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HomeMy WebLinkAbout0034 CHILDS STREET - Health 34 Childs Street � Centerville A = 20 010 4 No. 42101/3 ORA FssELTIE 10% (o 9 0 0 0 j r •' 1 Commonwealth of Massachusetts -0/0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 34 Childs St Property Address YN Michael Cox 4 Owner Owner's Name information is required for every Centerville t/ MA 02601 9-7-2018 -r3 page. Cityrrown State Zip Code Date of Inspection Q 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 A. General Information �` filling out forms V /"ff (`�3 U&-- on the computer, use only the tab 1. Inspector: key to move your cursor-do not David J. Burnie use the return Name of Inspector key. High Tide Septic Solutions a� Company Name 3 Perry's Way Aff Company Address E. Harwich MA 02645 Citylrown State Zip Code 774-216-1440 S1386 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. 1 am a DEP approved system inspector pursuant to S j Qn 15.340 of Title 5(310 CMR 15.000).The system: o`0%N OFgs�ii,,�� ® Passes ❑ Conditionally Passes ` ? allt)h%l!D Ir ' ❑ Needs Further Evaluation by the Local Approving Authority c' ' ''' -+ 9-7-2018 'd�i6 F IN S P c'�°°°°° Ins WO of s S 16 n a t u ni Date 1f11illilll111 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 the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �C d V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 34 Childs St Property Address Michael Cox Owner Owners Name information is required for every Centerville MA 02601 9-7-2018 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: ® I 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: The system is working as designed. 1500 gallon septic tank, distribution box and 2/500 gallon drywells, stone lined. 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 34 Childs St Property Address Michael Cox Owner Owner's Name information is required for every Centerville MA 02601 9-7-2018 page. Cityrrown State Zip Code Date.of Inspection B. Certification (cont.) 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 ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �( 34 Childs St Property Address Michael Cox Owner Owner's Name information is required for every Centerville MA 02601 9-7-2018 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 asses if the well water analysis, performed at a DEP certified laboratory, for fecal Y P Y P rY 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 %day flow t5ins-11/10 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 34 Childs St Property Address Michael Cox Owner Owners Name information is required for every Centerville MA 02601 9-7-2018 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 gr'ound 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•11/10 Title 5 Official Inspection Fond: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 34 Childs St Property Address Michael Cox Owner Owner's Name information is required for every Centerville MA 02601 9-7-2018 page. City/Town 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): 330gpd+ t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 34 Childs St Property Address Michael Cox Owner owner's Name information is required for every Centerville MA 02601 9-7-2018 page. CitylTown State Zip Code Date of Inspection D. System Information Description: 1500 gallon septic tank, diistribution box and 2 500 gallon drywells. Number of current residents: seasonal Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if.yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): yes Detail: 2017=29.000 gallons by 365=80 gpd.....2016=48.000 gallons by 365=132 gpd I� Sump pump? ❑ Yes ® No Last date of occupancy: uuankknown 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•11/10 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 r 34 Childs St Property Address Michael Cox Owner Owner's Name information is required for every Centerville MA 02601 9-7-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: current Date Other(describe below): current General Information Pumping Records: Source of information: No Pumping records 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: ® Se tic tank distribution box, soil absorption s stem ❑ 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .•�'< 34 Childs St Property Address Michael Cox Owner Owner's Name information is required for every Centerville MA 02601 - 9-7-2018 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: Installed 4-6-2010 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 22" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line. 10+1 feet Comments(on condition of joints;venting, evidence of leakage, etc.): Normal as to what we could view. Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1500 gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 34 Childs St Property Address Michael Cox Owner Owner's Name information is required for every Centerville MA 02601 9-7-2018 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 30" Scum thickness Distance from top of scum to top of outlet tee or baffle 18" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape&estimated Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at normal working level. Tees in good condition.Tank is in good working condition.The tank should be serviced every 3 years. 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•11/10 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 34 Childs St Property Address Michael Cox Owner Owner's Name information is required for every Centerville MA 02601 9-7-2018 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•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System.Page 11 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'f 34 Childs St Property Address Michael Cox Owner Owner's Name information is required for every Centerville MA 02601 9-7-2018 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 normal level 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.): The cover is 12" below grade. Normal level, minor carryover and no evidence of leaking. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Located and opened, found dry. t5ins•11M0 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 34 Childs St Property Address Michael Cox Owner Owners Name information is Centerville MA 02601 9-7-2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 2 500 gallon drywells. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Located and foud dry. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 �• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,ram 34 Childs St Property Address Michael Cox Owner owners Name information is Centerville MA 02601 9-7-2018 required for every page. Cityrrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 34 Childs St Property Address Michael Cox Owner Owner's Name information is required for every Centerville MA 02601 9-7-2018 page. City/Town State Zip Code Date of Inspection 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 t5ins-11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 15 of 17 TOWN OF BARNSTABLE LOCATION 'Tt C/j/�C ' SEWAGE# VILLAGE ASSESSOR'S MAP dt PARCEL..�_r. .. .... INSTALLER'S NAME77777 . SEPTIC TANK CAPACITY LEACHING FACILITY: X. NO.OF BEDROOMS `3 +V6. COMPLIANCE DATE: PERMIT DATE: ---- Separation Distance Between the I of ` Facility .� rrir. �''' private Maximum Adjusted Gramdwater 7lable to the Bottom Leec)vng �. Wooer Supply Wail.and Leeching Facility(If any wells exist on site or within 200 fm of leaching facility) Edge of Wetland and Leaching Facility(if any wcdands oust within 306 feat of leaching OWility). lckv OA le IArRPED INLET OUTLET � `r CP PIT TT ;'14 �-)LAvi!' l J f 3 S4 / C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 34 Childs St Property Address Michael Cox ; Owner Owner's Name information is required for every Centerville MA 02601 9-7-2018 page. Cityfrown 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: 12+ 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: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Permit#2016-097 , no water to 12' ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: see below You must describe how you established the high ground water elevation: well#aiw 230, zone D level 20.46 calls for a zero adjustment. grade to dry test