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HomeMy WebLinkAbout0055 CROSBY CIRCLE - Health 55 Crosb Cent r y(C � , r e vine A= 188 _062 ' fi NL R .j R ++ois,n►G�,NN c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Crosby Circle Property Address r Williams 7 Owner Owners Name information is required for Centerville Ma 02632 7-1-19 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any' , way. Please see completeness checklist at the end of the form. Important: A. Inspector Information S -r3 When filling out ' I forms on the computer,use Douglas A Brown only the tab key Name of Inspector to move your D.A. Brown Inc cursor-do not Company Name use the return key. P.O. Box 145 Company Address Centerville Ma 02632 City/Town State Zip Code 508-400-7159 SI 4297 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7-1-19 Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system.owner and copies sent to the buyer, if applicable, and the approving authority. Please note; 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. t5insp.doc•rev.7/26r2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Crosby Circle Property Address Williams Owner Owner's Name information is required for Centerville Ma 02632 7-1-19 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: At time of inspection this system met all passing requirements. The leach Chambers were opened and found to be dry. This report can not predict the future performance under the same or increased usage. This report is not to be used for bedroom count determination. 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 I Commonwealth of Massachusetts P ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f� 55 Crosby Circle Property Address Williams Owner Owner's Name information is required for Centerville Ma 02632 7-1-19 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts r= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 55 Crosby Circle Property Address Williams Owner Owner's Name information is required for Centerville Ma 02632 7-1-19 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Crosby Circle Property Address Williams Owner Owner's Name information is required for Centerville Ma 02632 7-1-19 every page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) 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 Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Crosby Circle Property Address Williams Owner Owner's Name information is required for Centerville Ma 02632 7-1-19 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 55 Crosby Circle Property Address Williams Owner Owner's Name information is required for Centerville Ma 02632 7-1-19 every page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2017------204 2018-----237 gpd This system Is not designed for use with garbage disposal. Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp.doc•rev.7J26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 55 Crosby Circle Property Address Williams Owner Owner's Name information is required for Centerville Ma 02632 7-1-19 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commerciallindustrial 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Crosby Circle Property Address Williams Owner Owner's Name information is required for Centerville Ma 02632 7-1-19 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: s.a.s installed in 2-18-11 per as-built card Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑.40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 55 Crosby Circle Property Address Williams Owner Owner's Name information is required for Centerville Ma 02632 7-1-19 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: varying Distance from top of sludge to bottom of outlet tee or baffle Scum thickness varying Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): If tank has not been pumped in the past 3 yrs I recommend pumping at time of transfer and at least every 2-3 yrs there after for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Crosby Circle Property Address Williams Owner Owner's Name information is required for Centerville Ma 02632 7=1-19 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Crosby Circle Property Address Williams Owner Owner's Name information is required for Centerville Ma 02632 7-1-19 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): box was functioning properly at time of this inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 55 Crosby Circle Property Address Williams Owner Owner's Name information is required for Centerville Ma 02632 7-1-19 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 8.5x35ft ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 55 Crosby Circle Property Address Williams Owner Owner's Name information is required for Centerville Ma 02632 7-1-19 every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Chambers were dry at time of inspection 12. 