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HomeMy WebLinkAbout0024 ELIJAH CHILDS LANE - Health 24 ELIJAH CHILDS RD., CENTERVILLE l A= I ,i Slll J� c� UPC 12534 No. 2-153LOR HASTINGS,MN tNo. t�� q Fee THE COMMONWEALTFI OF AASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION =TOWN OF BARNSTABLE, MASSACHUSETTS Yes pplicattott for Th5pozar Q�pgtem Cottgtructtott �e 't Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑.Complete System Individual Components Location Address or Lot No. Cry/,/ZLP Owner's Name,Address,and Tel.No. C CST. ���✓ l�J�/'.l�o>./ TOE, Assessor's Map/Parcel /�� — �� �� `� �����(✓ �'Q'.a/.� d Ill Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building 40PZe'LP+ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 ® gpd Design flow provided 3 gpd Plan Date �� —/� — �� Number of sheets O Revision Date Title Size of Septic Tank �]1'�J'T�wC� `"®0 (5:XeType of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this j3pard of Health. Signe Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued I P bn Ll./J Fee�V �� THE COMM,ONWEALiA-6F-M"ASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION " OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for nizpogal 6p5tem Con0truction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑.Complete System /individual Components Location Address or Lot No.olZzLP Owner's Name,Address;and Tel.No. LP Assessor's Map/Parcel f Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building 44PZ`'.+ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date �� —✓��-/,Z Number of sheets i ./ ! # Revision Date Title 11 Size of Septic Tank .@`�(/J'�/�''l�' e�'�4&0 (=44e.Type of S.A.S. P4r4eg'" GR'. 4 A, 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 Apard of Health. Signe - ems' Date .0� 7— Application Approved by Date,. :2 �--- Application Disapproved by: Date for the following reasons Permit No. Date Issued 1 �--- -———— ———'—————— ---------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance >r THIS IS TO CERTIFY,that the On-site Sewage Disposal System-Constructed ( ) Repaired ( r) Upgraded ( ) Abandoned( )by OD". J Z46�0 &,,00r jyoeyJ"ic- at :L ✓ P Z-,^- has been constructed in accordance ) with the provisions of Title 5 and the for Disposal System Construction Permit No. QG/a 3 It 2 dated � � 1 Installer (7>?w Designer 4Vo44/® 4�? /j,Y�jJOp Or P #bedrooms a Approved design flow 3 C-1 gpd The issuance of this permit shal not be construed as a guarantee that the system/wiz` ff n t'I I igned. Date ��� Inspectof No. © Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS lwio pozal *- p5tem Construction Permit Permission is hereby granted to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) System located at y'i ,�G✓,-I./A C/�/L.C3 J' L�" c and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permiDate Approved I ) r�- ' Approved by DEC/19/2012/WED 10:47 AM SandwichTownOffices FAX No, l 508 833 0018 P, 001/001 'down of Barnstable sae rod Regulatory Services Thomas F.Geiler,Director 1 ' " Public Health division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508- 62-4 4 Fax; i)8-790-6304 Date: ��. tg Za(Z, Sewage Permit#a 39,9.A,ssessor's Map/Parcel Installer&Designer Certification Form Designer: l Q�j Installer: Address; _ � ��"� ��� Address: 141.,4641'S On �� was issued a permit to install a (date) installer) ' septic system at based on a design drawn by (address) dated 6 (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 distaibution box and/or septic tank, Stripout (if required) was inspected and the soils were found satisfactory. l 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 R r '-tions. Plan revision or certified as-built by designer to follow. SWpout(if r-, Acted and the soils were found satisfactory. OF DAVID I3_ C. ef—I(Insta ler's Signa l MASON ni 0 No.1066 �, /sT (D signer ignature) � r PLEASE RETURN TO BARNSTABLE PUBL, _�M fE OF COMPLIANCE WILL NOT BE ISSUED VN.L u, isu t q i twi ft,ORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice fomrsldesignerr ertificn6op fonn.doc TOWN OF BARNSTABLE LOCATION 47 J AA C111Z,t9 P SEWAGE# o7 Ufa �9 VILLAGE e ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. 0_-M /eWO---- A/f S -0 p� SEPTIC TANK CAPACITY XI PT' G o® 6r-We LEACHING FACILITY:(type) (size) NO.OF BEDROOMS 3 OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: .0oz- d=O �si6Ta� Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /2 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 (�-4*? � _ - pow ' Town of Barnstable P# Department of Regulatory Services STABLX Public ' c Health Division 200 Main Street,Hyannis MA 02601 Date Date Scheduled 4 Tine; Fee Pd: Soil Swab l A` k- �sAv��Y� ty sessm'erct or' Se Performed.13 1 "l ! i Dzsposal 2 =witfiessed By: LOCATION& GENERAL IFION Location Addressp7 /, ��o J�� !99 �j O��jjs,`� �1�GAssessor's Map/Parcel / — ' �7'� ®'d�i/O NEW CONSTRUCTION REPAIR3 cl> / /� Land Use Slopes(%) Surface Stones Distances from: Open Water Body____-,___ft possible Wet Area Drinking Water Well ____ft Drainage Way _ Property Line __ft ,• Others ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands n Proximity y to holes) Parent material(geologic) O Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Rabe Estimated Seasonal High Oroundwater Method Used: DETERMINATION FOR SEASONAL HIGH WATER TABLE Depth Observed standing in obs.hole: Depth to weeping from side of obs.hole: in. Depth to soil mottles, in Index,Well# Reading Date: Index Well level in, Oroundwater Adjustment_ ft. Adj,factor Adj.droundwnter Level;.,. PERCOLATION TEST bate�.