HomeMy WebLinkAbout0026 CEDAR POINT CIRCLE - Health 26 CEDAR POINT CIRCLE,,CENTERVILL
A= 228 113, _
UPC 12534
No.2-1153_LOR
HASTINGS.MN
No. i
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Ye
L .,PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE MASSACHUSETTS
� Application for Mig ool * gtem Congtruction Vermit
B 0
1� Application for a Permit to Construct( )Repair( Xpgrade( )Abandon( ) EJ Complete System 0 Individual Components
Location Address or Lot No. Owner's Name Address and Tel.No. O
Vl 10W FC(�l Ark 77S �`�/(v
Assessor's Map/Parcel •A �^ f -2 Lt_ CE04t 9 l- Co[ tr WI Lk
InstalIeE'�s Name,Address,ande'el.No. Designer's��Name,Address and Tel.No.
LAW s�
Typ of Building: 4W
Dwelling No.of Bedrooms Lot Size b.a3 sq.ft. Garbage Grinder( N)u
Dot Other Type of Building A No.of Persons Showers(-)) Cafeteria(
` Other Fixtures
esign Flow `7 :( gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been d [�issued B ar of h. 7
Sign Date D (�j
Application Approved by J Date
Application Disapproved for the following re 67s
Permit No "'` Date Issued
NAIV5*777 6 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
k. '.A Ye
[� PUBLIC HEALTH DIVISIOON. -TOWN OF,3,ARNSTABLE., MASSACHUSETTS
Q fication for Dig_ozal *pztem Conftruction Permit
V 00
Application for a Permit to Construct(,, )Repair(Xp rade( )Abandon( ) D Complete System O Individual Components
w_ Location Address or Lot No. 1 � Owner's Name Address and Tel.No. 7 7 JLP I
vl FC(£61AtJ
Assessor's Map/Parcel / q^� 4 fa r ;-��
.Y N� `G Qi / _ �O.
Installe's Name,Address,an&Tel.No. Designer's Name,Address and Tel.No.
era o�77 �v t� ! �,XV
Type of Building:
Dwelling No.of Bedrooms "1 Lot Size 3 b a� sq.ft. Garbage Grinder(ram)
Other Type of Building No.of Persons 3 Showers(`Z ).Cafeteria( �u
QD Other Fixtures "
r= Design Flow `7 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
s
�Y
` 1
=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 th Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue .- thaw Bgdof Hafth. _ f
Sign ' (((,,- r n— . Date. ✓wJ
F
Application Approved by �7 1 C11 Date
Application Disagproved for the following re s
ti
' -•pi M.?1.+.l" ..yam.. .s -
.. .w Permit No �.r Date Issued
t
----- --- -- — ———————————— — --------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CE FY, that the Off'-site Sekvage Dis osal System Constructed( e aired ( )U graded( )
Abandoned( )by �or7o /Or �A,5 /)It
G
at Z� L" �I/" Z /'C- 2L- h constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit N . dated
� Installer Designer ,
The issuance of this permit 11 'ot b co rued as a guarantee that the s s em Ix
will function as designed G' "
Date._ Inspector /�/'
—————— ————————————————— ————— •/�
No. � Fee
< THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
_ Oigpozal *pgtem Construction Permit
Permission is hereby granted to•Constr ( ) ayr )A)U rade( bandon ,p ,3
System located at Z �/� l'G
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 in be mpleted within three years of the date'
this pe
c
Date: ( Approved by ,
07/12/2007 12:14 5083627606 ANNE MICHNIEWICZ PAGE 02
Town. of Barnstable
Regulatory Services
= 2 Thomas F.Geller,Director
NAM Public Health Division
soap
Thomas McKam,Director
200 Main Street,Hyannis,MA 02601
Office. 508-842-4644 Fax: 508-790-6304
eWilmer Cog9flimflon
Date: ��• a� sewage Permit#c2nQ T-767AMmor's MAPTarcel .Zt.% l it-mv
Designer: 1. s0 SURD Installer: ?