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 55 Crosby Circle Property Address Williams Owner Owner's Name information is required for Centerville Ma 02632 7-1-19 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments uu� 55 Crosby Circle Property Address Williams Owner Owner's Name information is required for Centerville Ma 02632 7-1-19 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately I i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Crosby Circle Property Address Williams Owner Owners Name information is required for Centerville Ma 02632 7-1-19 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: none at time of perc test 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: 6-2019 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain.: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Crosby Circle Property Address Williams Owner Owner's Name information is required for Centerville Ma 02632 7-1-19 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. Z B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION 5S�Cwdy SEWAGE#2010_4!�:Z VILLAGE Cc tt[v.��� -- . ASSESSOR'S MAP&PARCEL 116-06 2 INSTALLER'S NAME&PHONE NO.-1&4,k, �ouy.t 1wC �,�A y2n�pS3t� SEPTIC TANK CAPACITY I OCO Q Isfi wb LEACHING FACILITY.(type) A rc_ 3C, 14 C t4-20 (size)a 3'X 3 f NO.OF BEDROOMS 3 OWNER�0 PERMIT DATE: 11'It;WL_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 300 feet of leaching facility) Fed Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY�yak�,w,J A tm-10- 1ZRCK aacl<,ylao" .k t- ti3,z 2-Y'7.S 3-w.g `J'194 VW-41.s 4G i 3 https://townof bamstable.us/Departments/Assessing/Propertyyalues/HMdisplay.asp?mappa... 7/9/2019 a I No. 9-o i o — Yq 7 Fee C V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS apptitation for mispoSal 6pstrm ConstrUttion Permit Application for a Permit to Construct( ) Repair(✓Upgrade( ) Abandon( ) ❑Complete System ��'nI dividual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. %� f ors Assessor's Map/Parcel j�-�,L ►� J Inssttalller's Name,Address,and Tel.No. Designer's Name,Address, and Tel.No. �%�.5� �✓r�W�1l�/lea` �N'peal t'Y'6i�V- �C�i/L Type of Building: Dwelling No.of Bedrooms .3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Ats Y No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided 173 gpd Plan Date L116 6c) Number of sheets ILI Revision Date Title Size of Septic Tank Type of S.A.S. "7PC 3c d c d io gs,& 3S 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 of Health. Signed Date /� hc jjo Application Approved by Date o Application Disapproved by Date for the following reasons Permit No. o -y 7 Date Issued 2 0 No. 0 I - 1 I , j a, Fee �U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4plitation for Misposal *pstem Construction Vermit Application for a Permit to Construct( ) Repair(vyUpgrade( ) Abandon( ) ❑Complete System Vndividual Components Location Address or Lot No. SS`(ro 51p�j 6 yc 1 e CF,.)4cy o N Owner's Name,Address,and Tel.No. Assessor's Map/Parcel I ffl- 2 3�ry t"S s, a � Insttalllelr's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.!i covew Y �t Type of Building: am. Dwelling No.of Bedrooms 'j Lot Size 17/1 _sq.ft. Garbage Grinder( ) f Other Type of Building �„�� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided 373 gpd Plan Date Revision Date 14&8� Number of sheets 7�, Title Size of Septic Tank F „�„` Type of S.A.S.-A/r Ir- -J Description of Soil Nature of Repairs or Alterations(Answer when applicable) i,,35#r, nI e w G A,S 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 of Health. ti Signed Date 7 6 O `Application Approved by R ., Date t A� lication'Disa roved b `" PP PP Y Date - for the following reasons Permit No. )L U /L -q 9 7 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(t/� Upgraded( ) Abandoned( )by I A,/Z. at k y (,4e ,o a r .p has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. o U_ 7 dated i i Installer U„�� � "! tom „` -("A„� Designer r #bedrooms Approved design flow :31 gpd The issuance of this permit shall not be construed as a guarantee that the system wi funct' n as designed. Date d2 '� 1 J Inspector Or 1<j -------------------------------------------.