�.� Thme.. Fof ,. mac[,! — Time at 9" c ;(� Timeat6"e @ Time(9"-6") Rate,Min./Inch �7j Y • i t ; 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 tube conducted within 100'of wetland you must first notify the Barnstable Conservation Division at least one(1) week prior to•beginning: Q:ISEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. o i to c % ravel to 0-7 o DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon SoiI Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel s i e DEEP.OBSERVATION DOLE LOG Hole# Depth'from Soil Horizon Soil Texture , Soil Color Soil Other Mottling (Structure,Stones,Boulders. Surface(in.) (USDA) (Munsell) o' Consistency. o Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other ' Boulders. Munsell Surface(in.) (USDA) ( ) Mottling (Structure,Stones, Consi ten .x t ' • i Flood Insurance Rate Map: S ` Above 500 year flood boundary No_ Yes ...�___ i Within 500 year boundary No_ Yes •4 s, Within l00 year flood boundary No_._ Yes 1 .� Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi terial exist tn,al('areas-observed throughout the area proposed for the soil absorption system? If not,what'is the'.depth of na rally occurring pervi us material? N' ° Certification G� ` I certify that on �� ` (date)I have passed the soil evaluator examination approved by the Department of Environ ental Protection and that the above analysis wasWperfornmiedd me consistent withthe requi ing,exper s and r" n d cribedin 10 CMR 15Signature Date ` Q:\SEPTICIPERCFORM.DOC TOWN OF BARNSTABLE LOCATION SEWAGE# VILLAGE e '-y0. ASSESSOR'S MAP&PARCEL��/ S"7 INSTALLER'S NAME&PHONE NO. TTi �'!�a �� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) P29 (size) NO.OF BEDROOMS 3 OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility A2 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 ro aJ a 441 000 COMMONWEALTH OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION _ ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 24 ELIJAH CHILDS RD CENTERVILLE, MA 02632 Name of Owner PETER BEST Address of Owner: 183 PRINCE HINKLEY RD CENTERVILLE MA. Date of Inspection: 8/21/00 Name of Inspector: JOHN GRACI i am a DEP approved system inspector pursuant to Secdon 15.340 of Tide 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 Telephone Number: 608-664-6813 FAX 608-564-7270 CERTIFICATION STATEMENT 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 inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date:8/21/00 The System Inspector shall su it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING NOW AND EVERY TWO YEARS. I revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 24 ELIJAH CHILDS RD CENTERVILLE Owner: PETER BEST Date of Inspection:8/21100 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nta 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. n/a The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,Is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nla Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced n/a The system required pumping more than four 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 V revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 24 ELIJAH CHILDS RD CENTERVILLE Owner: PETER BEST Date of Inspection:8/21/00 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. .I 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has aseptic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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,Method used to determine distance nla.(approximation not valid). 3) OTHER n& rf revised 9/2/98 Page 3 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 24 ELIJAH CHILDS RD CENTERVILLE Owner: PETER BEST Date of Inspection:8/21/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No ' X Backup of sewage into facility or system component due to an 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 1/2 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a 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 I 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level In the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: The system serves a facility.with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply iu X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone it of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/90 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 24 ELIJAH CHILDS RD CENTERVILLE Owner: PETER BEST Date of Inspection:8/21/00 Check if the following have been done:You must indicate either"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 None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been Introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the Interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 