Address: T� 11it. r4 �' Address: '
on 'pro � � �J 2' , was issued a permit to install a
(date) (installer)
septic system at Z.Cb CSVA� "T G1R��based on a design drawn by
-P 'IFted ' 1 •'�.obrJ R�„1l "7 ?r J�''
(designer)
1 certify that the septic system referenced above was installed substantially according to
the desip,which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
1 wrttify that the septic system referenced above was installed with major changes (i.e.
grmter 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.
of
nOGF-Ft
PPUk- ,
(instal s lgnatur ) ""jCu,slaaaa
,p CIVlI.. �,`ifr
gp J4�
IOpAI ,f
(lie tgner's S"�nat (A tx Design amp Here)
nr YOU,
Q:WeWth/Sapti*/Daiww Cer ifiagdon Fo m 3-26.04.doc
,J
Town of Barnstable P#
Department of Regulatory Services
Public Health Division Date `O
200 Main Street,Hyannis MA 02601
Date Scheduled 0 Time—�—`— Fee Pd. V-e
Soil Suitability Assessment for S wage Di sal 1
Performed By: La�t�X S. 1. r Witnessed By: ^rr�GJ'W" r
f LOCATION& GENERAL INFORMATION
Location Address Z 6 ce C ^ LTG'; Owner's Name
Address 2 6 C e��
Assessoes Map/Parcel: 2 � /i3/do Z �oT L Engineer's Name C;f,0&1- SG'rvP1/
NEW CONSTRUCTION REPAIR Telephone# S�"� -
Land Use -S�c t�t` Slopes(4a) '�� o Surface Stones L6e 06somvl-A
Distances from: Open Water Body Iwo, ft Possible Wet Area _ft Drinking Water Well 4 ft
Drainage Way tJ Q ft Property Line Zc> ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes)
r
awl ��Il�tlj�,'�• w�a�t� .
itr T lot' 1
'f� sA.Nt4toe tC� 1n"V\k ' qr" W
Parent material(geologic) (-Al-Ndt L8 r,� Q Depth to Bedrock u�
Depth to Groundwater. Standing Water in Hole: i Weeping from Pit Face PG le
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used: .• W in,
Depth Observed standing in obs.hole: In. Depth to soil mottles:
Depth to weeping from side of obs.hole: In, Groundwater Adjustment 3k_Ar ,.._ft-
Index Well# Reading Date: Index Well level Adj,f'Actor_ Adj.Groundwater Level
PERCOLATION TEST Date Thne aM
Hoe#Observation ( '2— Time at 9"
N �I
Depth of Perc �� Time at 6"
7;:
Start Pre-soak'19me @ Time(9"-6") ---------
End Pre-soak 1'D rwl e) Z49A (A-�b OVI(A 60 vK Q r
Rate Min.Mch y M
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 1009 of wetland,you must first notify the.
Barnstable Conselrwation Division at least one(1)week prior to beginning.
\ Q:\SEPTICIPERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole# 1
Depth from Soil Horizon Soil Texture .Sdil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consistencv. ravel
0-
1<
32-120 � �eeP, Jan �
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
yy l� Consi ten %
_3Q�� C�rnn�l aTt fru.� 6 A 0
L
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color. Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistengy,%O e
DEEP OBSER TION HOLE LOG Hole#
Depth from Soil Horizon Soi exture Soil Color Soil Other
Surface(in.) (US ) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,
Flood Insurance Rate Mau:
♦. 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? ..�.
CertiScation •
I certify that on v, 9 (date)I have passed the soil evaluator examination approved by the
Department of En ironmental Protection and that the above analysis was performed by me consistent with
the required trainin expertise an perience described in 310 CMR 15.017.
Date
Signature
e Q:\SSEpTlMERC11ORM.DOC
TOWN OF BARNSTABLE
LOCATION SEWAGE# 7 7
VILLAGE C ASSESSOR'S MAP&PARCEL 2.21i4-11307.
INSTALLERS NAME&PHONE NO. 06r-WaU: C'.or►StrueA;61, Sic-?7l-%,1`i
SEPTIC TANK CAPACITY 16W ec✓,6,
LEACHING FACILITY.(type),S'- \ C-"64 S 9ZO (size)80-.'A i S Q.