------_-________--------__-______________-__-_--______________-------_________-_-----------_ No. D0110 - y Fee 141 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS isosal *pstert�Construct[ou Vermit Permission is hereby granted to Construct( ) Repair( : ' Upgrade( ) Abandon( ) System located at ,1 S F p r,c y /",; and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction m ust be ompleted within three years of the date of this permi Date ( / A Approved by Town of Barnstable woe Regulatory Services SL Thomas F. Geiler,Director Public Health Division MAW ►'� Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: 2-/I-// Sewage Permit# Assessor's Map/Parcel 0 —® kQ Z Installer&Designer Certification Form Designer: Installer: Address: dl-e--<<'✓Pj WdAS r Y\ (. Address: �¢ _ C)-)c 1�Q 1 L w ems s ;-e 1 m( 12C4 J�11-Q M t_ On (, in was issued a permit to install a (d e) (installer) septic system at S (2f Z�i S t Cr,r _A� based on a design drawn by (addre s) � �e✓ Nam, �, �-dated (1 1 O (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. Stripout (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. Stripout(if re inspected and the soils were found satisfactory. ;(H OF M4 PETER T.; WENTEE 31: sler'tals Signature) v CIVIL, `� 9 No.3510910 Q �O,r FG�ST PF. � esigner's ignature) (Affix tamp 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. gAoffice formsWesignercer ification form.doc �. Town of Barn sta f Department of Regulatory Services i f Publ><c Health Division 'Da" . CJ U> v,. M Main Street,-Hyannis MA 02601 bate Scheduled 0 U Vine Fee Pd. c a. ICJ Soil Suitability Assessment for Sewage sposal [ Performed By: ✓ �AC E.t—q re Witnessed By: d t/,` w G A�: LOCATION&:GENERAL INFORMATION Location Address Owner's`Name 5- Cris�Y :;mac le e �fih�a )� C�dl Address S- ..Q.�-G' c( $)1� s-ems Assessor's YMap/Parcel: r Q 1 .. L' t,Nkz ,i.., . ,.Q�.3 7 g�' /© Z Engineer's Name 6 elf t�!1,C -1 _ NEW CONS RUCTION REPAIR" . Telephone# 3 7 7 „ .. Land Use'` $ (,�i.C✓t �-I Slo es '� ,11. �.� . p ( ) Surface Stones Distances:from: Open Water Body ft Possible Wet Area / G F �_ft Drinking Water Well ( ft Drainage Way U5,ff Property Line � �ft Other. ft 'SKETCH:(Street name,dimensions of lot,exact locations of test holes&_peratests,locate`wetlands in proximity Wholes)7.1 - -- 1 Z� s C 6,Y �t-z ' 3 ` Parent material(geologic) Depth t0 Bedrock Depth to Groundwater. Standing Water in Hole: `� Weeping from Pit Face Estimated'Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER'TABLE' Method Used: Depth Observed standing in obs.hole: In, Depth td soll mottles. Depth to weeping from side of obs.hole. in, lDepth to so moftle tneflt ft. Index Well.# Reading Date: Index Well level Adi.lhetor Actl:dttlufldwdterLeVpl,;,m PERCOLATION TEST Date- Time Observation J ' Hole# ( - ,t �tlGy`S Time at 4" _ Depth of Pere Z ' ' � �� t -���' Time at6" Start Pre-soak Time @ � S '15me(9`%6") End Pre-soak Rate MinJlnch Site Sui lability Assessment. Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1)week prior to beginning. Q:\SEPI'ICIPERCFORM.DOC ' DEEP.OBSERVATION HOLE LO'G Hole# Depth.from Soil Horizon Soil Texture: Soil Color Soil Other Surface{in.) (USDA).) ( ) Mottling, Stnicturc;$tones;.Boulders:. r t y �S -2 t v x • DEEP OBSERVATION HOLE'LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other USDA Munsell Mottling (Structure;Stonesi:Boulders. Surface(in.) Consistency, DEEP OBSERVATION HOLE LOG Hole# Depth from. Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell)' "Mottling (Structure,Stones,Boulders. catisistenylk-Gravell DEEROBSERVATION HOLE LOG Hole# Depth'frorn Soil Horizon Soil Texture Soil Color Soil Other Surf ace,(in.) (USDA) ' (Munsell) Mottling (SConsistency,100W) tricture,$topes,Boulders. Flood Insurance Rate Mau y Above,500;year flood bound Ni_ Yes "wtthi"n'S00 year'tioundary No Yes VJithtn 100 year-flood boundary No Yes Death of'Naturally Occurrent=Pervious Material Does at=least four'feet.of naturally occurring pervious tnaterial exisrn all areas,observed throughout,the area proposed for the soil absorption system? Ifnot,what.es the depth'of naturally occurring pervio materials _ ...r Certification 1 certifytliat on f (date):I have-passed the sotl_evaluator examination approved by the De artment of Environmental Protection and that the above anal sis was performed by me consistent with P _ y the :�anin peruse and expen,^ence-described in 0 CMR 15.017 ' Signature Date 1 _ t SEP t7EtPBRCF RM:DOC Q•\. TOWN OF BARNSTABLE 'LOCATION 55 C CUSBV C%,(c)am SEWAGE# 20JQ_4!