24 ELIJAH CHILDS RD CENTERVILLE Owner: PETER BEST Date of Inspection:8/21/00 FLOW CONDITIONS RESIDENTIAL: Design flow:_M g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):I Total DESIGN flow: = Number of current residents:A Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):JLQ Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NO Last date of occupancy: 6/30/00 COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: nLa gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):JLQ Industrial Waste Holding Tank present:(yes or no): KQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:n& Last date of occupancy: nLa OTHER: (Describe) nta Last date of occupancy: Wa GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no): If yes,volume pumped W& gallons Reason for pumping: Wa TYPE OF SYSTEM XSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: 1995 Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2/96 Page 6 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 ELIJAH CHILDS RD CENTERVILLE Owner: PETER BEST Date of Inspection:8/21/00 BUILDING SEWER: (Locate on site plan) Depth below grade: $Q Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: n/a Diameter: WA Comments: (condition of joints,venting,evidence of leakage,etc.) nla � SEPTIC TANK: X (locate on site plan) Depth below grade: 24 Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) Wa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ D& Dimensions: 1000 gallon septic tank Sludge depth: A Distance from top of sludge to bottom of outlet tee bF'baffle: 211 Scum thickness:-Z Distance from top of scum to top of outlet tee or baffle:-2A Distance from bottom of scum to bottom of outlet tee or baffle: nLa How dimensions were determined: measured Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) Septic tank and all components are structurally sound Recommend pumping system now and then maintained every two years- GREASE TRAP: o_ (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: nLa Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:iVa Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: Wa Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) ! a n/A +t revised 9/2/98 Page 7 of 11 I , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 ELIJAH CHILDS RD CENTERVILLE Owner: PETER BEST Date of Inspection:8/21/00 9 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Wa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) pia Dimensions: n& Capacity: n/a gallons Design flow: n& gallons/day Alarm present: MQ Alarm level:.Na_ Alarm in working order:Yes_No_ MQ Date of previous pumping: n& Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n& ri DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:level with bottom of pipe Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The D-box is structurally sound. PUMP CHAMBER: MQ (locate on site plan) Pumps in working order:(Yes or No): MQ Alarms in working order(Yes or No): MQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nla s 9 revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 ELIJAH CHILDS RD CENTERVILLE Owner: PETER BEST Date of Inspection:8/21/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nIA Type: leaching pits,number: 1000 gallon leach-pit leaching chambers,number: -n& leaching galleries,number: ji& leaching trenches,number,length: n/a leaching fields,number,dimensions: nla overflow cesspool,number: n/a Alternative system: n& Name of Technology: jVA Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION.NEVER MORE THAN 1'IN CESSPOOLS: - (locate on site plan) Number and configuration: n/A Depth-top of liquid to inlet invert: nta Depth of solids layer: Wa Depth of scum layer. n/A Dimensions of cesspool: n(a Materials of construction: n& Indication of groundwater: n/A inflow(cesspool must be pumped as part of inspection)nta 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:nta Dimensions:Wa Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& revised 9/2/90 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 ELIJAH CHILDS RD CENTERVILLE Owner: PETER BEST Date of Inspection:8/21/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house)` n/a l� �IkC �U Deck l�l O . � At BA sC, bB GL revised 9/2/98 Page 10 of 11 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 ELIJAH CHILDS RD CENTERVILLE Owner: PETER BEST Date of Inspection:8/21/00 NRCS Report name: nfa Soil Type: nla Typical depth to groundwater: n& USGS Date website visited: Wa Observation Wells checked: MQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) z, _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) Usgs maps and charts t revised 9/2198 Page 11 of 11 �TOWN OF BARN T °LOCATIOI�� �1 —`"� �� �EWAGE # VILLAGE \A ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) d NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 6 AA a 3 AC VK �° ASSESSORS MAP NO� � Y PARCELN DATE:_6L1_5-.f_95 PROPERTY ADDRESS: 24 Eli ah Childs Road 10 ------- --------------- i �pp Centerville Mass ------------- ------ 4 � , 02632 ------------------------- .. 19 .,4 On the above date, 1 inspected the septic system at the above ad This system consists of the following: A. 1 —jV'G0 gallon Septic tank: 13. 