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HomeMy WebLinkAbout0119 CHILDS STREET - Health 119 CHILDS STREET, CENTERVILLE A= 249 005 UPC 12534 ' No.2�153LORs>� HASTING8,00 o 59� No. Al00 .00 Vt— THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS _ ZippYication for Tkopool *pgten Con!aructiou.Permit" Application.for a Permit to Construct( . )Repair( Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 5 0 8—2 21 —0 5 3 6 119 Childs St, Centerville Lenore Lyons Assessor'sMap/Parcel 249/5 119 Childs St, Centerville Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4 Wm E Robinson Sr Septic Sery Eco-Tech PO Box 1089, Centerville 43 Triangle Cir, Sandwich Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder(no) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 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) Install a new Title 5 leach system to plans of Eco-Tech, #ETE-2226 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 vironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this rCof H Signe Date Application Approved by Date Application Disapproved for the following re s s Permit No. 10,5 C751?ZnDate Issued t f No. ( . Fee THE THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS t Application for Mi�pogaf *pgtem'Congtruction 'Permit Application for a Permit to Coristruct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 5 0 8—2 21 —0 5 3 6 119 Childs St, Centerville Lenore Lyons Assessor's Map/Parcel 1 1 9y Childs i lr1 s,, p . u 4 9 j s l; ;s^erttervi.`�.1_ Installer's NamesAddress,and Tel.No.' 7 7 5-8 7 7 6 Desi nee's'Name,Address and Tel.No ,3 6 4—G 9 d g . Wm 1; Robinson Sr Septic Sery Eco—Tech PO Box 1089, Centerville 43 Triangle Cir, Sandwich Type of Building: Dwelling No.of Bedrooms} 4 Lot Size sq.ft. Garbage Grinder 00) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date s Title Size of Septic Tank Type of S.A.S. r Description of Soil Nature of Repairs o Alterations(Answer when applicable) Install a new Title 5 leach system to plans of Eco—Tech, ETE-2226 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 Code Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this_Bcoafd of Heath. Signed �lr� l i /� �f� /r'7� Date '/ l �� -21 Application Approved by . ��`'i'� a� /rJ i.lX �1 Date s. / , t j Application Disapproved for the following re - gn�s _mot� Permit No. /1t � ? _� Date Issued THE COMMONWEALTH OF MASSACHUSETTS I' Lyons BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired (X ) Upgraded ( ) Abando e by Wm E Robinson Sr Septic Service 9 � Chi s Street, c.entery e n ha e constructed in accordance at with the provisions"© it e 5 and the for Disposal System Construction Permit Nc _ ' <./dated (1 l 5 j Installer ''" Designer-- 0' r The issuance of this permit hall not be construed as a guarantee 'the syste 1-7il•1 f c ions designed. Date <6 Inspect\or_ $100.00 Ni. / Fee Lyons THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migogal *pgtem Congtruction Permit Permission is hereby lg a�rte`dd,1,t1 go8sstru�ccttre)eI epair�erit2rVil(le)Abandon( ) System located at L _ 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: Cons ction bustbe completed within three years of the date of tftl/ Date: !( ! �� / A roved b Y • Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, y 1 COU&Hb4,hereby certify that the engineered plan signed by me dated 1/(4, / s , concerning the property located at id 5 9f" meets all of the following criteria: • Two soil evaluations excavated for detailed examination(no hand augering).and two percolation tests shall be conducted. • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation Z�-1 Z +adjustment for high G.W. q,2t9= 3 0`3 Z DIFFERENCE BETWEEN A and B �- SIGNED Q�4 6TL— P"� DATE: �� NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. gASeptic\percexemp.doc Town of Barnstable zik Re" hlol N �nu Sel N ices RHARN'ZrAo U, MA, 16 9 I)il ectm "00 INIaili 'Stl eel, 111,11111is. M'A 0.1oo1 Officc: 508-862-4644 ,ix: 5()X-79()-(0(0 & I)Csiullcl. Certification Fol-111 Date: Designer: Eco—Te-ch Installer: Wm E Robinson Sr Septic Address: 43 Triangle Circle jk(I(II-ess: PO Box 1089 Sandwich—.