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HomeMy WebLinkAbout0038 CROSBY ROAD - Health 38 CROSBY ROAD Centerville - A=299-127 t 5MEAt No.2-153LOR UPC 12534 smead.com • Made In USA No. � 1 ' Fee (/�• THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftphtatiou for Noposal 6pstem Coustruttion 3permit Application for a Permit to Construct( ) Repair(/�/Upgrade( Abandon( ) ❑Complete System Individual Components Location Address or Lot No._::�&P C,P7 0,PR/t/ !C®, Owner's Name,Address,and Tel.No. Assessor's Map/Parcel o7o'P 5;' I�X 7 cl*1_ Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 7 7 1— Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 d gpd Design flow provided . tea gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank "7�i pri.ate /©® O Type of 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.4ealth. Signed Date Application Approved by ry . Ak liVz/,n_ L-C IiCj Date ?- t"1�_ Application Disapproved by Date for the following reasons - Permit No. a _l I Date Issued f7 No. z r".• 6? Fee / t��• THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1 Yes UBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS F 9ppYication for Misposal :patent Construction Vermit Application for a Permit to Construct( ) Repair(Upgrade Abandon( ) ❑Complete System Individual Components Location Address or Lot No C',or C f',,9/V 'cQ, Owner's Name,Address,and Tel.No. Assessor's Map/Parcel o�laZ 9 /�X 7 Gc�'✓T /y�yh�Ci Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: F Dwelling' No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building t:�R e--^ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 d gpd Design flow provided �� - gpd Plan Date �'-� o�/ -/© Number of sheets Revision Date Title Size of Septic Tank �'Xi s'Ti d' /o o O Type of S.A.S.J2?-OA- 0os•- 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 oflJealth. Signed Date 7 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ') d 1(' Date Issued ------------------------------------- ------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded Abandoned( )by at a d'�J' G 4e OJ'&,K jPT04.0 G e�✓1- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.W 0- 1( dated 7/)1 o Installer CT/I7j `G�.�34��j'` Designer Q4,W/4tP X%,/��s/✓�o #bedrooms -_'Ir Approved design flow- A �O gpd The issuance of thP-1 rmit shall not be construed as a guarantee that the system will Qh(ictio\"41 desigyj Date j� Inspector 6/�' S. No. a d t'� 'aL D Fee /L) c THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS Bisposal 6pstent Construction ernut Permission is hereby granted to Construct( ) Repair(� Upgrade( L) Abandon( ) System located at G o`7� 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 must be completed within three years of the date of this permit. Mac" Date a /0 Approved by f "�F�cY�'/f(�"��(� p Jul 21 10 O2: 20p p. l 'Town of Barnstable IWO r° Regulatory Services Thomas F.Geiler,Director rr►iu+srnrs�.�. Public Health Division jDr n.rar�°' Thomas McKean, Director 200 Main Street,Hyannis,MA.02601 Office: 508-862-4644 Fix: 508-790-63W lmstaller& Dcsi2ner Certification Torin Date: o►er: �1!I f .� �I Installer: 3CRIF 6 '6�L Address: . �ji � �L� k l Address: iz Oil ?� 2CII V �_1 �A1 _ C. _was issued a porrrit to install a (date) ` (installer) — septic system at j� 60vv _ . i based on a des*drawn by dated (designer)--- ` - 3.,cerlify that the septic systern referenced above was installed sub::taxil ally according to .he design, which may include minor approved charges such as late / relocativ�z of the d.istt2bution box and/or styptic tank. _ I certify/-that the septic system ref"erejaced above was itnstallod with':rrajor clxanges q.e. greater th= 10' lateral relocation of the SAS or any wx ic:d'relocation of any component of the scptic_gystean)but in accord,=c with State &Local Regetlations- Platl rovisio or, certified as-bu:1t by desi&er to follow. � H OF if 'V r cCS !v— DAVIDGy� . l3. unstallez s Sl€,uatuzc) NIASO �' No.toss saN1TO (IU er s Signature) (Axlix gner'.s Stamp Here) T PLEASE AS_E RETURN TO LA S7['A�X�l�"PUBLIC RCALTH U�'VxSI�St 114 C 'I'F, GE COMPLIANCE W11X NOT XF, ISSUED,UNTYL B0'Y'H:•"PHIS'FQ.RM�AN1) AS-- BUILT CARD ARE RF.Cvp'""'..')eHE 11AMNSTAIRLE PUBIJ!