�7 ,,VILLAGE ASSESSOR'S MAP&PARCEL -U�i INSTALLER'S NAME&PHONE NO. s--r2( -YS V SEPTIC TANK CAPACITY 1000 LEACHING FACILITY:(type) A f c %c. N C t4-20 (size) jq,S-X 3S__ NO.OF BEDROOMS 3 OWNER PERMIT DATE: 1 (,1 10 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 , ( ,�y� A 'ZACK vex-41-10' t- 13,2 , 2.-- y,,cl f y-7$,LI -Vo- zi.s ►�� �;yG t0 3 k VB....30 Ivo.._.J_ .-3.l,d.y ............._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH eAMOVEM TOWN OF BARNSTABLE App iration for Diopoii al Works Tom3 trartion Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sewage Disposal System at: ................1._5�.... .... ................... . ........................................................ Location-Address f`� or Lot No. Owner ^a ` p !Ad g Installer Address � Type of Building � Size Lot___________________________Sq. feet U Dwelling—No. of Bedrooms____._ ____________________ ...Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .................................. W Design Flow___________a gallons per person per day. Total daily flow--------- 535.0.................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—1 o. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------ ------------- Diameter--____/....... Depth below inlet...I?............. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ a ••-•-•----•-••••--------•-----•-•------•------••--•••-•-----------•------------------------••-............................................................... 0 Description of Soil............................................................................... -----------------------------•---...................................................... W U ------•--------•------•------•-----------------------------•--•--•••----••---------•••.......••---•----••-•----•-••----------•-•---•-••-•-•---------••••----•••-••--............---•-------••---......•. ---•---•---•-------------- -•--••••-------•--•••-••---•-•--------------•••-•---•=--•••...•-••••-••--•-•--•--•------------- ........................................ U Nature of Repairs or Alterations—Answer when applicable_.....� ! -.___-. XID Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i sued b; rd of heak4. Signed - - = --..------- ................... .......................... ................Date................. Application Approved By ----------- Dace Application Disapproved for the following reasons: ... ....... . ................................................................. ..... .............. ........................ --------------------------------------------- ------------------ --- ---- ------- -------- -------------------- ------- ---- --------------------------------------- ---------------------- ----------------- ---------------- ;te Permit No. ---... .oZ- -�-- Issued Dace ZFRz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 7-d -yz Appliration for Diipusal Works Cnnnitrurtilan ramit Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sewage Disposal System at: ........ ------- ........................................................ Location-Address or Lot No. .... - --l ........ .. - - ---•---------------•�'.....-W�. :.-...................................................... Owner wa � . .:- j r, �Address i I)s A ...._ .:.. _......... Installer Address Type of Building Size Lot....:. ....................Sq. feet U i. Dwelling—No. of Bedrooms..... ................................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building No. of persons............................ Showers YP g ---------------------------- P ( ) — Cafeteria ( ) QOther fixtures ------------------------------------•-•---------------.•-•••--------------•-••••••••--------••----•••••---------------------•-•.....------......--•--- W Design Flow-----------5 715— per person per day. Total daily flow.._.......�-�,.0.................gallons. WSeptic Tank—Liquid-ca.pacity..........._gallons Length................ Width.........._..... Diameter................ Depth................ x Disposal Trench—No..................:.. Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No---/------------- Diameter....___/0_..... Depth below inlet._12............ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) - ~I Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..................... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ C14 -••-----••----•---•-•---••-•------•-•-••-----•-•------------------------------------•---•........---......................................................... 0 Description of Soil.......................... x c, -----------------------------------------------------------------•-•---••-------------- W --------•--••--•--•---•-•---•••--••--•••---•-•--------•--•--------•---•----•--••=--------------•-•-----•------------•--=-----------• = .................. •---•-... U Nature of Repairs-or Alterations—Answer when applicable GdtT . .......... ..... (�I(. . ---r Agreement: -The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental 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: Signed A w --7" `.. :. ." Y - rs -- .. Date q ApplicationApproved BY ---------------- ?� ---------------------------------------------------------------------------- --------- V-. �Date - Application Disapproved for the following reasons: ---------------------------------------------------------- --- ----------------------------- ------------- .............. ------------------------_------------------------------------------------------------------------------------------.------------------------------------------------.-----------•------------------. --------------------- ------........ Date Permit No. Issued Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 01Pr#ifirate of (fo ttylinure THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired by = '' 0 =--�--- - --------57:e-� ........................................................------------------- ---------- ------------------------ Installer at G--Y b -------C.... G........---------------------C... =.!/1l'l has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .../--��...-_3 &..L--1_._.____.. dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU�D AS A GUARANTEE THAT THE • SYSTEM WILL FUNCTION SATISFACTORY. DATE-- ------------------=...... ------------------------------------- Inspector ----------------- � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 9 TOWN OF BARNSTABLE Disposal Workii Tunutrutiun tirruti# Permission is hereby granted------_---------_�_±��'1t�__.� ����-� ✓���� �C to Construct ( ) or Repair�(�..an Individual Sewage Dis osal System - at No------------------------------------- - - Ic v c�S 6-/- - e •-L-I--e. e--e-eA-7- ---------------------------•----------------------•----------------------------- Street as shown on the application for Disposal Works Construction Permit � ,U_ Dated.......................................... �y (��-,. -�-------------------------------------------------------- DATE. T `7 CJ Board of Health FORM 36506 HOODS Q WARREN,INC.,PUBLISHERS - a ti v TOWN OF BARNSTABLE C LOCATION lg' & CvrcvLbaSL C—OmGe_ SEWAGE # 9�-.�, 36Y VILLAGE_ ASSESSOR'S MAP & LOT $• 4� INSTALLER'S NAME PHONE NO. 5-�IC SEPTIC TANK CAPACITY LEACHING FACILITY:(type) f� -- -cpG' (size)„(Q NO. OF BEDROOMS PRIVATE WELL OR P BLIC WAT l/ BUILDER OR OWNER yyyys v—N\lmc"t-- oj DATE PERMIT ISSUED: '-J a V .^q DATE COMPLIANCE ISSUED: `7- 17 - / VARIANCE GRANTED: Yes No l.� Dq � �c1� 1(Q1C3-sk� 01T r ' `LOCL.TION- _ SEW.QC,E PERMIT MO. - -A-M-STAL L E R _U-W E 6--A D_.DR E S S- -- --- -- -- - D AT.E -COMPLI hJ ACE i A DGl No.------ Fink ... A.:.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........OF..............................I...... ----------------... ........................ Apphration -for :41-4pngtt1 Works Cnonstrurttvit Vrrnift Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal stem at: _ V' h ---------- Lo ation.Address or Lot No. t O�w er '1 ddress :.�:/.dl .t. ------------ � Installer Address Type of Building Size Lot_.__/®�a ___Sq. feet U Dwelling�-, ., No. of Bedrooms_.___J_�_t`�_____._�__�______________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons.--------------------------- Showers ( ) — Cafeteria ( ) P-4 Other fixtures -•---------••------------------•---------------------------------- ----•--•-••-----•-------------------------------- W Design Flow.......4_Z-�_------------------------------gallons per person per day. Total daily flow.....�®�__-----__--_-_____-.-.--_--.gallons. 9 Septic Tank—Liquid capacity-i'�.M gallons Length---------------- Width---_..--.-.._- Diameter---------------- Depth---------------- xDisposal Trench—No. .................... Width-------------------- Total Length----_-_.