----- Centerville On ✓ Wm E Robinson Sr Sept.,q. .issued toinstall it (illstallei.) septic S%?StCIllat119 Chi lds—St-,--_Centerville Imscd on it design drawls by (ilddl-css) Eco—Tech dated 11 -14-05 (designer) I Cut1k, Ulm the 'sel)[ii C SvStCIII I-C I CICIICCd J)ovc was 111'stallcd slit'stalillally accol-dill" to the dcslgil. which stay includeapproved dialig's such as lateral relocation (fl, the distribution t)'-)X iIIld;'O.I SCI)tIc tank. I certII)v that the S'Cj)j.Ic-s%'stcm i-cfacilced above was installed \vIt1j Illil' - changes (I.C�' jol geatcr than 10' lateral relocation ol'the SAS or allv vertical relocation of ally CoIlTollclit of the SCptIC sy.s(CIII) but III i1ccol-dance with State & I mcill Regulations. PLI'll I-CV11111.)II M* CC[-Ilf[C(i iIS-hLII1t by dC,1;I"IICI- to follow. OF F DAVID D. (Install- Signature) COUGHANOWR D No. 1093 GISTe NITAR\ (Desiglia's Slit'lliltl.H-C) z:- (Afl-lx Desigilel's Stalill) I lei-C) ITFASE, RETURN TO BARNSTABLF PUBLIC HEM 'I'll I)IN"ISION. CE'RTIFICA1 F' 0F COMITLAN(Ij WILL NOT BF, ISSUED UNTIL 130"I'll 'FIII's FORM ANI) AS- BUILT CARI) .\RF T11F. ITBIAC IIFALTII I)IN I'll.vNK, YM. Q- 11ca11h Septic Designs Gmil-Itmilm I ,[III ' COti1\40\WEALTH OF NtkSS?,CHL•SETTS j E.xF_cL'T1VF_ OFFICE OF E?��+'IR0'.\. IE�TAL AFFAIRS - DEPARTMENT OF ENVIRONMENTAL PRO CTION 0%E WINTER STREET. BOSTON. Dt.� 0=1Q6 bl?-=S_•�:{� _�. MAivEg ,> Taft . 1 1998 Vr11.LIA% F.WELD •i.:. yFq(H�NSTgg� LDS'CC EPT Sc:: Govwnc- 'B STRL ARGEO PAUL CELLIXCI � ` D Lt.Governor SUBSURFACE S"cWACE DISPOSAL SYSTEM INSPECTION FORM .... Corrirrissic PART A _ • __._ _ '' CERTIFICATION .: ._-_• . � Address of Owner: Property Address; , �`�71% 5T1 �v��.,K.vl11,2, '(If different) Date of Inspection: Name of Inspector. f`t'. �el V t' 1 Epd=C;ra am a DEP approved system inspector pursuant to Section 15.340 of Title S C310 CMR 13.000) Company Name:P, M�Z,` Mailing Address: -4) �o� P �� H f�Sf•/i�>?2 / e-Z_4-q Telephone Nurnoer: r s e _4*$5— _Cc ? ol CERTIFICATION STATEMENT 1 cen,N that I have pe-scnall% ,rspec:ed the sewage d:s*esal intern a: this address and that the information retorted be:ow is true, accurat and complete as of the time of ,nspec,o-. The ,nspec:;on %as base' on my training and experience to the proper fu c,c- an maintenance of on-site sewage d,sposa; systems. The miern: Passes _ Conc,t.w^ai:\ Passes _ ♦eea% Furthe• E••aluaraR Ey the local Approving Authority Fa. � .. Inspector's Signature. Date: 1 T;,e Sv!-.e-r Ins:eco• sha" s::brn,t a cc;v of this inspec:on reccr, to the Apvcving Authenn. within th,rav (301 dzys of completing this inspec':,on. It the sv!tem is a share= wstem- o• has a de:.gn flow of 10.000 g.+c or greater, the ,nsoe;cr and the sysem owner shall subm: the re-.a- to the acorepnate regional a::,ce of the De,a-merit of Envircnmenta' Frotec':,or.. The ong:na! should be sent to the mtem cw and copies :--,; to the buyer. if applicatle, and the ap=raving authorin INSPEOTIOti SUMMkRY: Check- A, E, C, er D AI SYSTEM PASSES: I have not found any information which indicates that the system viciates any of the failure criteria as defined in 310 CMR 13.3C Any failure criteria not evaluated are indicate_ below. COMMENTS: 61 SYSTEM CONDITIONALLY PASSES: One e, more system components as described in the 'Conditional Pass' se^.ion need to be replaced or repaired. The systern, u: completion of the replacement or repair, w approved by the Board of Health, will pass. Indicate yes. no, or not determined (Y. N. or ND,. Describe basis of determination in all instances. If 'not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Cenif,ate of Compliance (anached) indicating that the tank was installed within twenty (201 years prior to the date of the inspection: the septic tank, whether or not metal, is cracked, structurally unsound, shows subsuntial infiltration or exfiltnit,on, or tr failure is imminent. The system will pus inspe^.ion if the existing septic tank is replaced with a conforming septic e11 as approved by the Board of Health. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: ej SYSTEM CONDITIONALLY PASSES tconttn.,,!,d Sewage backup or'breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: ' broken ptpefs) are replaced _ obstruction is removed :. distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe!51.:The system will pass.. tnsoectton if twith approval of the Board of Health): broken pipers; ire replace: obstructor is removed Cj FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which reouire furthe• evaluation by the Board of Health in order to determine if the system is failing to prate-- t public health, saie:y and the environment. 