NO.OF BEDROOMS L/
OWNER k �yn 9 ids
PERMIT DATE: 7-2*-UG COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility.(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY C:a�c k J,,a C-v:.r i.q
3 ILA-
- d
1 q5 e
i "
� Commonwealth of Massachusettsnental Affairs
Executive Office of Enviro
Dept. of Environmental Protection ,Jol„t GrAd
D.E.P. Title V Septic Inspector
one winter Street,Boston,Ma. 02108 Dp P.O. 13ox 2119
Teaticket,MA 02536
(508)564-6813
WILLIAM F.WELD
Governor f
ARGEO PAUL CELLUCCI
Lt.Governor SUBSURFACE SEWAGE DISPORT q SYSTEM INSPECTION FO(RIVAL
CERTIFICATION
F
26 CEDAR POINT CIRCLE CENTERVILLE MAP 228 PAR 113 LOT 2r fssseo towner: 6Property Address: 99Date of Inspection: 10114I98RICHARD BAXTER;BOX 562
Name of Inspector:
Jo G MR 15.00
I am a eE approved
yste inspector
U Section 15.340of Title k(310 C
Company NamAddress and TelephoneNumber:
Z is true,accurate
CERTIFICATION STATEMENT
eceon. The inspection was performed based on my
I certify that I have personally inrss ec t training and experience in the proper function and
d the sewage disposal system at this address and that the information repo
and complete as of the time of 1 p
ti
maintenance of on-site sewage disposal systems. The system.
This inspection Is based on criteria defined In Title V
code 310 CMR 16.303.My findings are of how the system is
x Passes performing atthe time of the inspection.My inspection does
_ Condition iy, asses rovin Authority not imply any warranty or guarantee of theiongevltyofthe
_ Needs F t r Evaluation By the Local Approving septic system and any of Its components useful lire.
Fails
Date: t91114198
Inspector's Signature:
Approving Authority within thirty(30)days of completing this
The System Inspector shall s bmit a copy of this inspection report to the App d or greater,the inspector and the system owner shall submit
inspections. If the system is a shared system or has p design flow of onme al applicable and the approving authority.
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if
INSPECTION SUMMARY:
Check A,B,C,or D:
q] SYSTEM PASSES:
x I have not found any information wAny indicates
violates
e
criteria not evaluated are indicated below. criteria
defined as in 310 CMR 15.303. Any
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES: on completion
_One or more system components need to be replaced or repaired. The system,up
of the replacement or repair,passes inspection. not.
Indicate yes,no or not determined(Y, N,or ND). Describe basis of determin
PY Of a Certificate of
ation in all instances. If "not determined",explain why
20 ears prior to the date of the inspection;or
The septic tank is metal,unless theaowner or operator has t he tank was installed rwith n twenty ovided the (te;ynspector with a co
CoMpliance(attached)indicating that
substantial
tion or
tration,or
the sept
ic tank,whether or not metal, is cracked,structurally unsound,
shows
replaced with
asseptic tank n
failure is imminent.The system will pass inspection'rf the existing p
as approved by the Board of Health.
(revised04127A7) • Telephone(617)292-5500
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 P
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 28 CEDAR POINT CIRCLE CENTERVILLE MAP 228 PAR 113 LOT 2
Owner: RICHARD BAXTER;BOX 552 CENTERVILLE
Date of Inspection:10114198
D]SYSTEM FAILS(continued)
Yes No
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 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is 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. if the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 25 CEDAR POINT CIRCLE CENTERVILLE MAP 228 PAR 113 LOT 2
Owner: RICHARD BAXTER;BOX 552 CENTERVILLE
Date of Inspection:10114199
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_X_ — Pumping information was requested of the owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
— flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
x As built plans have been obtained and examined. Note if they are not available with N/A.
x The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
—X_ — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System,have been located on the site.
x The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected
for condition of baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge,depth of scum.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)[15.302(3)(b)]
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Add re55: 28 CEDAR POINT CIRCLE CENTERVILLE MAP 228 PAR 113 LOT 2
Owner: RICHARD BAXTER;BOX 552 CENTERVILLE
Date of Inspection:10114199
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 g•p•d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 2
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy: We
COMMERCIAL/INDUSTRIAL:
Type of establishment: nia
Design flow:U gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: rda
Last date of occupancy: nia
OTHER:(Describe) rds
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
SYSTEM WAS LAST PUMPED IN 1995,INFORMATION FROM OWNER
System pumped as part of inspection: (yes or no)Ne
If yes,volume pumped:0 gallons
Reason for pumping: rda
TYPE OF SYSTEM
Septic-tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records, if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date Installed(If known)and source information:
SYTEM I814 YEARS OLD.