-_____--_ Total leaching area--------------------sq. ft. Seepage Pit No....../............ Diameter..... . ___. Depth below inlet____________________ Total leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.-------------------------------------------------------------------------- Date-----_------------------- ------------- a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water------------------------ IX4 Test Pit No. 2:_-_--___-_____minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ 9 --------------------------------- ------------------------------------------------------•--------------------------------------------------.................. 0 Description of Soil............................................................................................... -------•---••--•----•-••-------•---•------------------------------------ x -----------------------•-------•-- �� :� �" x -•--•--------- -----------------------------------------------•------------------- -•---•-• - ----------------------------•---------------------------•--------•-------••------•---------------- V Nature 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 Article XI 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. Signed---- �l' GI Date Application Approved BY -/Z�o ' ----- ate Application Disapproved fort .e following reasons:--------------------------------------------------------------------------------------------Da.-............... ------------------------------------------•--•---•---• -----------------------•-•-------•-----••---------------------------•----•-•--•------------•--.........:--------------------------------------- - Date 7 PermitNo. ,3-- ........................................ Issued..................... .................................. Date No......v E...... FEic............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... -_ -.. ._ ._ _........_......OF..................I..............................................................-------- Appliratiun -fur Uiuputittl Works Tomitrurtiun Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: •--•------•----------------•---------------------------------------------------------------------- ••--•----•-•------•--••--•----•--••••••-••-••••----•••--•-••-----•--••••-------•••--••-•••--•••-. Location-Address or Lot No. --••------•---------------------••------'---------•------••------••---•--••••••••'--••-•-•••'••• -•--•-•••-----•-•••--•--••--•-----••-•••••••••-•••••......•------•--•••-•••••••-•••-•••...•-•'---- Owner Address W -•-•--•--••----------•-----....--•---•----'•---.......---------•----------------••---------'----•- --•---•----•------------------•-------.......----------....--•-•--•-•---...-:--------._...-•------ Installer Address QType of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms_-----------------------------------------Expansion Attic ( ) Garbage Grinder ( ) PW-, Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) P4 Other fixtures ............................................ d ---------------------------------------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow --____________---__--_._--_______-..-._-.---gallons, WSeptic Tank—Liquid capacity--.-----_--.gallon Length---------------- Width................ Diameter_-.--..._-----__ Deptll.__._---__--. x Disposal Trench—No..................... Width-------............. Total Length-----_--____-..._--- Total leaching area------------------..sq. ft. Seepage Pit No.__.-_------------- Diameter-------------------- Depth below inlet.................... Total leaching area.---..-._-----_-_-sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by--------------------------------------------------- -----------------•--•• Date---------------------------------------- a Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water_...-_----_._--.--._..-- �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-.----.---.-_------.-_. r+ •--------------------------------------------------•---------------•-----------•-----•--------•---- .................................................... 0 Description of Soil----------------------------------------------------------------------------------- ---------------------------------------------------------------------------------- Ux - °.-........ 