1) SYSTEM WiLL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTiONING IN A MANNER WHiCH WILL PROTECT THE PUBLIC HEALTH AND SAFtiY AND THE ENVIRONMENT: Cessaoal or pn.ti is within 50 fee: of a surface water Cesspool or pri%-v is w ith,n 50 ieet of a bordering vegetated wetland or a salt marsh. 2) SYSTE.M WiLL FAIL UNLESS THE BOARD OF HEALTH GANG PUBLIC WATER SUPPLIER, IF APPROPRIATE} DETERMINES INES TH. THE SYSTEM 15 FUNCrIO-I.NG'IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFt�Y AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS, and the SA< is within 100 feet to a surface water supply tnbutary to a surface water supciv. The systern has a septic tank and soil absorption systern and the SAS is within a Zone I of a public water supnty well. The syste•n has a septic tank and soil absorption system and the SA—; is within 50 fee: of a private water supply well. The system has a septic tank and sail absorption system and the SAS is less than 100 fee: but 50 feet or more from a private, water supply well, uniess a well water analysis for coliform ba&e.na and volatile organic compounds indicates t. the well is free from pollution from that facility and the pre-,wince of ammonia nitrogen and nitrate nitrogen is equal tc less than 5 ppm. Method used to determine dismnce (approximation not va(io). 3) _ OTHER SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DI SYSTEM FAILS: You must indicate either "Yes" or "No' as to each of the following: have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 13.303 The bans for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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. Sta:ic bou,d levei in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool lrcuid depth in cesspool is less than 6" below invert or available volume is less than 112 day floe. Reeuired pumping more than. 4 times in the last year NOT due to clogged or obstruc:eo pipe s . Number o`times pumped _. Any portion o`the Sod Absorption System, cesspool or pnv)• is below the high groundwate• eievaner Ar.. por::on o:a cesspool or privy is %ithir. 100 fee: of a surface water sucoiv or tributar to a surface v.ate- suppi} Any Par:= of a ce<_spoo' or privy is N ith.ir. a Zone I of a public well. � Am pc-jo-. e'a cesspool or prnz• is \,%rthin 50 feet of a private water suppl-, well Any por,,or. bf a cesspool or pri.ti• is less than 100 feet but greater than 50 fee: from a private %ater supoly well with no acceo:abie %ate• qualm, analysis. If the \ve!I has been analyzed to be acceo:able, arach copy of well water analysis for coliform bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: 1'ou must indicate either "Yes- or "'moo" as to each of the following. The folio:r.g cr,te•ia app;,6 to large systems in addition to the criteria above: The system serves a facilir, with a design flow of 10,000 gpd'or greater (Large System; and the system is a significant threat to public hea!th 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 3.00 and.6.00. Please consult the local regional office of the Department for_furthe.r.informa ion. (rwl�.d 0�/:5/971 Page 3 of 10 . r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Ut;U41 Date of Inspection:,`I`' Check if the following have been done: You must indicate either 'Yes' or 'No' as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been ootained and evarnmed. Note if they are not available with WA. The fac:lm or d%vellmg %vas inspec ed for signs o-'sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site .vas inspected for signs of breakout. All systen- components, excludine the So-1 Aosorption System, have been located on the site. r The sept.c tank manholes were uncovered. cpe-ied. and the interior of the septic tank was inspected for condition of '—C banies or tees. materia� o• construction. dimensions, deptn of liquid, depth of sludge. depth of scum., The size and local-on of the Soil Absorption 5.