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 CEDAR POINT CIRCLE CENTERVILLE MAP 228 PAR 113 LOT 2
Owner: RICHARD BAXTER;BOX 552 CENTERVILLE
Date of Inspection:10114198
SEPTIC TANK: x
(locate on site plan)
Depth below grade: T15"
Material of construction:x concreate_metal_FRP_Polyethylene—other(explain)
If tank is metal, list age nia . Is age confirmed by Certificate of Compliance No ('Yes/No)
Dimensions: Le'e'^H5'7'-w4'10"
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle:32"
Scum thickness:0
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle:0
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS.
GREASE TRAP:
(locate on site plan)
Depth below grade: rva
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: Na
Scum thickness:rva
Distance from top of scum to top of outlet tee or baffle:rva
Distance from bottom of scum to bottom of outlet tee or baffle: We
Date of last pumpingn,
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
We
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 8,
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction Iine:TOWN
Diameter: nla
Fraimments: (conditions of joints,venting,evidence of leakage, etc.)
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 26 CEDAR POINT CIRCLE CENTERVILLE MAP 229 PAR 113 LOT 2
Owner: RICHARD BAXTER;BOX 552 CENTERVILLE
Date of Inspection:10114199
TIGHT OR HOLDING TANK:
(►ocate on site plan)
Depth below grade: rda
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: n1a
Capacity: rda gallons
Design flow: rda gallons/day
Alarm level:_n1a Alarm In working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rda
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
rVa
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_ve:
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
n1a
(reyleed 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 CEDAR POINT CIRCLE CENTERVILLE MAP 228 PAR 113 LOT 2
Owner: RICHARD BAXTER;BOX 552 CENTERVILLE
Date of Inspection:10/14/99
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
rda
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers, number:Na
leaching galleries,number: We
leaching trenches, number,length: rda
leaching fields,number, dimensions:nla
overflow cesspool, number:n1a
Alternate system: rda Name of Technology:_rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
THE LEACH PR IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY,THE PR WAS 3'OF WATER IN RAT THE TIME OF THE INSPECTION.
CESSPOOLS:
(locate on site plan)
Number and configuration: da
Depth-top of liquid to inlet invert: nla
Depth of solids layer: rda
Depth of scum layer: nla
Dimensions of cesspool: rda
Materials of construction: rda
Indication of groundwater: rda
inflow(cesspool must be pumped as part of inspection)
rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rda
PRIVY:_
(locate on site plan)
Materials of construction: We Dimensions: rda
Depth of solids: rda
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rda
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contlnued)
26 CEDAR POINT CIRCLE CENTERVILLE MAP 228 PAR 113 LOT 2
RICHARD BAXTER;BOX 552 CENTERVILLE
10114/98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
Io A
O<'
� ll
g� 13ti
Pape ! of 10
(revlaed OMT197)
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
26 CEDAR POINT CIRCLE CENTERVILLE MAP 228 PAR 113 LOT 2
RICHARD BAXTER;BOX 552 CENTERVILLE
10114/98
Depth of groundwater 12
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS MAPS AND CHARTS
(revised0412T19T) Palo 10 of 10
(l T OF BARNSTABLE
.00ATi r1 `.l at 'Ift CV( - WAGE #
,sr)LLAGE -C1 �l�sL ASSESSOR'S MAP '&2 LO �--
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1 000
LEACHING FACILITY: (ty ) P�-ok* tk— (size) I oQ()
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) - �� Feet
Furnished by
i
®G
AA
'AC31 ,.s
THE COMMONWEALTH OF MASSACHUSETTS
BOAR OF HEALTH
Appliratiuu for Disposal Works. Tonstrortiuu Errant
Application is hereby made for a Permit to Construct (,Ll�/Or Repair ( ) an Individual Sewage Disposal
System at:
......cv?!��w .......................................L.V-r......0..................................
Location-Address or Lot No.
......................_. ------. >r..... . ! v' '-- ---------------------------•----- .........................
Address
a .....................................
Installer Address
Q Type of Building Size Lot..��4? 3...Sq. feet
Dwelling—No. of Bedrooms................ .......................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
p' Other fixtures .----•--•------------•-•-------•------• -
W Design Flow..............S��----------- -------gallons per person per day. Total daily flow____.............._� .........gallons.
WSeptic Tank—Liquid capacityt�492D.gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------I-------_eiameter.......�.__._._. Depth below inlet..._&......_... Total leaching area.: 0..sq. ft.
Z Other Distribution box ( Dosing tank ( ) 9
Percolation Test Results Performed bye'�f� 'F-`lll ._ :._ Q!� -- -- Date......