1 —Di i s.�x_�hution box. C. 1 -1000 gallon leach pit-. -Eased on my inspection, I certify the following conditions: A. TL'*s' is a title five septic system ( 78 Code ) B. System is in failure. C Needed repairs, to meet code. A. System pumped. B.- All covers raised-B. Tank,Pit,and Distribution box. Leaching pit installed. SIGNATURE: Name: J.P. Macomber Jr: Company:_J-P.Macomber & Son Inc. i Address: Box 66. --------------------- _— Centerville,Mass .- 02632 Phone: 508-775-3338 I THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY 1 JOSEPH P. MACOMBER & SON, INC. .Tanks-Cesspools-LeachfIelds Pumped & Installed Town Sewer Connectlons P.O. Box 66 Centerville, MA 02632-0066 775.3338 775-6412 �. 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION �-' CTION FO �RM , Address of property 2q L JatA Cc-4 `LpS fz Owner 's name Pe.�t / 9r ��°`Q C��T�2�l U, 6 Date of Inspection �U kA C 10) tqq`S PART A CHECKLIST Check if the following have been done: Pumping information was requested Health. of the owner, Occupant, and Board of -None of the system components have been pumped for at least two veCks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained available with N/A. and examined. Note if they are not available The facility .or dwelling was inspected for signs o� g f sewage back-up. The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on site., the The septic tank manholes were uncovered, opened a nd the septic tank was inspected for condition of baffleshorltees, Of material Of construction, dimensions, depth of liquid, depth of sludge, depth of scum. � The size and location of the SAS on the site has been determined on existing information or approximated by non-intrusive methods.based The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION $ PART B FORM SYSTEM INFORMATION FLOW CONDITIONS If residential �L number of, bedrooms number of current, residents garbage grinder, �- laundry yes or no T connected to system, yes or no 14avC v P -� Seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: i2E5E i,.�TZ. Last date of Y�civP�iEO occupancy EVCZ L am, T\,c 10 V E GENERAL INFORMATION Pumpin records and source of information: �'beT"E 5 5�v� ✓K �,p N�A-t l T�-�t rU P — system pumped as � if yes, volume part of inspection, yes or no Reason for pump ping:Type of system Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy -- Shared system (yes or no records, if an ) (if yes, attach Other y) previous inspecti(explain) on Approximate age of all components. Date installed,information: d, if known. Source of c Sewage odors detected when arriving at the site, yes or no g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued ' SEPTIC TANK: 10M (locate on site plan) ,, depth below grade: 1g'M 2q material of construction: Y_ concrete metal FRP other(explain] dimensions• !�,"' tO X -A-Cb sludge depth distance from top of sludge to bottom of outlet tee or baffle _2 scum thickness distance from top of scum to top of 'outlet tee or baffle distance from bottom of scum to bottom of outlet the or baffle. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) A ru VL00LC_p TA-3 rVZ ET"N CC0 U C O a20 i m O rl)— Loc»G E p L 1 K--F_ l'T' `=. DISTRIBUTION BOX: (locate on site plan) �5 depth of liquid level above outlet invert �. Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) L i ou i O oV E2 0 P50 GJ BI/ v eV 62P1 3(_+kE S 069Ees ' PUMP CHAMBER. (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but ma be approximated by non-intrusive methods) Y If not determined to be present, explain: vboT F Type leaching pits and number leaching chambers and number 1 _ ��� tV �tT leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number. Comments: (note condition of soil, signs of hydraulic failure, level Ofon condition of vegetation, recommendations for maintenance or repairsne,, tc. ) CESSPOOLS (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil,condition of vegetation, signs of hydraulic failure, level 'of pondin9, recommendations for maintenance or repair e s . tc. ) PRIVY: (locate on site plan) �l t materials of construction dimensions depth of solids Comments: (note condition •o f soil, signs of hyd_aulic failure, ' level of.ponding, ` condition of vegetation, recommendations for maintenance or re airs t ,etc. ) 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM j PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' 0 ,,0 � Q0 W c—T TI11 1'U lC)Q' + 16 DEPTH T • ::GROUNDWATER 71 , to gro ter method of: . determination or approximation: > fo QUA EC, SOS' - L a. x '� YMu..A .uw a .0�.w � • w 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) 40 Backup of sewage into facility? LODischarge or ponding of effluent to the surface of the round or surface waters? g ` S Static liquid level in the distribution box above outlet invert? 40 Liquid depth in cesspool <6" below invert or available volume< 1/2 day Y Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structural) unsound? substantial tantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: l�U below the high groundwater elevation? within 50 feet of a surface water? within . 