•stem on the site has been determined based on. The fac,lin ovvne, ,ano occupants. tf difterent trom ow•nert were provided with information on the prope• maintenance of Sub-Surface Disposal Svstem. Existing information. Ex Plan at 6.0 H. _ Determined in the field +r am of the failure'criteria related to Part C is at issue, approximation of distance is unaccevtabie (15 301 31ti? P. 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Propert% Address: Cl9 &<<�S Owner:kvkv.� l J Date of Ihspection;� ks FLOW CONDITIONS RESIDENTIAL: Design floN o.d./bedroom for S.A,-S Number of becrooms Number o'current residentsCL� Garbage g% der (yes or noJsx Laundry co-•^ected to system (yes or no! Seasonal use tyes or no!:i�j ll Water meter readings, if available (last two i2 year usage tgpdt: t� Sump Pump Ives or not Lai: da;e o'occupanc%• pw� COMMERCI4L'INDLISTRIAL: ` Type of establishment Design fio%% ¢a!jonsida% Grease trap present tves or no_ Indus-ma! Taste Holding Tani; oresen;. ves or no_ :on-sanita', %&ante discnarger to the Tftie 5 ;%,es or no_ X%ater meter readings if availabie Las:pare o: o .:p2nc. OTHER: .De_cribe Last cote of occuoanc. GENERAL INFORMATION PUMPING RECORDS and source of rniormatioc System pumped as par, of inspection: Ives or no._ttkj If ves, volume pumped ¢allons Reason for pumping TYPE OF SYSTEM Septic tank/distribution bozrsoil absorption system Single cesspool Overflow cesspool P rn). Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technologv etc. Copy of up to date contract? - Other -- APPROXIMATE AGE of all Components, date installed (if known) and source of information: Sewage odors detected when arriving at the site. (yes or no)_ _ •. (raviaaC 0�/:S/9?1 Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORtit PART C SYSTEh1 INFORMATION (continued) Property Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) t" Depth below grade. Material of construction. _cast iron _40 PVC _other texplain Distance from private water supply well or suction Ir Diameter Comments: (condition of joints. venting, evidence of leakage, etc.) SEPTIC TANK: 5ii (locate on site pi Depth below grade material of constructto concre:e _me-.a _Fioe•glas! _Polyethvlene _othertexplain If tans is me:ai. Iis: age _ Is age con:irmec o. Ce^.fica:e o: Compuance _('res.-No Dimenstor.s tjfti1_ Sludge depth L► Disiance from top o: s?ucee to boron of outie: tee o• ba�ie aii Scum thickness A`l u Distance from top of scum to top o' outlet tee or ba-ie Distance from bo torn o'scur-: to bo-o o; out!e: tee e• bane Flow dimensions %ere determined ►fl 14�S� , Comments trecommendation for pumping. condition of inlet and outle! te<s or baffles. depth of liquid level to relation to outl t invert. struct ral integrity, evidence of leakage, a:c t W tl.► w GREASE TRAP: (locate on site plan; Depth below grade: 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: Comments: (recommendation for pumping, condition of islet and outlet tees or baffles, depth of liquid level in relation-te-outlet-invert;structur-al-- — ,ntegrity, evidence of leakage, etc.; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propem Address: O%ner: Qz� Date of Inspection: TIGHT OR HOLDING TANK: 'Tank must be pumped prior to, or at time, of inspection) (locate on site plan, Depth below grade. material of construction. _concrete _metal _Fiberglass _Poiyethyiene _other(explain) Dimensions: CapacitV gallons Design floe gal)onsda. Alarm level A:arm in corking orde• Yes. _ No Date of previous pupping Comments (condition of inlet tee, condition o- a!a•m and float switches. etc.) DISTRIBUTION BOX:�/� docze on site p:a- 1 �' De::t�i o! licuid le e' a00%e oune: in\e- ,u./ QUfLr Comments note leve! and dis—ibui-or is eaua' evidence of soft s carn•over, e.tdence of leakage into or out of boa, etc. " PUMP CHAMBER: (locate on site plan. Pumps in working order: (Yes or No, Alarms in working order (Yes or No Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (r.vysad 04/25!97) Paq. 7 of 10 SUBSURFACE SEIWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addr-ss: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):LQ> (locate on site.plan, if possible: exca, -on not required, but may be approximated by non-intrusive methodsi If not determined to be present, explain. Type: leaching pus. number. L leaching chambers. number:_ leaching galleries. number. leaching trenches. number,length: leaching fields, number, d.