hole is 12', the bottom of the leaching is 5.5' below grade. this allows for a seperation to the bottom of the dry test hole of 6.5' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r�a 34 Childs St Property Address Michael Cox Owner Owner's Name information is required for every Centerville MA. 02601 9-7-2018 page. City/Town 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 � r " No. 120 Lb L _ r FeeZo G� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rpplitatlon for Misposal *pstrm Construction Vrrmit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) A.omplete System ❑Individual Components Location Address or Lot No / Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel Ins er's Name—Address,and Tel.No. `T ,/�j� Designer's Name,Address.,and Tel.N / Type of Building: Dwelling No.of Bedrooms 3n Lot Size sq.ft. Garbage Grinder( ) Other Type of Building � �J - No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 gpd Design flow provided , gpd Plan Date Number of sheets .J 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 Certificate of Compliance has been issued by this Board o a h. Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ;_01 66 Date Issued ' r� f O +rear` ! �7161) No. L 6 1 f 6 �+ M Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for Mispo8al 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No �p/Z' ✓� � S,T Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Inst ler's Name ddress, d Te.No. Designer's Name,Address,and Tel.N F� ��3 - �'� Type of Building: Dwelling No.of Bedrooms '� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building CMG No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) J-3 d gpd Design flow provided gpd Plan Date" / �� Number of sheets / Revision Date Title Size of Septic Tank �j' S �O� '� Type of S.A.S. Description of Soil �� O �✓ ��� p�.r-� 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 issued by this Board o a h. 000/,0;6- r Signed / Date r Application Approved by Y Date ��" ,b Application Disapproved by t Date for the following reasons / Permit No. � 1 U l_ 6 Date Issued LI l ---------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of CDIIttJrIaIILP 000011 THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by 4`r4!5"49 a 6✓50,1:- at 3 y C/i�i1 �?_ cG� has been constructed in accordance / with the provisions of Title 5 and the for Disposal System Construction Permit Noc9016- 097 dated Installer `J ` � Designer e24f/".6 A #bedrooms 3 Approved design flow gpd The issuance of t is permit shall not be construed as a guarantee that the system will fian ct^ion as d, igned. Date I '� Inspector ---------------------- ---------------- - -=------------------------------------------------------------------- No. GI v Fee THE COMMONWEALTH OF MASSACHUSETTS j PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS i Misposal �&pstrm Constructio Prmtt i Permission is hereby granted to Construct( ) Repair( ' Upgrade( )� Abandon( ) System located at G 'G3 Jl and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with j Title 5 and the following local provisions or special conditions. Provided:Construction must b completed within three years of the date of this permit. Date /'� Approved by Town of Barnstable �r.TNE 1p� Regulatory Services Richard V. Scali,Interim Director + sa[uvsrast. . . �0� Public Health Division 39. Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 20Vqewage Permit# Assessor's Map\Parcel '—TI Designer: 'IJU> Installer: Address: �` c% � 1 i Address: i�a� On """ as issued a permit to install a (date) (installer) 1� based on a design drawn by septic system at ,'A ((address) J° Ao, ►mil ' °v� dated 1 �� (designer) I 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 co gj��'ance with the terms of the approval letters (if applicable) F ry VAVIU �y c NIASOi J n� (Installers Signature) -� �C3 No.loss Al ( ignature) (Affix Desi mp 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. QAGSeptic\Desiper Certification Form Rev 8-14-13.doc m TOWN OF BARNSTABLE `R LOCATION `S T SEWAGE# ���� ®97 VILLAGE �d��L' ✓i �r,Q ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 00�4:fe'e�' ,&�� 6VIe, �® LEACHING FACILITY: (type) 'C0~C4Z e,-'_Gt' (size) 0�14aX:0$4X .