100 feet of a surface water supply pp y or tributary to a surface water supply? within a Zone I of a public well? Lo .within 50 feet of a bordering vegetated wetland or sal (cesspools and privies only, not the SAS) ? t marsh within 50 feet of a private water supply l PP Y we 1• LO less than 100 feet but greater than 50 g feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water an alysis . for coliform bacteria, volatile grganic compounds, ammonia nitrogen and nitrate nitrogen. TOWN OF BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION - -TYPE OR PRINT CLEARLY- — -- - PROPERTY INSPECTED STREET ADDRESS L Q A%t-k ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Peter Best PART D - CERTIFICATION NAME OF INSPECTOR• E 1 7(L Sly L Lt V 64 W i y COMPANY NAME C0N.DgL)L7-7%21,rvT TU V C)S C_P 1 1717`A�{�O �r`Q '►.1 C COMPANY ADDRESS Box Street Town or City State ZIP COMPANY TELEPHONE ( 775-) 3338 - FAX ( 790 ) 1 578 - CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system al this address and that the information reported is true , accurate, and complete as of the time .of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. �„I.,�..':Y� w:. s . System FAILED* "TER The inspection which I have conducted as 4&u7id tat the system fails tc protect the public health and the a Zvi oti��i'� 3 icordance with Title 5 , 310 CMR 15 . 303 , and as speci f ical r+a c ��o^ � .P1RT C - FAILURE CRITERIA of this inspection form . x. SSt i � . Al Eti,,� Inspector Signature L7t .�_� Date �u�ES l S One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the 'inspection FAILED, the owner or operator shall upgrade the 'system within .one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.doc l3� "L � t � 'I"he Town of Barnstable • Ilealth Uepartment 367 Main Strect, Hyannis, MA 02601 1� Office 508-790-6265 Thomas A. McKean FAX 508-775-3344 Director of Public Health Date ---- 'Y 24�_ 1995 The onsite sewage disposal system located at _LOT-53_-24-ELIJAH'CHILDS-RD.- - JUNE , CENTERVILLE --- ----------------- --- - --- was Inspected on ------- UNE-2222,- ----1981--- and was found to be In compliance with the State Environmental Code, Title V. ----------------------------- --------------- Date SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART D CERTIFICATION Inspector : Peter Sullivan PE Location : 24 Elijah Childs Road Centerville Date :June 10,1995 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. truly yo 0 �, ., OF eter Sullivan PE PETER SULLIVAN `y Distribution: Pdo. 29733 Original to system owner `��'sTfifi„Q � Buyer "s'ONa L Board of Heath No......... � �� -- F$s.4....!Q............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratioit for Di!7,}iooal btu 1u5 Tonotrnrtion Vrrmit Application is hereby made for a Permit to COTIStruct ( ) or Repair)(X ) an Individual Sewage Disposal i. System at: C G ........2.4...FAij.ab...Childs-..Lana.............................. ••---••--- - ......... Location-Address or Lot No. P _.1a�$. ........................•-------•-............................ ................... •--••--•-------•--......--•--................................................. Owner Address GQtvber----Jx-............................................... ----...------------------...........................--•--•--........--------••--•-•-•-............ Installer Address dType of Building Size Lot............................Sq. feet U Dwelling-X- No. of Bedrooms----------------3-------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a+ Other fixtures .............................-........................................................................................................................ d gallons. W Design Flow............................................gallons per person per day. Total daily flow............................................ga W 'Septic Tank—Liquid capacity............gallons 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..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) •-' Percolation Test Results Performed by-------- ----------------------------------------------------------•------ Date...................................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water........................ c4 •-•---•••------•-------•----•-----•-----------••---•-------••-•.....---•---••---•-•----•••-•................•••-----••...---•••......---•-•-----.....-•--.... ODescription of Soil............................................................................................................................................................. .......... vSand.•&---Grave-1-•-...••------•......•••---•--••••-------••---•-•-••-•-----•--....••--•...••---.....-•-•----••-•.........••----......••_.. W ........................... ........................................................-................................................................................................................... v Addin an additional leach Nature of Fe airs or Alterations—Answer when applicable.................g._.............._......._._......._........_._......_-___-...-..___.-.-••--- pit t� an existing--.tank box...plt............................................... ..._. 