-ne-isions overflow cesspool, number Alternative s%-stem Name of Tecnnotog- Comments ino( condition of soil. s!gr. of h. 'raulic t' ilure, leve' of onding. condition of vegetation, tc.t —91 c► v U N Iv CESSPOOLS: J6 (locate on site plar. Numbe, and coniigura:-on Depth-top of liquid to inlet Inver, Depth of solids lave- Depth of scum laver Dimensions of cesspooE Materials of construction Indication of ground�,%ate- inflow tcesspool must oe pumpez as par, of inspections 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.): Irwis.d page 8 of 10 Y • r 'L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued PropertN Address: OKner: Cw— ,Uie—, Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM. include ties to at least two permanent references landmarks or benchmarks locate all Hells within 100' (Locate where public water supply comes into house) Ap— ` reooJ•� L 33 tz.va..d 04'25!57) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Adores•• Owner:Oeszz-t .�J Date of Inspection:����9 Depth to Grcunclwate��Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained iron Design Plans on record Observation o-*Site (Abutting properT. observation hole. basement sump etc.) Determine it irom local conditions Cnec'• %%ith local Sparc o• -iea!:- Chec'� FEMA macs Cinec�. pump ng recores Check local ev;a,-ato•s ins:alle•s use '-5_5 Da-a r• Des r be in ,cu- o••- ro- 0. es:ao?-:-,ec the Crounc%&ate• Elevation (Must be compieteC L �Y,�- toc�Lc" Page 10 of 10 f s ' t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Disposal Works Tonotrixrtion Vrrnttt Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systemat: � I..�.1S........... ..........X ----------------------•-----.. I.�.....---•----..............-----........---......... Location-A res or.Lot No. ..................�. ..v.. .t —...... ._�. �.:... �... ----------------------------------------...•-•..... Owner Address .................... J�1.. 2�,s.r ._. . ..... c? ....-----------..............-•-•-----•--. Installer Address ^ Q Type of Building Size Lot.. ..Sq. feet Dwell Gar Grinder (AI&I Other—Type s ng oof BB ldi gmA)MJ�eW, ....... No. of personsnsion Attic wUI Showers � )bageCafeter a (� Other fixtures ..-. tc........... �/ W Design Flow........f �....�.._...._._..gallons per person per day. Total daily flow...........33.J...................gallons. WSeptic Tank—Liquid capacity.t........gallons Length.....10..... Width......4....... Diameter-----4........ 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 (t/f Dosing to ) y.._ Percolation Test Results Performed b '1Jeeef!.e.......�!? 'f! .... Date.__.-I„�a Test Pit No. 1...�-q�..-...minutes per inch Depth of est Pit.................... Dept to ground water........................ f% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ p; .......................••............r.....................................................I.......---•--- O Description of Soil....Q.' I. I.®AXtl......�.-.-:o?P s;iL.......n�.----•I.... ...Lp .......----+5.�t.LlS....W v �2c�L .�..............---.-----•---- ... 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 AITI LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Si d......._��� � $.te�< �c............. a 3 Date Date Application Approved By ......................................................................... ........................................ Date Application Disapprov o reasons:.......................•-------------------------------•------...................---•-------........-----....-- ...........................•-----•---••••-•-•••....---•-----••--•......••--•--•---•--...........•--•--------•-•--------.....-----•••------••----•...............••-•--------------•-•--•.....---.....•-- Date PermitNo......................................................... Issued..................................................... Date ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t..(' ............OF...... ):ST_X_k3k-.. ................ ...... ..... Appliratinn for Di4pnal Workg Tnnitrnrtinn Famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ._t ........... ........ �� ...............•---...