�( GN rn2�'�� -/S NO.OF BEDROOMS OWNER ®X PERMIT DATE: X —,OOOK COMPLIANCE DATE: 6 Separation Distance Between the: '000® �s�TG�r� 10 �� Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 3c,Ids s y 3 e no F � r TOWN OF BARNSTABLE LOCATION 3 / C ,% l I D S SEWAGE # �5-LAGE ('ej I eX-u 1 ASSESSOR'S MAP& LOT 9 G/6 INSTALLER'S NAME&PHONE NO. r SEPTIC TANK CAPACITY LEACHING FACII.ITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet f leaching facility Feet Furnished by A ', �u v Q 1�. F I.LE # n5021► CENSUS TRACT # C IENT: John W. Kenney DEED OOK 2-436 PAGE 279 OV ERA William A. Cox & Mildred R. LAN OK 166 AG 25 LOT PPI, CANT: 1il C11 L. C & r. i.s ox AS S RS PLAN PCOT N0RT6A6E I NSPE .CT10N PLAN OF LAND I N BARNS. TABLE y SCALE. JANUARY 3, 1986 , ; LOT 3 LOT I 2g'` id./F MCMANUS 3.. M 134 40't 1 STORY W/F Ll .,, c�v m Ci-1ILDS STREET I CERTIFY TO ATTORNEY J.OHN W, KIntNNI YE THE BOSTON FIVE CENTS SAVINGS BANK .AND ITS TITLE I PISURANCE COMPANY, THAT THERE ARE NO VISIBLE EINCRJACHMEN'T$ OR EASEMENTS ;EXCEPT AS SHOWN .AND THAT THIS PLAN WAS OPR PARED UNDER MY IMMEDIATE T4E LOCATION OF THE- Da,:EL.LING AS- SHOWN HEREON a�`A��� of I S IN COMPLIANCE WITH THE LOCAL APPLICABLE r/`Z KEtdN�i6i ?01'4I113 BY-LAWS 4'IITH RESPECT TO HIORI.011T'A:L. ��- �II3:i�l ? O IAL .i :=slal.i rEF°� 4 T-S Ff >1 1RA No. 2kt716 THE DWELLING .SHOWN' HE-Ir% .. ��0 EL 1 T FALL WITHIN ;aF';vt:IAI. FLOOD I ��°.i�t:� .0i1- : -IA S I3f:d..1I+4EATs c ;� A CRAP OF COMMUN y Y ::`25Q('1r:��C ���� �a Land Surveyors Civil Engineers 01he PostonPllh ,�$Uxtq 17Z pilliant St_ �TdD�60forb, 1 02740 GENERAL NOTES: (1) The declarations made above are on the basis of my knowledge, information, and belief as the result of a mortgage plot plan tape survey inspection made to the normal standard of care of registered land surveyors practicing in Hassachvsetts. (2) Declarations are made to the above named r.lient only as of this date, (3) This plan was not made for recording purposes, for use in preparing deed descriptions or for con— strtictions. (4) Verifications of property line dimensions, building offsets, fences, or lot configuration nay be accomplished only by an accurate instrument survey. DEEP•OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Shcl Color Soll• Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. nst_ wncy,%'Orayell IL = 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) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil 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,Stones:Boulders. Consistency. Flood Insurance Rate Map: Above 500 year f lood boundary No— Yes Within 500 year boundary No es ' Within 100 year flood boundary No.,,�._ YEs • � Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring per I aterial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the dep of' aturally occurring pe vious matoriall Ceitifiication I certify that on. 1© (date)I have passed the soil evaluator extimination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required traininTertis, n e erience described in�10 CMR 15.017. I Signature Date Q.NS.EPTIaPERCFORM.DOC s Town of Barnstable y S ,tl� / . Department of Regulatory Services '• > Public Health Division � 7 l / �'J]I.On Date 1 / MA � 4� ra7Y 200 Main Street,Hyannis MA 02601 ' • Ell MA'1 h (,� t \ _ .' Date Scheduled ` IwA TftnB ee' d. Soil Suitability Assessment for Sew ge Disposal Performed 11y:a)q n ' '/ ' IC�-�"v : y i �✓►�.�I �1 v Witnessed B LOCATION& GENERAL INFORMATION Location Address P;r- Owner's Name p Address Assessor's Map/Parcel: Engineer's Name ��d NEW CONSTRUCTION REPAIR Telephbne# Land Use. Slopes(96) Surface Stones .. Distances from: Open Water Body ft Possiblc Wet.Area ft Drinking Water Well ft Dralhago Way ft Property Line ft Other ft SIMI TCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to(toles) Parent material(geologic) Depth t0 Bedrock Depth to Groundwater. Standing Water In Hole: Weeping ft•01n Pit PAC@ Estimated Seasonal Nigh Oroundwater,, Method Used: I3E- ERIVUNATION FOR SI ASONAL,ffi GH WATER TABLE Depth Observed standing in obs.hole: In, Deptll to