< MAIL D "3ZON. 11 l ANK YOU. Q; I;calttJRcplic/I)csi„nur('rr'tal.ic�tion.i'onn ° i TOWN OF BAIRNSTABLE LOCATION S � ���'>' 0FOA4 SEWAGE#o7o��-�/� VILLAGE C �/�T ram' I f e. ASSESSOR'S MAP&PARCEL --219 /a? 7 INSTALLERS NAME&PHONE NO. (55�/32 SEPTIC TANK CAPACITY 0"'0 ® O LEACHING FACILITY.(type),PXeWGAl 4-1ZOi' 104size) NO.OF BEDROOMS .3 OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: der 7- 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 �, � ��� �o, �, 3�, �- s� . _ G � �_�� � � �� � �' � C / -� �� 3 0 -4 Town of Barnstable P# 13° l.5 $ Department of Regulatory Services a Public Health Division Date ° �rtertits, KAM 039. �� 200 Main Street,Hyannis MA 02601 Date Scheduled Ild Time Lf— Fee Pd. Uv Soil Suitability Assessment for Sewage D'sposal Performed By: x Witnessed By: LOCATION & GENERAL INFORMATION Location Address !7 (y C JV J� �Oo�� Owner's Name j r V;4 k S QUA ,, 1r1`e- Address Tl � Assessor's Map/Parcel: a 9—�� 7 Engineer's Name,d1.t/S/t0 NEW CONSTRUCTION REPAIR Telephone# — 1J 97 Land Use -- AD\9.X—M Slopes(%) W Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wet nds.0 imity to holes) �I t � K Parent material(geologic) C155—1w,106t 1 Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face v v Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles; __. in. Depth to weeping from side of obs.hole: _ in. Groundwater Adjustment____________ .ft. Index Well# Reading Date: Index Well level _ Adj.factor— Adj.Oroundwater Level Observation PERCOLATION TEST Date-- 'I hne Hole �— Hole# Time at 9" Depth of Perc V , Time at 6" Start Pre-soak Time @ Time(V-61 End Pre-soak J�� Rate Min./Inch / Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel 42 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel cqgtj le J DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. C ns'stency. Graygl) ----------------- Flood Insurance Rate May: Above 500 year flood boundary No— Yes Within 500 year boundary No Yes Within 100 year flood boundary No iz Yes _ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? depth of naturall occurring er ious material? If not,what is the p g p AI ----� Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Envir mental Protection and that the above analysis was perfo ed by Ime consistent with the req ' training,expertise and a nc described in 3:10 CUR 15.017. Signatu Date Q:\SEPTICVERCFORM.DOC c COMMONWEALTH OF MASSACHUSE`I'TS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION h W ' d F yt \a 4, TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 38 CROSBY ROAD C NTERVILLE,MA 02632 Owner's Name: JANICE R GERS� Owner's Address: 703 GR EET,FRAMINGHAM,MA.017 Date of Inspection: 7/18/01 a t r Name of Inspector: (please print) JOHN GRACI RECEIVED Company Name: . SEPTIC INSPECTIONS Mailing Address: A RO BOX 2119 TEATICKET,MA.02536 AUG 0 7 2001 Telephone Number: 508-564-6813 FAX 508-564-7270 TOWN OF BARNSTABLE CERTIFICATION STATEMENT HEALTH DEPT. I certify that I have personally inspected the.sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally Passes _ Needs Furt a Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 7/18/01 The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.RECOMMEND PUMPING SYSTEM NOW. ****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. Titlo 5 Incnw•tinn Form r,il sr10n0 i Page 2 of I 1 t OFFICIAL INSPECTION,FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 38 CROSBY ROAD CENTERVILLE,MA 02632 Owner: JANICE ROGERS Date of Inspection: 7/18/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.RECOMMEND PUMPING SYSTEM NOW. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If not determined please explain. n/a 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. ND explain: n/a n/a 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 _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a 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 _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 38 CROSBY ROAD CENTERVILLE,MA 02632 Owner: JANICE ROGERS Date of Inspection: 7/18/01 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the,Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS''and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to'or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a ;. $ti a 9. 1r 3. 1 Page d ot'I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 38 CROSBY ROAD CENTERVILLE,MA 02632 Owner: JANICE ROGERS Date of Inspection: 7/18/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone t of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] _ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or,"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a'tiibulary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any;question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. ',_ie 9 Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART B CHECKLIST Property Address: 38 CROSBY ROAD CENTERVILLE,MA 02632 Owner: JANICE ROGERS Date of Inspection: 7/18/01 Check if the following have been done. You must indicate "yes" or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection '? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? I � X _ Was the site inspected for signs of break out'? X _ Were all system components;'excluding the SAS, located on site? X _ Were the septic tank manholes uuncdvered,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 ? X _ 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: Yes no X Existing information. For example,a plan at the Board of Health. X _ 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(3)(b)] a �P 0 at. Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM ?NSPECTION FORM PART C SYSTEM INFORMATION Property Address: 38 CROSBY ROAD CENTERVILLE, MA 02632 Owner: JANICE ROGERS Date of Inspection: 7/18/01 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 0 Does residence have a garbage grinder(yes or'no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: 6/1/01 COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CM 15.203)- n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a < TYPE OF SYSTEM X Septic tank,distribution box,soil'absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1985 Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 CROSBY.ROAD CENTERVILLE, MA 02632 Owner: JANICE ROGERS Date of Inspection: 7/18/01 BUILDING SEWER(locate on site plan) Depth below grade:30" Materials of construction:_cast iron _40 PVC Xother(explain): 20 PVC Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER AND A WELL SEPTIC TANK: X(locate on site plan) Depth below grade: 24" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle:30" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal—fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 I - Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 CROSBY ROAD CENTERVILLE, MA 02632 Owner: 3ANICE ROGERS Date of Inspection: 7/18/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspect ion)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): DISTRIBUTION BOX IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 CROSBY ROAD CENTERVILLE,MA 02632 Owner: JANICE ROGERS Date of Inspection: 7/18/01 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6'X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: nia n/a innovative/alternative system Type/name of technology: nla Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT APPEAR TO BE FUNCTIONING PROPERLY.THE PIT WAS NOT INSPECTED UNDER NORMAL USE.THE STAIN LINES IN THE PIT INDICATE THE PIT HAS BEEN FULL 6" TO PIPE. CESSPOOLS: (cesspool must'be pumped aspart of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a , Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a :7,k (1 Page 10 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 