-•----------...rr ....._.. Location-l aress or Lot No. !` -!. .1.-j�-r........:[�-- ?. .�... a. ............................... .. -•-•....--•---•----------------------------------- Address w ....... ------------ --------- ..............------......._..--------.........._..--- jai�574 Installer Address Type of Building Size Lot.__ . �.f��..____.Sq. feet ., Dwelling—No. of Bedrooms_._..._.... .............................Expansion ttic (A/4 Garbage Grinder 01 aOther—Type of Building .(rSl _' ....... No. of persons------- -----------------_ Showers Cafeteria (Wo dOther fixtures ...--P:c ------------------------------------------------------------------- ---------•---••-----------------------.---------------------- w Design Flow........ ....S_,� ........gallons per person per day. Total daily flow...........3-3.0...................gallons. WSeptic Tank—Liquid capacity-_----------gallons Length------ ..... Width......fit._..... Diameter-----4........ 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 (L-of Dosing tank C ) J Percolation Test Results Performed bf �° .__ !71% f Date...._. ' �� a y .....-- ...fT -r ........... Test Pit No. 1... _ minutes per inch Depth of rest Pit...__.._•..____..... Dept to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ....------•----------------------•- t •--- ----- r------...... O Description of Soil...... '..� ....I.'_rttro7.:_.:.g 'r� �_ �„"� . ...6-�-- L { --...... d ........................................................ 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 operation until a Certificate of Compliance has een issued by the board of health. Sig Date ApplicationApproved By. ...` ---•-•------.....-•---........-•--------•---•----•--------•-------- Date Application Disapproved. lowing reasons:........................................................................................... ---------------------•------------•------.....--•-••------------...........-----------.....-•---------------..............--•-------•-••------••-----•------•--•...----------------------------•--••---. Date PermitNo......................................................... Issued-........................................................ Date THE COMMONWEALTH OF,MASSACHUSETTS i BOARD OF HEALTH ....../. .Zf. .................OF................ (%r/ tCj..'� ` �......................... Trrtif iratr of Tompfittnrr THIS 1 TQ C T�FY, That/the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by- '' ... ..... �. �d ----•----•----------------•-----------...------•-•-----------......_.._.......------......---..._..........------..._...-----.......... at.-- . ..........5............... Inds lerl.---•--......_...---•--.......................... •.�4si `yT- ..........•---•-•- has been installed in accordance with the provisions of T�jT P of The State Sanitary Cobed in the application for Disposal Works Construction Permit No._8-- ..__.,rl................ dated__ ___ .................. THE ISSUANCE PF THIS CERTIFICATE SHALL NOT BE CONST ED AS A GUARANTEE THAT THE SYSTEM WILL FVT ION SATISFACTORY. DATE... . ...................................... Inspector... .. . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH S.S� ............. !�'..........'OF........ V . � No.. ..................... FEE.- C ................� Dhipvoal nrk un tr�rtrtj n rrntit Permission is hereby granted........ . tes............. � j�`rl.. _` to Construct �orle aip ( ) an Individu Sewa e Disp1System atNo.---•-•-••j�--•----CC�-S.......S . --- !l:? C'/2 l/t t --------------------------•--------..............._ . - Street as shown on the application for Disposal Works Construction Permit No.................... ..:.._: ............... ........................................... o--•• ................................................. � DATE.......... ._Z�...-Y�-----------................................................ ar of Health FORM 1255 A. M. SULKIN, INC.. BOSTON r - tY .1 - t 4Y 0 SUR��y �9 1 > ti A'f',, s �o o c[ri ti .�� � �,• � sin\ � I tIMI � LSD � ., � t - �� N. �O �� Q lil° hh�dJO E Rio 2 sr qFj I�rEsr'9 �. r. ti 1 4 Via` 2o? ' AL ,r o SE y A No.10951 k; Iflo .9 /. FSS10N Kl + �9. Pa. 0 ._.-__..