Soli)nottleat Deilth to weeping from side of obs.hole: Ill. Oroundwater Adjustment Index Weil# Reading Date; Index Well Adj.tltotbr Adj,0ivundwt1ter Leval Observation PERCOLATION TEST bate T nim Hole# Tlmo at 4" Depth of Pero Time at G" Start Pre-soak Time Q � �'^ �^ • 2 Time(V-G") End Pre-soak / �J Rate Mib./Iuch Site Suitability Assessment: Site Passed 5itp Fulled: 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,you must first notify tlLe Barnstable Conservation Division at least one(1)weep prior to beginning. Q:1S EPTIC\PERCFORM.DOC a Y . Z 34 Childs ST, Centerville, Garage / 5,6» 6 12 8'691 Slab Notes: 2' 4"slab with reinforcing wire on 6 mil plastic VB and 4"gravel. concrete apron to extend 2'6" North elev beyond foundation at front. South identical without entrance door West elev East identical without garage doors s s s concrete apron Foundation notes: 26' wide x 22' deep perimeter foundation walls. anphor bolt Footings to extend 5"on both sides of foundation. imbedded 8" 18 x 12, footings @ 4 below grade. 2x4 keyway o.c. of footings for walls. 8"walls to 8" nominal above grade. 1/2 x 12" Anchor bolts for 2) 2x6 PT sills 6' oc and 12"from each edge or corner. 4' Framing schedule: Double 2/6pt sill plate. Walls: 2x416"o.c.with 5/8 ply, white cedar shingles. towalls keyed Garage door headers double 2x10, window headers double 2/6. to footing. Roof: 2x8 16" o.c. with 5/8 ply and asphalt shingles. ^ '" 12"x 18„ �` 3Y �,IJ sl CV4 ----- ------------------------ ---- ASSESSORS MAP : PARCEL " TEST HOLE LOGS , - 1) The, installation shall comp with Title V al;d M own o1*q1*6 h.)ard of FLOOD ZONE: �,/d% G/� �` SOIL EVALUATOR I lealth Itegulations. REFERENCE: ` WITNESS : 2)V0�c�T�_ 2) The installer shall verify the location of utilities, sewer inverts and septic i • �' ._ . 3� 'jl T -M - DATE: /4, I —� components prior to installation and setting base elevations. PERCOLATION RATE: 3 All gravityseptic piping to be 4 inch Sch 40 PVC at 1/8" c i foot. The first two feet out of the d-box to the ieachir, shall be level. �i tad _ 4) This plan is not to be utilized for property line determination nor any other TH 1 TH-2 purpose other than the proposed system installation. �d �' ,1 l0 5) All septic components must meet Title V specifications. l 6) Parking shall not be constructed over H10 septic components. P,�� 7) The property is bounded by property corners and property lines. tb t �Dj 8) The property owner shall review design considerations to approve of total LOCATION MAP /�� p �I� � design flow and number of bedrooms to be considered For design. Receipt of payment for the plan and installation based on the plan shall be deemed 4 }, approval of the design flow by the owner. Alt, 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean sand per All, Title V specs. HID 10)System components to be 10 feet from water line. Sewer ! nes crossing the L water line shall be sleeved with 4 inch SCII 40 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service SEPTIC SYSTEM DES G N line. The line is to be sleeved as aforementioned and maintained in place. J 11) If a garbage grinder exists it is to be removed and is the responsibility of the y owner to ensure such. FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such 1 / exists. 13EDROOMS AT GAL/DAY/BEDROOM - GAL/DAY 13)"I ne installer shall verify the location, quantity and elevation of the sewer lines exiting the dwellin- rior t dwelling" o the installation. SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting Title V requirements. &O-GAL/DAY x 2 DAYS - GAL I - USE 1 GALLON SEPTIC IANK - ✓ SOIL AB OR ION SYSTEM I t _ . O. ' ;t e"+, 4 F Z tV tf^ L.J , SIDE AREA: �C ?. ' ' IZ� �( �� �,1 ( �� / o I)AOVICI BOTTOM AREA: r 23� �10 . .. ,- x , Ott o MASON t v a No. 1066 aCd > t` G/STEM . �1 J ,�-e S..E.-P-. C SYSTEM SECT I ON A000 M _ w'vl(o 10, -lm fl�� 5 a 2i�rG. Rt 52 GAL �I,�� /G 'c` .._ t LJ 0 Z71 SEPTIC TANK 51�Ip , r — q( Wtle, 54V- q2,Lj1 i s ►�o,nC� SITE AND SEWAGE PLAN�� 5z � o LOCATION ., 1 V� Mft PREPARED FOR : 0 SCALE: DAV I D B . MASON ?6 DATE: ► Ito Z DBC ENVIRONMENTAL DESIGNS W EAST SANDWICH . MA Z DATE HEALTH AGENT ( 508 ) 833- 2177