:6"UP,13"DOWN ELEV. 4'OF STONE ALL AROUND OUTLET:6"UP,14"DOWN (25'x 12.H_202'DEEP) CAPACITY=349 GAUDAY GAS BAFFLE ) AT OUTLET TEE (TO BE VENTED) N REQUIRED VARIANCES FROM TITLE FIVE: TH-1 85.0 TH-2 85.5 1.SECTION 15.221(7):PORTION OF LEACH AREA TO BE GREATER THAN T BELOW GRADE(VARIANCE OF 2'). ELEV. ELEV. TEST HOLE LOGS FILL FILL DECK 48" 81.0 42" 82.0 ENGINEER: THOMAS McLELLAN,P.E. O/A HORIZON O/A HORIZON 92 94 WITNESS: DAVE STANTON,R.S. 10YR LOAMY SAND SAND 3/1 10YR 3% 54" 80.5 48" 81.5 / I DATE: 8-26-15 _94 FAMILY B HORIZON B HORIZON I PERCOLATION RATE: <2 MIN/IN LOAMY SAND LOAMY SAND ROOM Q l BED BATH DINING KITCHEN 66" 10YR 6/8 79.5 60" 10YR 6/8 80.5 / 92 ROOM ROOM C HORIZON C HORIZON \ i BATH MED-FINE SAND MED-FINE SAND 0 2.5Y 7/4 PERC AT 6' 2.5Y 7/4 w �� _•,\ �- 90 160" 72.5 144" 73.5 0' ` �w 88 BED BED NO GROUND WATER ENCOUNTERED \/ - = _ ROOM ROOM ROOM 86 oQm �----- -,�� _ - -� --__a4 NOTES: a°� \ X J / GARAGE w I- I- 12„ J / / 1.VERTICAL DATUM: ASSUMED 88� , J / / F 82 EXISTING FLOOR PLAN spruce 2.MUNICAPAL WATER IS AVAILABLE. e ay • i / f `. 62� 3.SCHEDULE 40-4"PVC PIPE TO BE USED THROUGHOUT SEPTIC SYSTEM. / o � S / �a 7 3 Q 12" 8``_W 84 / kn � -- >6 F 4.ALL PRECAST UNITS SUBJECT TO TRAFFIC LOADS TO CONFORM WITH AASHTO H-20 SPECIFICATIONS. vQ spruce r i / ` 5.PIPE PITCH= 1/4" PER FOOT(UNLESS NOTED OTHERWISE). Co o a� 82 6.FIRST 2'OF PIPE OUT OF D-BOX TO BE SET LEVEL. 80 / eptic9a//o 3e�cST/N � 7.THE SEPTIC SYSTEM HAS NOT BEEN DESIGNED TO AGCOMODATE THE USE OF A GARBAGE DISPOSAL, 86-- _ 6" / - ST tanks lliF0,40� J i\ 8.ALL CONSTRUCTION DETAILS ARE TO BE IN CONFORMANCE WITH THE STATE OF MASS.ENVIRONMENTAL th 2 tree/ to' fna</N�M \ CODE(TITLE FIVE)AND LOCAL HEALTH REGULATIONS. h 8SO4 \ +1 78 9.CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR TO CONSTRUCTION. th-1Y _ eR/ w,� 4,�TCOk •c \ ` 10.GROUND COVER OVER ALL SEPTIC SYSTEM COMPONENTS NOT TO EXCEED 3'. p,184.6 �1 n\ 0 11.FIELD SURVEY PROVIDED BY TERRY A.WARNER,P.L.S.,HARWICH,MA. 6 t 761 12.THIS PLAN REQUIRES THE REVIEW AND APPROVAL OF ONE OR MORE TOWN DEPARTMENTS AND 84 tree 7 IS SUBJECT TO CHANGE UNTIL SUCH TIME. 13.EXISTING LEACH PIT IS TO BE PUMPED AND FILLED WITH SAND OR REMOVED. O�q FO .40 74 14.D-BOX TO BE WATER TESTED TO ENSURE LEVELNESS AND EQUAL FLOW. qT NF 15.DESIGN ENGINEER TO VERIFY SUITABLE SOIL CONDITIONS AT TIME OF CONSTRUCTION. IF SOIL IS 83.2 Rk/NG' 834 78� J FOUND TO BE UNSUITABLE,IT IS TO BE REMOVED WITHIN 5'OF PROPOSED LEACH AREA AND `.� 5' i 11' O ' ( REPLACED WITH CLEAN MEDIUM SAND. 83.1 82-... 74 -, 82 r( ^�0 -APP (TO g OX.ELECTRIC O 76 80� 78� \\ E MARKED OUT) FOk SITE PLAN \\ �� 80 \76 LOCATION: 40 MIL POLY LINER - / / 74 768 BENCHMARK AT 336 CAP'N LIJAH'S " CENTERVILLE, MA 20'x 4'DEEP �72 RIGHT CORNER TOP OF LINER=79.5 \ / 74 72 / OF BOTTOM STEP PREPARED FOR: BOTTOM ELEVATION=75.5 / 70 ELEVATION=84.53 RAMZI ZAINEH 41 s N864167 \ ( aw DATE:9-2-15 SCALE: 1"=20' 7 b Wii•V E � BASS RIVER ENGINEERING -H MAS JL . McL LAN, P.E. P.O.BOX 1163, EAST DENNIS,MA 02641 508-385-3426 OR 508-364-9048