- 10 fV o �p\ Gtkacn-m-D 0EiVEVJA'f �I J + +, } 1 .o 0 J IiLI� rJtGT'i=\ 26 IOD�-F I VN ly 01 �/4 _ 80 a° q, LEG :ND" —=5 85' 42' ,o.. L'/ All EXISTING SPOT ELEVATION 0„O CERTIFIED PLOT PLAN ' EXISTING CONTOUR ----- ® --'— FINISHED SPOT ELEVATION FINISHED CONTOI�R O Lpr l D Lo-r lZ CµILDS �TAEET CENT avt IN APPROVED s BOARD OF HEALTH . 2wi�eC , oz3 I9 a3 DATE . . -AGENT .- I SCALE+ I '' 9 30' DATE+Ju�.Y LD E'L�GE ENglNEERl G Ca.IN [R.B Ba,vs►AL - „. I CERTIFY THAT THE PROPOSE® EG�I3TERE REGISTERED 831�.,, BUILDINGI SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS ENGI E R URVE J bD OF ®AitNISTA81�.E, MASS. 712 MAIN STREET A.A.MH-YANNI S, MASS. '00 .a ATE -EG. LANDSURVEYOR- � s F' No re /F F/.TNeR TANK OR GEAC.y/e!G P/T 4Re MORE THA:•✓ /2••®E4ow /D P7" M/ O��rq 24'p/•�i M E TER G ONCR E T� CO YE.� S,,WAZZ 8E BAOUcS Y7 TO GRADE. /,-;,Y EXTRA CO/VCf�L'7. 4'PYC P/Pd j�Fq uY C/�S T /RO/Y C o�/FR S',�A cope" F/TCN /F/rV DR VEyV.4 Y Y� % ✓r= C 4,V Jy," CYJrYCRET� " 4 E SA N JCAe 1!Q!0/D L E1ViC ti r t ; M1 2�4AYf R i 3 8 - /dT /MJN'PITGN GIG " t a. . , s . . . • o' •e' D/ST WA SHFO S?27NE !s' Arm TAAitCBoje ► • a d , . . ar 's ♦ f •°EFFECT/.VL • ♦ 4. � » ♦ • a♦ DGaTX'' ♦ • ' ip WA31dED STONE o v -� � a a,:. i:_ 0 • a • •' -• !!• 1, O � 6 a. - 1 ;. 'wfn yam, ♦' x t _ ,¢ �71 .::L-�/�x . s t,a . •". � • ♦ ♦ • O.♦ ,. PREC.45T,$E�.PAGe"_ a��/ K sr'..` x Sg 1S" S ` sa • e • • `• s a • �' 'ar P/7"OR EQU/V. jNt/gR'r.EL�EY.4T/DNs _ 794 5 X � Q -t 8s l�k f�„ � � � /� • � �L= Gp.c:�: _i S} i D/!- �. ;. x FT. D/A, At g OIJ�`LE g`SEPT C x ::.... TER,T r h� lllE�fE�"A/3TR/BUTIJ� 8Q?l FF °k _ SECTJB/i/ OF GRO N dt st9LE � D!•STRlBIITt�H�AX`3�.-'L F7' '`,#� 4,J&WA � LEACM1,VG` !�/T. �+ � ,IIcT, y Z. ,t.A C �� / a Tit�L'Lr1TZON � t/ll�l ER OF D,ECAJ DR 'aV V T 3 DIM�NS/OtV Ci �� �7• M tN Ta:T.at FTT/Msr'Eo FLOHI`33o G.6L:fDA� L TEST AI 3'O/L.7 ST ,P SNO/L '7116:f T MUM8F.?Q,/c 40ACXlJVG: Pl7S_ �" �LG'K `j5 5: ��-Et�B/R2AL Jv.�� . 2 i, 19 83. -e L TE T OF' SO/ ST Ct1tNG:.REAt P!T'` 188 ,S`a rT 1 e�Pe:n i SG/LTS WJTN--Ss--D jr ..icy I$. -', R 30£TCOMtF�ICX/N<r,P�RP/T { SQ, FT. -.n e. o,L.. . PeVCCZAT/D/Y AA-r—w T�Tr►G-"1�AGN//YG AREA 2�w ,Sq FT. Fae<�cot�� ioM R.47'� 2 lio H OF - C y tt. d2 AL HORSE w ,► f� �`� " �; �No..10951�4 Q HL0 RED az =NG1)V EzRl vc co /NG. 7/Z.MA/M ST. .YYF�.Vn!/S. rtilA�3. c • ,.Ev re t �..a� . 1ONA\ [] NO DUNS kV,4TCR WIV,COC/iVT��..® CL/E/r 'P .v�i G LINO T ELV. C` _ ? [� : RO L�iR.TE.P A . � " _ — 1. L O C-IT ION � SEWAGE PERMIT NO. VILLA IN T EQ'S NAME & AD,0N USS GUILDER OR OWNER — DAT E PERMIT IS.SII E D o ®`® ATE COMPLIANCE ISSUED f//wy _ �_ - _ _ o 4:-_, .;� �^� M, Y� P , P{ � , � � , ���� � �; � ' ,�- j'y��.� .� �� �� TOWN OF BARNSTABLE Lea:AT10I `� C�-I L I'�S ST_ SEWAGE # -;�00 V!UAGE� CLfv76z2yILLc ASSESSOR'S MAP & LOT `)9 " S INSTALLER'S NAME&PHONE NO. Lln- E. ,` -W2wss , S&^i Ic S&(4vicb SM J � SEPTIC TANK CAPACITY (o a v LEACH�IG FACIL=: (type) 1 ,6NC-Gl t S (size) 3 3•S-X td,s X NO. OF BEDROOMS BUILDER OR OWNER THA,�.(6:p-/ LVO is PERMITDATE:=�! 9uaJ— COMPLIANCE DATE: t J uv� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility f � 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 'roe 6 a G F tZC-AJ 0 F ptoQ IE ar � A-, a� P , p-Qax P SAS . . . _ hR y �7— TOWN OF BARNSTABLE t COCA ION SEWAGE # VILLAGE ` _ ASSESSOR'S MAP & LOT `aS 00 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1000 r� LEACHING FACILITY: (type) Q 1 , (size) NO.OF BEDROOMS BUILDER OR OWNER ?EFdWTMATE: tjjb�5 3_COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility O 0 Feet Private Water Supply Well and Leaching Facility (If any weUs exist on site or within 200 feet of leaching facility) N 'I Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 f et f leaching facility) Feet Furnished by rd f w, A-' -�' r V16 w � �y'2 33 FLOW PROFILE ALL PIPE ELEVATIONS SPECIFIED ARE INVERT ELEVATIONS TOP OF FOUNDATION RAISE COVERS TO WITHIN 6 in OF FINAL GRADE EL 55.78 +- ONE INSPECTION ESER FOR �i LEACHING GALLERY �D-BOX 2 1/2"ESTO ER OF I/8' 3- DROP FLOW LINE 10- = 14- 48- GAS�� PRECAST 5/4--1 V4' BAFFLE DRYWELL STONE BOTTOM OF 52.95+- 6 in SOIL ABSORPTION EXISTING STONE 51.63 LEACHING SYSTEM EXISTING BASE EXISTING 51.80 51.50 GALLERY Ewsn►�G 5.00 rt 1000 GALLON (END VIEW) a9.so EMSTNG SEPTIC TANK 39.5 rt a) 5 rt 12.5 rt b) 14 rr ADJUSTED 30.32 SEASONAL HIGH GROUNDWATER ITl L4 z c�x oW N <� Z >�,�i n r-� m r7-On _ a x �zz �ti N t°to 3 o�m D i c O,Z 70 t} 08 s v � $ g \ U3HS N N 01 lLn Z \ mm , \ mZ r No / N cnvD Z � lobZ o0 ( n my +1 G>3 rn v , N 3 -n $ a o>rn m qa < m u,N> 3 /a31�M y q)m Z C5 / \ m 7p nl n � m °oN Z GI 2 Z- 3c nr Z 0 ni Z N o as D , —I p_ 0 z ' C =� N � w m �o rm o >ile � m � Z 0 1 NJ ; m O = p � cn(n �g�� rn Z —i —4 n m g a , ''k m o mok o0 �N>o 0 � fTl = m � coMM ���m � mN o m von, If�t� mm m Z 0 R1 � �1 < �' c� ON/L ? � n'2 k nG)2 I v Se H � rl'I m rll vTO �1 n �-n -1 x 0 i v o < q"�° ITi 7cZ I cal 'L?.