CROSBY ROAD CENTERVILLE,MA 02632 Owner: JANICE ROGERS Date of Inspection: 7/18/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. peck. 6 A< Sq3 PA a�3 gc �a /3W 4 � pSl t4 5 Y �n Page I I of 1 1 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 38 CROSBY ROAD CENTERVILLE,MA 02632 Owner: JANICE ROGERS Date of Inspection: 7/18/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain:n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12 FEET I_ TOWN OF BARNSTABLE LOCAT7;0N S WAGE # 1 .11 A N,Z,LLAGE ASSESSOR' F INSTALLER'S NAME&PHONE NO. SEPTIC THINK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: ��y&h Maximum Adjusted Groundwater Table and Bottom of Leaching Factli 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 byt'�\ �� '_ l Q ed- ® e 1= �� 8 A 4A N P<Sq FA35; 6030 cQ��� s. 2 p t fp i e t _ r _ - s i s -y. t-- e- i 9 .__ -- — — — — — --- -- k tCS .. . - - --- - ----- - --- - --- - _. ` 4 -�-� --- 1 '71 • ate. ----- -------- s 4 G h �5 -- gg- — F ..ey ; e l� A x r / F a FNJ r _ } 5 s p f4 J `a t t 57, ra it n 3 .. '� �..—,._,,,_,�'•rcvn caa.��se �_ .___. - -�` —_ 'a"e'rfl+'.e°�-�:a,�� -- � 'nr a. - -- I t No............... 7.-��y Fxs..... .��..... THE COMMONWEALTH OF MASSACHUSETTS �- BOAR® QF HEALTH v �/ r��y� `V � �y...- OF...... .��/.1.�`���•---.----•-----•- Appliration for Disposal Worko Tawitrurtiott Prrutit Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal System t ............�...................----------------- .. � /_ .................. tion-Address or Lo N . e Owner A dd res nstaller Address Type of Building Size Lot . Sq. feet aDwelling—No. of Bedrooms....................... ..........Expansion Attic ( ) Garbage Grinder VW:9 p� Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ----------------------------•-•• . • - ? W Design Flow............... _ ------gallons per person per day. Total daily flow._......... _Z.................gallons. WSeptic Tank—Liqui capacity.. ' allons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------�.......... Diameter------------ Depth below inlet.................... Total leaching area. 4..sq. ft. Z Other Distribution box ( ) Dosing to ( ) '-' Percolation Test Results. eems�.. Performed by-- s ' ® a .... �I7ate ---i� -- � as Test Pit No. 1...�_�xlinutes per inch Depth of Test Pit------ ,____- Depth to ground water..... ___. "( (z, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_-__-_.-._-____---.__-_. ✓ -•----------------------------------------------••-••••••...........•---• ----••. ............................. 0. Description of Soil -` �•--.... {��� "' �� -C. f. .................. x V ....---•-•-••-- ..... - --- - -------------------------------------•------•----------------------------------•----- W --- `"o""-.-�-------------- ��' ...................................-.............................................. U Nature of Repairs or A erations—Answer when applicable____________________________________________•-•--------•-•-_-_---___-____---__-•----•-------__. ----------------------•----.....-----------....----------------------------------------------------------------------•----- Agreement: The undersigned agrees to install the afor. escribed Individual S wage Disposal System in accordance with the provisions of iITLi� 5 of the State Sanitary ode— The undersig d f rther agrees not to place the system in operation until a Certificate of Compliance has been ' e b th boar f h. 4y 5 r Signed.......... ---- -- ---- --- --- - --- ----•---------------------- fff��� ----- -- -- -- / ate Application Approved By.... ...........• ••--- ....................................... ----- Date Application Disapproved for the following reasons----------------•----------------•---------------------------------------------------------------................ Date Permit No..........--. .r q- - .................. Issued-------� 1--Date ................... / s � � da THE COMMONWEALTH OF MASSACHUSETTS BOARD j F HEALTH ..----....OF...... .. .,� .'