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 bee jised b the boa stealth. Signed .... .. ._.. . 6./26./.95........ ............................ . .. l/.. 1�I..... ... Application Approved By ...................... ........ ,r�. ....... 'I ................................................................ Ua�e Application Disapproved for the following reasons: .......... ............................. ...............................................................................:.......... .............................................. ........................................ ...................Issued ........ .........Permit No. ............................ ........... ..� ........ ............ Uate THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Qlteltifirate of Q-Tompliancie THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired KX ) by 7.P,rtacom►-)er Jr at ..?.`�....�''.1 .j.a}1....Chi_lds....Tune.._Cent_ervi..-l.l..f..........................................._..... ..............................._................... ............... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Cod as described in the application for Disposal Works Construction Permit No. ��.- ."/_SCU. dated .� �. �/ " THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. Y. �y .......................... 7 Ins ec > .._....DATE.... . ....... ..... ........._.......__..._.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH < -a TOWN OF BARNSTABLE30 . No..l....... -�.:.. Uioposal Worko 101-lonotrnftinn Vprrmit Permissionis hereby granted....... ..J_r........................................................................................... to Construct f ) or Repair:f.X ) an Individual Sewage Disposal System 74 T, a all !7—hilds r one Qen at No...:.:- E...•--. = ' = =...ir>Y_rva.1 le ---• Street as shown on the application for Disposal Works Construction Permit N/o9��-1���ated__.._r�._ ?----- f�....... � Board of Health DATE------•••.............. ................................ __FORM 36508 HOBBS&WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE LOCATIONSE'WAGE 02 �' _4 VILLAGE/'U) 11e ASSESSOR'S MAP & LOT`7Ja� 7 INSTALLER'S NAME & PHONE NO. MACOmbe r Son--toe)c SEPTIC TANK CAPACITY [00 0 LEACHING FACILITY:(type)o7 ?b 4�$ (size) BOO Q. NO. OF BEDROOMS P L OR PUBLIC WATER BUi1.r)FP.OR Ow,JpR DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: r. �� • C U �� �3 (mil �� d$� � '�� � \ � \ / l �`� :t .� 0 ►1/b't'� t� J1�� � 3 0 No......... F�a...$.... . ............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiou for Di-ripwial Workri Tomitrurtiou rumit Application is hereby made for a Permit to Construct ( ) or Repair 4X ) an Individual Sewage Disposal System at: r/� ........24...Bl i.j_ab...Cbilds--Lana------------------------------ ........... ._...-•--•--------•------•------•-•..................-•-- Location-:\ddress or Lot No. ............................................................. ............................................................•...............................•..... Owner Address a ........ ...Jx--............................................. Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling-Y- No. of Bedrooms----------------3-------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures _______________________________ __ W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit_.................. Depth to ground water--.--...__.---_-_---.._. Test Pit No. 2................minutes per inch Depth of Test Pit_----------------- Depth to ground water_.................... . ----------------------------------------------------------------•-----------------------................--•------..._......----•-•-•-•-•---------•-----••---- ODescription of Soil........................................................................................................................................................................ v ........................................... and--&---Gravel-----------•-•----...--------------------------------------------------------------------------------••••--•------•••--••- W ------------------------------------------------------------------------------------------------------------------------------------------------------------........................................... IZ: Addin an additional leach U Nature, f Repairs or Alterations—Answer when applicable-----­---------- .......p---------•--.....an existing...tank box--- pit' 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 bee is ed b the boa ,health. Signed 6.f 2.6./.9 5 Application.Approved By ..... . l �/ .._...... - - /, Q�. Application Disapproved for the following reasons- -------------------------------------------------------------------------- -------- ---------- ----------------------------------------------------------------------- --------------------------------------------- ------------------------------------------ ---------------------------------------- Dare Permit No. g 7- ........... Issued -.- P�-------------------- Dare ——— -------------------------'r---- —————— t = . . No: .----- ....... j _ Ficit .