-4 tV 0) f1T z rt' c�D zp a S°= Z 5 >49V c v o cn C r z r CV �2�'Fo w �a�� zA o 1111H p z � 0 SE m � d siL�s � o 9>� co � � Z 3 p �� �l � O ® -� ` 13381 S S071HJ C7 �-'�� n z m rn 3A MVS31NN3)1 Y m o�� p = 3Amrm a� z �iz� � z r Z � > 3 N-1 y� Z o Z O _� r G Ill A9838MV2IlS vvm� Nun3 Z Z y 3 ,�, D CJ7 a DATE OF TEST: NOVEMBER 14. 2005 SOIL TEST LOG SOIL EVALUATOR: DAVID D. COUGHANOWR. RS DESIGN CALCULATIONS WITNESS REQUIREMENT WAIVED - NO VARIANCES SOUGHT NO GROUNDWATER ENCOUNTERED TEST PIT I PARENT MATERIAL: PROGLACIAL OUTWASH DESIGN FLOW: 4 BEDROOMS X 110 GPD - 440 GPD ELEVATION - 54.75 PERC AT 56 in : 2 MIN/INCH IN C SOILS SEPTIC TANK: 440 GPD X 2 DAYS - 880 GALLONS DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER USE EXISTING 1000 GALLON SEPTIC TANK IF IN SOUND STRUCTURAL (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING CONDITION. IF NOT. INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) 54.75 0-6 Ap LOAMY SAND 10 YR 3/2 NONE FRIABLE DISTRIBUTION BOX: USE 3 OUTLET D-BOX, 6-32 B LOAMY SAND 10 YR 4/6 NONE FRIABLE 52.08 SOIL ABSORBTION SYSTEM: A 33.5 ft x 12.5 ft x 2 ft LEACHING GALLERY CAN LEACH 32-64 Cl MEDIUM TO 10 YR 4/6 NONE LOOSE COARSE SAND Abot - (33.5 x 12.5 ) - 418.75 sf Asdw - ( 33.5 -, 33.5 - 12.5 , 12.5 ) x 2 - 184.0 sf 64-144 C2 MEDIUM SAND 10 YR 6/4 NONE LOOSE Atot - 602.75 sf 42.75 Vt 0.74 x 602.75 - 446.03 GPD NO GROUNDWATER EN O UNTEREDOUTWASH USE A 33.5 ft x 12.5 f t x 2 ft GALLERY. Vt - 446.03 GPD > 440 GPD REQUIRED TEST PIT 2 ELEVATION - 55.00 PERC AT 52 in : 2 MIN/INCH IN C SOILS EPTH SOIL USA SO((INCHES) HORIZON TEXTU EIL MUNSELL) MOTTLING SOIL COLOR SOIL OTHER LEACHING GALLERY CONSTRUCTION DETAIL 500 GALLON DR YWELL 55.00 DIMENSIONS AND DETAIL 0-6 A LOAMY SAND 10 YR 2/2 NONE FRIABLE WIGGINS CONCRETE 500 P GALLON PRECAST DRYWELL USE H-10 LNT LEACHING UNIT OR 6-36 B LOAMY SAND 10 YR 4/6 NONE FRIABLE EOUIVALENT INSTALL ONE INSPECTION STONE RISER TO WITHIN SIX 52.00 ,� INCHES OF FINAL GRADE 36-68 CI MEDIUM TO 10 YR 4/6 NONE LOOSE s'-s-X 4*-10-X 2*-9- AND INDICATE LOCATION COARSE SAND 2 ft EFF. DEPTH 33.5 f t ON AS-BUILT PLAN 68-126 C2 MEDIUM SAND 10 YR 6/4 NONE LOOSE rn 44.50 M '^ O O O O O O ° ul 0 33 00o Opp in N Q N o00000000aoo �OOpO NOTES 0000a0000a�oo pOp ly 1) GARBAGE GRINDER NOT' ALLOWED WITH THIS DESIGN 2) ALL LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM. 33.5 ft ��2 in 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15) 4) INSTALLER .TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM. 5) EXISTING LEACH PIT TO BE PUMPED, COLLAPSED. AND FILLED. OR REMOVED 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE GROUNDWATER ADJUSTMENT 7) LINES EXITING D-BOX TO RUN LEVEL FOR 2'-0' BEFORE PITCHING DOWN EXISTING GROUNDWATER LEVEL 8) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES BASED ON TOWN OF BARNSTABLE SEWAGE DISPOSAL SYSTEM PLAN AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK GIS DEPARTMENT RECORDS. -TO SERVE EXISTING DWELLING 9) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT EL LONG POND 26.12 PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. INDEX WELL MIW-29 DIANE THAYER & LEMORE LYONS IO) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. ZONE D READING DATE OCT. 2005 119 CHILDS STREET CENTERVILLE. MA II) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL READING 8.2 STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH ADJUSTMENT 4.2 ECO-TECH . ENVIRONMENTAL SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING ADJUSTED GW 30.32 12) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM REPAIR AND CHECKED 43 TRIANGLE CIRCLE SANDWICH MA 02563 FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE. ETE-2226 NOV 14. 2005 2/2