1----------------------------- ----------------------------------------------------------------- ------------------------------------ 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 Article XI 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. Signed-------------------------------------------------------------------------------------- ................................ Date Application Approved By......... ...:l� ---------- 1--../ccv------- Date Application Disapproved for ie following reasons:----•--------------------•------•--•----•------•---------------------------------------------------------------- ••--•--••••••••-•••-•••...••-•...•-••-------•----------------------------------------••---•--••-•-----------•----•---•-•--•------•----------------------------------------------------------------•--- Permit No.__k3�`�f Date ----------------------------------------- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0 .../......................... ..... ................................................................. C�prfif irate of f�uutli�tnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) CS - .09'�e/' c.. 1 lr �pu SG�` -------------------------------------------------------------------------------------•--- Installer /ate ���S �I /�r< has been installed in accordance with the provisions of Article of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..... �,�-I_______________________ dated...._--__-__.____--_--__---__-.................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................................................------•-----•-••••-•-••••••• Inspector------------------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH LGc /..............OF....... .. .- No........ ........ FEE..f................................ Binpuiittl Workii (lIunitrurtiun Vrrmit Permission is hereby granted--------------J 1 . .........---------- -- -----••----._......----•---------------........----------•-------•---•- to Construct or Repair ( ) an Individual Sewage Disposal System at No............/ -..... ...... -----•----- / l/T��ii�l! ` �Sa ----------------------------------------------- Street as shown on the application for Disposal Works Construction Permit No.�j 3�f________. Dated_.__f.�._-__1f--_75----------- •---------------•--••-••-•-••--•--•------- - /� Board of Health DATE.....A--------------- -------------------= FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS BY DATE ril.:JLGI _.. .. ..,....�. ... ',SHEET NO. OF t.�1 lt� Y DATA'.. JOB tYD. L)P, V 1. kGFt; PLT Wit' OF-MUG' ya y 2 4T4 �. -- ion• orr --.�� SNc4VitJL wov 14,lq")< }eye. v r, G jA j L ,r1• jf. !� elf- r ' N LEGEND 98 ——EXISTING CONTOUR Bumps River Rd e�9 ® x 100.98 EXISTING SPOT GRADE c� end Z W EXISTING WATER SERVICE N Pie' G EXISTING GAS SERVICE 1� U UNDERGROUND WIRES Q QG s a TEST PIT 9 I a_ BENCHMARK ��9 LOCUS church Q�'P Bacon Lane Hill Rd x 8.3.4 4rO �b LOCUS MAP / ' NOT TO SCALE / // /' 104.95'/' // // i /83.81 x to OY �/x 98.32 / / x 901.98 i O ;P, o qy c3y� / j°�`-�-t NSPECTION/ ORT 62' W ENT // ' ' Of /awe INSTALL 40 MIL POLY LINER , ��y , / f� . edge TOP OF LINER, EL.=93.5 �/ ,� �oil / +101,10 BOTT. OF LINER, EL.=91.5 +. 9�`66 k / N tQy �� '101.53 `O 4_0 r x 8/43 x 9.4 cA TP-1� / c� 9417 , 4 9/ dD ' \ ''2 .99.03 0 0 °' / CB S;36'21" W A�.i// 103.05� 9GA HO ST100.00' � — 5.00' pLLY01 99)47 101,63 g8,8s _ TO BE PUMPED, FILLED W/ /// ��•....... } \ `�� SAND AND ABANDONED. ' tl A5.25•.+ / FLAG RET. WALLS EXISTING SEPTIC TANK �Z / g,BM OLEO _ & GARDENS TOP OF TANK, EL-=96.69 --- i .' / INV.(OUT) = 95.36t % 7'18 Q 98.86 I.84 9E/'57 S I WALK 104.26` 5.31 + i ]O4.25' I WALK x 1)2.39 BENCHMARK SET DEC T I/ 10 , OUTSIDE COR./CONC. PAD x , iEXISTNG EL.=97. 18 (Assumed) 94.91 HOUSE(#55) Cn 0 98 8 T.O.F.=84.Ot t;, 4 cn + 96---- :o//�'5 'O N PORCH GARAGE rrl r), p .0 / 104.52 0 \ 10 3.7 0 104.55 \ 9 - to 8 , \\ D z 104.20 \ Nfl x3 03.38 -- 1001, 6 : A 188-062 3 LOT 6 (PB 303\ — PG 61) LOT 15 (PB 99�\ PG 13) o �= TOT L AREA=20,803tS.F. Lu 0: x LAMP cn 101.11 10 62 - 100.00' "-, oil S 37-20'40" W UP ----- edge 0 PO 103.84 0 104.09 103,30 _V1 CROSB Y CIRCLE nn PROPOSED SEPTIC SYSTEM UPGRADE PLAN 55 CROSBY CIRCLE, CENTERVILLE, MA OWNERS OF RECORD Prepared for: D.A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 o REGISTE��`� F`' BURGESS, CYNTHIA & Engineering by: SCALE DRAWN JOB. NO. F E CURRIER, MARTHA S Engineering Works, Inc. 1"=20' P.T.M. 208-10 5 LADYSLIPPER LANE 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. lya l rf td OLD LYME, CT 06371 (508) 477-5313 1 1/18/10 P.T.M. 1 of 2 +I NOTE: TO PREVENT BREAKOUT, A 40 MIL POLY LINER SHALL BE INSTALLED AS SHOWN ON SHEET 1 AND SHALL EXTEND 5' BEYOND THE ENDS OF THE S.A.S. TOP OF LINER, EL.