� Al"Oration for UWposal Worke Tomitrnrtinn Vantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System 2�- �. -------- ----- -- - - tion-Address - or Lot N ................... /�-�. :. a -.---------------- 1 t • ', `Ll�:.t..S......----••--- Owner ».� Address y s nstaller Address Type of Building - Size Lot:Z.!! _g Sq. feet V Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder (1-40 Other—T e of Building No. of ersons____________________________ Showers — Cafeteria Q' Other fixtures - - W Design Flow...............:... __...._..gallons per person per day. Total daily flow____-__- .J ----. ----------gallons. WSeptic Tank—Liquid*capacity............gallons Length............... Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width...........7....... Total Length.................... Total.leaching area....................sq. ft. Seepage Pit No......../---------- Diameter............ . ... Depth below inlet.................... Total leaching area.Za5 ._sq. ft. Z Other Distribution box ( ) Dosing t34 '-' Percolation Test Results Performed b `� _ ,�r ....,.. .._' 'bate..... a Y ,}. ... -- a Test Pit No. 1... �inutes per inch Depth of Test Pit......J.k...... Depth to ground water--_-- (, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water................... ------ -----•--•--•-•---•....•-•-••--•-•---------••------•................ ...•---••-••......••- D Description of Soil---------- '"= ~`„ , � "" = a-'_. x ----------------------------------------- U Nature of Repairs or A tlterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual S wage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersig d f rther agrees not to place the system in operation until a Certificate of Compliance has been e by th boar f h. Signed------....} •q fr -- --- --- ........................... � � t e ... .. Application Approved BY............ """ `=�................:....--- ^---•--------------•---.....--•------- ..............11 5R5R...... Date Application Disapproved for the following reasons:............................................................................................................... ---•-•----------------------------•------•------.....-------•--------------------............--------------•...•--••-•-•--••-•------•-•••--••----••.................................................... © t� Date Permit No........ .^. - ---------------------. Issued.--------+-�---r---.-.)-.:"..-3..4.-------- Date THE'COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........I............................OF..................................................................................... (9rdifiratr of Toutpliatta TH S IS TO CERTIFY, That the Individual Sewage Disposal System constructed O or Repaired ( ) by - - cY ---•---•.............•-••--•-•........-•••---••••---•-•----•-•--•--------•-•-•••-••-•-.....................................•••••......--•---.....--------••-----•-•-- Installer 1 u too has been installed in accordance with the provisions of TITIF 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----� ......... dated--------- rf-71ft................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C NSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................. ....... ... .. ................................ Inspector...... ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t.� ......................................OF...................... ............................................. , b ae, No......................... FEE........................ Uifipasal ' ==nrkii Cnni#rnr�uan rrntit f.!Permission is hereby granted-------- ' --•----•-------------------------------•----.....----------........................ to Construct ( or,Repair ( ) an Individual Sewa a Disgos System - ...--- •--•--------------••----. -----•----••---••---•------.............. 4-11 Street 9 ..o i 7 ls� - as shown on the application for Disposal Works Construction Permit No.--_�__�'�__ Dated......................................... ................ . .......-----------------------------•--•-----=••..._.........---••- Board of Health DATE................................................................................ FORM 125S A. M. SULKIN, INC., BOSTON — - — — • Z Z p O i Z C f a L _ � Yy� I/ t 36 - - - a- 3 L?s1L.Y ;rL0% .* a '110x3 nSPonAL o1T _Ks Gda Gam.. i .,dcwAA1. AMGA • 132 �F. 417 v ... . sF s Z.S 330 G.P.D. ,),t �► "r J- :. 80?r TCWA A¢UA• t 13 Sr-. 01 • 1.p • 11 �6.PD. b'h TCdTAL. 4vG616W•44370 . 'rn?a ��.1 u•r Fc.ow • 33a' 6►�• `� q GElZGO1.dT10�1 QATE S ��iy 1-mlW,0¢ . . rip.. • 4::"1� ; 6006ALSerntTi.►NC -, tt .,K OF yqs ° v, LEnR�+P,v.r• y . p WlLL6AM. Gj,� a , i=i i ^_ Lam• o N Y E 5c J , �I,L 41.2 23 068 v {° a. fl No. 19334 ;f _ 4iC L c 9 e/�• r f g9,85 19.3C 6A �0/STEM 'mil r' ® �44 su[l� �`kp;°rJ:,AL ,.1 7; 'REMovC' ALL UNSU«ggLE i { MA.Te?_k A L 'FO 2 l0 F E tT)O 1L { 1 �.�� �►erL'r��►.15 +C�3 92= Toy► �.w• ,q3,p T6 At sl'PAPA 1000 &#A •A �o•w�� i�1 Q'pivi �w. Gam. 39•S ti� a !. 5.,aao� "` \ IWIA Seem l0 4;,• , -GOO _ 39 u+� �• ` k .�� S • i w 1 Fly 5 win+ �, � ,• , .,. • 10 3f i,4•�'!i � A CEC'•TtF1E0 PI.oT_�L P'RpF'1L� LoUjT101J lr ►TER.Vl61-.R) ASS. 12• w o �e•i-i�'' . 7 Uovc/AT PL.A�.J RL�E�e:NGE LGrZTIFV T�dAT 'fNE�"�we U,Nbr 5"aw 1•IF.Ql:C�1 GoAOO'%P YS W1TK TOE, SIDEu� � 8 Awo SETUAC j:raUICEMc►JT� OF T►AC ?LAki FOCZ a'l ,5k "T''RU6T t ► z-rA-bL E �l.r.l*� �y 1�T 'DA'l ED Jv►.y '�3>�9b� Lae_ATEa wlr"lW E F�.o�� p�,e•i�.t. �•i�lE IBC. v�.•t� 10•t0, Xl"\ RCGtS'm-asm LA,IJD SUCv�?•`(�C r 'R.1►S PLA►1 IS nloT 6AS6b useo To � A► u5�.�,tE..c'r _ OSTECv�uk,G. O /�(a►SS. i Mb oFFSE'r5 'r x•b uO Bt t Su¢veY , ^r LIUeS ti9PLl C.AI�.JT 's. L,�• TQu��' ASSESSORS MAP : ';A �a - - TEST HOLE LOGS ;i _ NOTES: PARCEL: I Z� FLOOD ZONEP�,1 SO I L EVALUATOR• `1 . _. ._. WITNESS : Tl� 1) The installation shall comply with Title V and Town of Barnstable Board of REFERENCE ._._ '] DATE: 2Ca �-'01 Health Regulations. iuti , 2 The installer shall verify the location of utilities sewer inverts and septic PERCOLATION RATE:� W!� r ) f5' � P '~ components prior to installation and setting base elevations. t - d' _..�`���_��..�_�...��:;..;���-+_ _ �.���._1�,. � �`__, _ �'., J�- j•� 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first p TH- I TH-2 two feet out of the d-box to the leaching shall be levelavft�x�' . (-A 4) This plan is not to be utilized for property line determination nor any other purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. t � a 6) Parking shall not be constructed over H10 septic components. LOCATION MAP _ �• 1 7) The property is bounded by property corners and property lines. 8) The property owner shall review design considerations to approve of total ' design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed p y i approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean sand per PAP 0 Title V specs. I 10)System components to be 10 feet from water line. Sewer lines crossing the _ water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service SEPTIC SYSTEM DESIGN pp pp g line. The line is to be sleeved as aforementioned and maintained in place. 11) If a garbage grinder exists it is to be removed and is the responsibility of the FLOW ESTIMATE owner to ensure such. 12)The installer is to take caution in excavation around the gas line if such BEDR0OMS AT GAL/DAY/BEDROOM '- GAL/DAY exists. 13)The installer shall verify the location, quantity and elevation of the sewer SEPTIC TANK lines exiting the dwelling prior to the installation. �s GAL/DAY x 2 DAYS - GAL __ .�_ ---------- --- � �. USE I GALLON SEPT I C TANK� 15R�'j XPV0 OF41ssq DAVID o ) SOIL, ABSORPTION SYSTEM S c Q -- � t Z s2k 0-4 SIDE AREA: k: �p � w�/p N BOTTOM AREA: Ix1v�- a, 7 = 050 �--� s +4� gN1TAR��' EPTIC SYSTEM SECTION or 1 QQD GAL D �, SEPTIC TANK _ r SITE AND SEWAGE PLAN LOCATION ' PREPARED FOR : ' ' , OC ' SCALE• W DAV I D 13 . MASON " DATE: z DBC ENV I RONMEN AL DESIGNS w EAST SANDWICH . MA 3 DATE H ALTH AGENT W ( 508 ) 833- 2177 --