Test Pit No. L..."Zt_minutes per inch Depth of Test Pit........1.4... Depth p to gro
und water....
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---___---__-___--_-----.
-----------------------------------------------------------•----.....--••----------------•--•---•-•--------------------------------------
--------------------
0 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 TITLIJ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
ratio unt' a Certificate of Compliance has bern., issue by the board of health.
------------------------------------------- �6X
>gnedW Application Approved BY ---•---- --------•-----•------- 6- �?.......
Date
Application Disapproved or t following reasons-----------------------•-------------•-------------------------•-------------------------------..................
-----------------------------•---•--------------....----------•--•---•---------------------•---------•--•--••--.-----•-•---------••••---•••---......----•------••••-••-••----•-•-••--•-••---•----------
Date
PermitNo......................................................... Issued.... .............................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARDQ OF HEALTH
...........Q.LIJ o...............oF...... ..........................
TrrtifiraU of Tompliaorr
THIS IS TO CE TIFY That the Individual Sewage Disp al S stem c ructed ( �orRepaired ( )
by ••• .
l: ..a.'., ern l-- .....................•------....---------
alter
ats I�. .��r ................................................
m r
has been mstalled in accordance with the provisions of TI L�; > of e S e Sanitary Coe es ed in the
'�. _ .
application for Disposal Works Construction Permit No.___.__.._"__ ______________ dated_... ._ .._Z____
;;TMSSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRII D AS A GUARANTEE THAT THE
I IIL NCTION SATISFACTORY.
DATE...:? ° •......................:........ ................ Inspector.. -- ------•-----......••-•-•-•-•--••----------------....-••-----••-•......---
• � J
F:n$.._.�°.................
# THE COMMONWEALTH OF MASSACHUSIETTS
BOARD OF HEALTH
..----......1'0'L�-Q.............OF......
1w. .
Appliration for Dispoii al Works Cnnnitrnrtiun Famit
Application is hereby made for a Permit to Construct ( LI-1/or Repair ( ) an Individual Sewage Disposal
System at: ' -
- ---
Location-Address _g or Lot No. _
r.. \1 5.� �r_ t =.................................{ I . T <� -- `----
W � -Owne��.. � Address
a ...................................... - ------•-•------• - ••-
Installer Address
Q Type of Building Size Lot__ _ r�U ..Sq. feet
U Dwelling—No. of Bedrooms.................3.......................Expansion Attic ( ) Garbage Grinder ( )
Othei—Type of Building No. of persons____________________________ Showers — Cafeteria
Q' Other fixtures __________________________________
W Design Flow............... ............. ......gallons per person per day. Total daily flow.....................��_a� ..............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---------(----------- .iameter._._.__....3------- Depth below inlet___._'.......... Total leaching area.__&-?�?__sq. ft.
Z Other Distribution box ( Dosing tank
aPercolation Test Results 'r Performed by.:`�)e_ .l ?f__. ._[ . ................ ......... _. Date_._. f_::__._ ____%.............
Test Pit No. I.....'?--_minutes per inch Depth of Test Pit--------1__4.... Depth to ground water.......
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •---•-•----------------------------- ------
•------------------
-__-_-----------•-•---•--------------
--------------------------------
•••----------------------
0 Description of Soil------------------ --------------------------
c.� ----------------------•------------ - -•-•---------------- ---------------•----------•----------------
----------------------------•-- ------- , ---------------------------------------------------------•-
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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
o ation nti a Certificate of Compliance has been issued�by the board of health.
}
01
PPlication Approved BY ----- -�"�-- - ( I........................ G igned
Da
Date
Application Disapproved f r th following reasons:................................................................................................................
----------•---------------•-••----------------------------------------------•-•----------...----------------------------------•---•----------•-•-•---------••---•----•--------•--------••------••-_-•---
Date
PermitNo......................................------------------- Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
!-- BOARD OF HEALTH
Trrtif irtt#r of TompfiFanrr
THIS IS TO CE TIFY, That the Individual Sewage Dispo Sys em co ucted or Repaired ( )
w ..
by......- :- ............................................
Inst [ler
at <- . _...._. --------------------- -----
c
has been installed in accordance with the provisions of TIT T 5 of e State Sanitary Co ��SC4�ein the
- z %application for Disposal ��/orks Construction Permit No____ ___________________________________ dated.....___ ._._�__._. .-.._. .____________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...........................................................•--•---•••---........ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD, OF HEALTH
........(��.�..::l.i.l..:5..........OF......... I I_•1�L �..-_i.. !6 (�
_ ? .. ........................