=93.5, BOTT. OF LINER, EL.=91.5 SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. INSTALL RISERS & COVERS OVER INLET INSTALL WATERTIGHT RISER & INSTALL INSPECTION PORT OVER END UNIT T.O.F. AND SET TO 6" OF FINISH GRADE. COVER SET TO 6" OF GRADE PROVIDE ACCESS TO GRADE OVER OUTLET COVER CHARCOAL ,] EXISTING F.G. EL.=98.0t F.G. EL: 96.Ot F.G. EL: 94.8-97.8(MAX.) VENT � MAINTAIN 2% GRADE MIN. OVER S.A.S. INSPECTION L = 43' L = 7'(MAX.) PORT ® S=1% (MIN.) p S=1% (MIN.) 4"SCH40 PVC 4"SCH40 PVC s"LY io"I 6 10.75" TO ff i4" INVERT EXISTING 40" LIQUID INV.=92.40 I ; ADD LL 3 ROWS OF 7 UNITS AT 5.0'/UNIT = 35.0' GAS INV.=92.77 PROPOSED INV.=92.60 INV.=95.36t D-BOX SOIL ABSORPTION SYSTEM (PROFILE) EXISTING SEPTIC TANK EXISTING (3 OUTLETS) ESTABLISH VEGETATIVE COVER BACKFILL WITH CLEAN NATIVE OR PERC SAND TO TOP OF CHAMBERS NOTES: E TOP ELEVT=92 83 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INV. ELEV.=92.40 INVERTS, PRIOR TO INSTALLATION. 2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE BOTTOM ELEV.=91.50 -~ ON A MECHANICALLY COMPACTED SIX INCH CRUSHED =-83- STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). 5' MIN. SEPARATION 3) INSTALL INLET & OUTLET TEES AS REQUIRED. TO HIGH GROUNDWATER EFFECTIVE WIDTH=8.5' 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE NO GROUNDWATER, EL=83.2 _ EXISTING MATERIALITABLE AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. _ USE 3 ROWS OF 7-ADS Arc 36HC UNITS WITH NO SEPARATION BETWEEN EACH ROW & NO STONE SEPTIC SYSTEM PROFILE TYPICAL SECTION N.T.S. SOIL LOG DATE: NOVEMBER 19, 2010 (REF#13,048) GENERAL NOTES: SOIL EVALUATOR: PETER McENTEE (SE#1542) 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL WITNESS: DAVID STANTON R.S.-HEALTH AGENT BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS Elev. TP- Depth Elev. TP-2 Depth OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE 94.2 A 0" 94.5 A 0" LOCAL RULES AND REGULATIONS,_.EXCEPT AS-REQUESTED BELOW: �- ----- - - " 310 CMR 15.405(1)(b): SANDY LOAM SANDY LOAM 1) A 2' variance to the 3' maximum cover over an S.A.S., for 5' cover. 93.7 1OYR 4/2 6„ 94.0 IOYR 4/2 6„ 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR B B TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE LOAMY SAND LOAMY SAND DESIGN ENGINEER. 1OYR 5/8 1OYR 5/8 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 92.2 24" 92.2 28" FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN C C ENGINEER BEFORE CONSTRUCTION CONTINUES. 42" 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. PERC 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 54" THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. MEDIUM MEDIUM 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. SAND SAND 8. THERE ARE NO WELLS WITHIN 100' OF THE PROPOSED S.A.S. 2.5Y 6/4 2.5Y 6/4 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE 83.2 132" 83.2 132" DIRECTED BY THE APPROVING AUTHORITIES. 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY PERC RATE <2 MIN/IN. ("C" HORIZON) THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING NO GROUNDWATER OBSERVED CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND 63.25" REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. 16" 34.5" DESIGN CRITERIA TOP VIEW 60" NUMBER OF BEDROOMS: 3 BEDROOMS END CAP END CAP SOIL TEXTURAL CLASS: CLASS I FRONT VIEW SIDE VIEW END CAP DESIGN PERCOLATION RATE: <2 MIN/IN REAR/TOP VIEW DAILY FLOW: 330 G.P.D. NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT SIDE VIEW DETAIL MAY DESIGN FLOW: 330 G.P.D. TO ERA ODUCT SLIGHTLY NGE NOTICE. ACTUAL UT RPRODUCTT APPEARANCE. GARBAGE GRINDER: NO 111111111, 4640 TRUEMAN BLVD EXISTING SEPTIC TANK: 1000 GALLON CAPACITY e HILLIARD, oHlo 43026 Arc 36HC DETAIL EXISTING PROPOSED DISTRIBUTION BOX: 3 OUTLETS MINIMUM ADVANCED DRAINAGE SYSTEMS,INC. UNITS MUST BE STAMPED H-20 LEACHING AREA REQUIRED: (330) = 445.9 S.F. PROPOSED SEPTIC SYSTEM UPGRADE PLAN .74 55 CROSBY CIRCLE, CENTERVILLE, MA USE 3 ROWS OF 7-ADS Arc 36HC UNITS WITH NO SEPARATION BETWEEN EACH ROW & NO STONE Prepared for: D.A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.80 SF/LF OF UNIT) Engineering by: SCALE DRAWN JOB. NO. En ineerin Works, Inc. NTS P.T.M. 208-10 (Arc36HC Units) 21 UNITS x 5.0 LF x 4.80 SF/LF = 504.0 SF 9 9 DESIGN FLOW PROVIDED: 0.74(504 S.F.) = 373.0 G.P.D. 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. (508) 477-5313 11/18/10 P.T.M. 2 Of 2