NO.... .. FEE.__..`.... ...........
�a� nrk� C�nn,�fr74�
Permission is hereby granted-------� --•--•-----•-•••-•. �' --
to Construct !� r Repai� n Iual ,rage Disposam
�_ / ____ „
Street / `��� �
as shown on the application for Disposal Works Construction Permit No...............___� ated___,_J____.._._;...........
' ------••----------------•------ --- --- ........................................................
Bo rd of Health
>}� DATE------------- - ---------------•-------•-•----------
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
(LOCATION �or C W2_ Irk L r-- No.__
VILLAGE �Ely�tzyt,�P, _ DATE 1-lG-,SZ
APPLICANT
t-•� �fZJST FEE 2Cj
ADDRESS-5-1 Pq,iyr>gt¢..ag (, ±j C"rEg0l�•S TELEPHONE NO. (Non-refundable )
ENGINEER EW E + IJIS 4'A"s 17ja5 PE• TEL INE, . 4 •-917ij
DATE SCHEDULED "j-j&-13Z
(Applicant' signature)
_ . . . . . . ovo . . . . . . o . . o . . . . . . . voo . . . . . . . . . . o . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SOIL LOG
SUB-DIVISION NAME ��'�pQ(L Y�IIJT DATE_ I-Q,-$Z TIME ko', 3d
EXPANSION AREA: YES -" NO `jP,+13 OO �r�1.i�S �' ENGINEER
TOWN WATER ✓ PRIVATE WELL BOARD OF HEAL'I'k
EXCAVATOR
SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and
percolation tests, locate wetlands in proximity to test holes )
NOTES :
N
c
r
r
PERCOLATION RATE: l�c1
TEST HOLE NO: ELEVATION: TEST HOLE NO: � _ ELEVATION:
2 2
3 3
4 4 -
5 5
6 6
8 8.
9 9
10 10 SA
11 11
12 12
13 13
14 14
15 15
16 •16
SUITABLE 'FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEP�.�HING PI S_
LEACHING!-TRENCHES
1/
UNSUITABLE FOR SUB-SURFACE SEWAGE . REASONS: _
NOTE : ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON_PERC TEST APPLICATION
ORIGINAL: COMPLETED IN ENTIRETY BY P . E . AND RETURNED TO BOARD OF HEALTH
COPY: RETAINED BY APPLICANT
`LOCATION ��� 2 9�, EWA �; E PERMIT NO.
C t-DAJL PT A
t
VILLAGE _
INSTALLER'S NAME i A,DDRtS-.S ,
A,A , w5
O U1LDE R OR OWNER F
1 G t-1 PdLD '
-. �,o• 21 a8 �JTt3�'ul vac.-a
DA'T E PERMIT ISSUED
.DATE COMPLIANCE ISSUED
i a
+ JVST.444&.
• ' � /
_ _ k
!
SMOKE DEFECTORS REVJEM
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6ENER44L NOTES.- DESIGN CRITERIA:
J. THIS PLAN IS FCW 771E DF.SI6W AND INPERT ELF_ Y A T1 ONS-' Df.S 6J11 FLOk:•
I MUSTRUCTION OF THE SEXA6E DISDO L BFLROOR Dk'ELLING & I10 GALIDAY PtA BaWOLK/
FACILITY ON Y. INVERT AT BUT!DIA, ��1•,Z,L _ INSTAL!_ A GAS BAFFLE P42�f�, E&ZALS �u � GALS, P&I DAY.
2. ALL CqM 5TRUCTION METHODS, NA TERIA;S AND INVERT IN AT SEPTIC Tr' rK 6.62^ ----- IN OUTLET TEE,
' MAINTENANCE FOR THE SEPTIC SYS7L;v' U4LL_ U `""`-- _ j \. ACCESS Cpy C# �zcOP�L SEPTIC TA,'.9C' REOUIRJ2t-
CLWFORM TO MASS. D.E.O.E. TITLE AND LOCAL INVERT CUT AT SEPTIC T�2NIC !6�?r1 6• E1�5' MLCST BE A'ITHIN
BOARD OF HEAL TH RE6ULATlaW. INVERT IN AT DIST. t30X �'',���� !��'� � O`� FIf/ISH 67�ADE, �1 L�� L190 &Rp X 20O - $�d
� ._ ' GAL.
3. ALL SEPTIC SYSTF.�! LONENTS SUB�I_CT TO
INVERT OUT A T DIST. f''JX •` _ •00 b I �• SEPTIC TAAfff' PQ0YIDat - 1 5 C?C GAL.
VEIICL E L OADIN6 (I.E. UNDO-Y DWI YE:fA YS ETC.) INYEIiT IN A" S.A.S. ` () -_f{ ', J�' ED STONE
SiW L BE DESIGNED TO Xl Ri STAND H-..'O L OADIN6. J r - -
I BOTTCH OF S.A.S. ��'S�J r. ������ • ; SIZE OF LEAalIN6 FACILITY REWM0
4. ALL SEXEN PIPE SIfL4LL dE SL��EDULE '0 Cf? ^J�SEAYE'1 GROUNDIrATLA _ 4 MIN. ,YA- STONE
- I cEYTIt/D i 6.37 -5a 2 .
APPROVED cOJAL. DESIW l7C. RA%E a �-5 NI�Nal
,4Dh 41,:,'TED &BOUND`,,A TEY _ 10 ` - ' DIST. :?CPXE7I S.A.S.
mfr. o ; 440 5ALLaA S PER DAr
5. 90'709E STARTING MV3TRU0T1X CALL DI6 .SAFE - � —y 1500 GAL. 5=210 N'21S� to
1• 000-32L' 4B44 FOR L0r_4TICW OF S�PTX TANK CH-20) , r' ! SIZE OF LEAaYIN6 FACILITY PROVID02-
LMDEr'6WOU.^l0 UTILITIES. ? (yj-10 ) p �F .- l.L-Dt-J GArp,q G 1 T`( C,D4sC ��'f.
/YC r F I LCN is G 5`1`k ��V 'ca 1�!!�' 6T�6. DATUM I S :4SSUM.EQ �Z -
9. '—HIS PL,t1'r IS FOR TH.� I1YS 1 L LA T.�OW / REPAIR ST TIC TANK 6 "OX TO BE SET LW ti E-L 8 ra_® '00 ! KA-MF� �5�•N ,y y�
S "F I I S.DEXALL. _ _ S.F. X 0 LA 6J°D
I 7. NO DETSWINA TION i1AS BEEN MADE AS TO COW 1ANCE OF SEPTIC .5YSTF,�! 4 MOT TO SE USED FOR SUAVE"I','!i n � CLb�ACTF17 CRUSflID STONE. y
6aVTRACTQR TO RATER TEST D-B0X TO BOTTOM L5 S,F. X 0- r - g g sPp
i MITH DEED RESTRICTIaV S LW ZONING 1 E_SULA T1a'VS. t1l'f�' 0,'°1 t°►' �'- ' ''
IT SHALL REMAIN r E OkAER'S RESPa S131L.1 TY TO S '�/ ' ''` `'` ' -.�f L EYf_7-NESS.
:?9TAIN ALL REQUIRED PFR�IITS• SPEC) IL PFJ>�fITS; TOTA!_S q /U'S S.F. rvZ GPD
I YAAIANCE.S ETC. FOR THIS PfXJECT.
I 2 ` ��f: ��r�+� Q�►-r�,-oa SOIL TEST PIT DATA
_ 'vl IO/V
B. If j;)ALL RDMIN Thf OMvt?'S RESPO .IBIL1`"TY/O HAVE r �T
r/ci�,D DA'ELLIr':s FOB, 5 :� �+'� `� f F"t �. T.P. -1 ►QG,, , D T.P. -2 p .'Lb
SItSi1/Fi T O ACCDUNT FCR TIC- �YIS T�� trRADE
AN; SOIL CL'NDI7-laiS AT Thy- L rr'�A T:Oi`i DF 77 - ( : . �1 f G '�• EL EY. GR`.D. ELEY. 1
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CONSERVATION COMMISSION; ON 10/03/00 EXP'`RAT ON �
v a� DATE 10/03/03. RENEWAL OF PRIOR APPI�OVAL,APF?:OVED CENTER VILLE , ^14A.
BY CONSERVA"'ION 8112/03, ASSESSORS MAP 228 PARC'=L 113-2
CANAL LAiv ' SURVEYING � PERMITTING
306 OLD FLY^/1OUTH ROAD,s�� O.-ISIv/ft- BEACH,MA.
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