` ... �............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Ubr.,Vwial Workii Tomitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair )(X ) an Individual Sewage Disposal System at: l • ..... .4. 1.ir ...S;h i sip... n� �.......................................................... Location-Address or Lot No. t............................................................. ............................... Owner Address WJ.4 P-,MAcQMb.P.:...Jr:..-• • ........................................-.......................................................... Installer Address d Type of Building Size Lot............................Sq. feet . V Dwelling-Y.- No. of Bedrooms----------------3-------------------------Expansion Attic Garbage Grinder aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 04 Other fixtures ------------------------------- -- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length-----------.---- Width---------------- Diameter-- Depth................ x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching.area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) �" Percolation Test Results Performed by----------------------------------------------------------- - ---:..-- Date........................................ Test Pit No. 1................minutes per inch Depth of 'Test Pit-------------------- Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------------------•--------------•----•---............_....._..---•--•-•-•---------••-•----------•--------------•--•------•-•------•----------------.--•-•- D Description of Soil - -n - --r ---e1 =. - - `{- - x Sand & Gav ................ W x Adding an additional leach U Nature f Re airs or Alterations—Answer when applicable................................. .............................................................. pit to an existing tank box pit. ------------------------------- ;........---•--------.......... 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 bee is ' edd b the boar health.. / � �� /K - --/26/95-------------------------------- Application. Signed ....... ..... ._ _...... ................ ------ ApprovedBy -------------------------- ------------------------------------ Application Disapproved for the following reasons: --------------................._..------------------------------------------------------------------------------------------------ - - - --....................._...........---------------.........--........._..........._------------------------..............---------------------------------------- - ........... Permit No. �"� .................'�� C7 - Issued -------...D�-------- Dare THE COMMONWEALTH OF MASSACHUSETTS N BOARD OF HEALTH TOWN OF BARNSTABLE CITWrtifira e of (ILlnmplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired tX ) by J.P.Macomber Jr - -.............. .. .--- --------- ---------------------------------._----------------- ------------------------------ ler at - 24Elijah,...ChildsLane --Centrvl7 . ----... e ...... --------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Cod as described in the application for Disposal Works Construction Permit No. ..._........_ dated ..t ?-���- .......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �* _... Inspector DATE....`" ' f..�--- ...... _----_----_------------------ ----_.-- _- --------- �� 7 --- -� . - THE COMMONWEALTH OF MASSACHUSETTS p� �� i BOARD OF HEALTH 5:- TOWN OF BARNSTABLE FEE. ..30, No.. ... Dispasal Workii (91injitntdion ermi� Permission is hereby granted-------J-.P.XaC0MbP__n-.J_•-d------------------------------------------------------------------------•---•------------ to Construct ( ) or Repair(X ) an Individual Sewage Disposal System at No.24 Elijah Childs Lane Centv --•-• -----•-- .....-•-------• ---- -. raJ.'LP ... Street as shown on the application for Disposal Works Construction Permit Nop�=�-���ated____�:_. .._�..��.._.�...____.... ------------------------------- • � Board of Health DATE................ -----------•------------•---•-•-••-•----------•----------... �4 FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, J.P.Macomber Jr. ; hereby certify that the application for disposal works construction permit signed by me dated 6/2 6/9 5 , concerning the property located at 24 Elijah Childs Lane Centerville meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. r SIGNED : DATE: 6/2 6/9 5 LICEN SEPTIC SYSTEM INSTALLER THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. L10 GA2sJoC 1✓ lbRl f.tb�IZ. eu . ��7-tc T+�t►L = 330.. ISo % • �35 6.Pt7. ioo-nO USA- l000 6A.t.. . PoSAL ' PIT - uSE loco (AAA-. 97.e M ' MaA - 1cj0 1�jp SF' E� rc 'Z.S , S-75 °so sr�. /Covcl .arwi.l`., t� r Tdt-A t- r ESIGtJ C. -�- r•N: r ,'TbTo t_ �Ql t_�f FLDW = 330'6.F'p. 0 I •� �� o : _� ? � Mlzcc)L&T.o c.l QATE : �r,t U 2�4{I IJ 0 2 1.aE5�S. ��. U1 B Z N G 'Aaaa 24 M/Aj. AlCrir,�r:� r'•' ;:,�fr4¢``';".�L s, �< . , ., LI..F.GT�-IG`p Gd. r 5w1T E i r r.1 •� Top I-uo z do to . /Z-� /R(j G• 1 .cRT7pTlJRc7i " 4- >1 ' LOAM .��PP� 1Ooo IIN M SuRSOl IPEs IW. Gruel. Z L'Q r it 4/p -btSfox.LIWv Tp►.l K L%Ar oPoT y r. W i T't-1 WA4kEU .� r 5T0►J�. O.D �' �' ' C-n ZTtFiEID PLOT PL.Aj� j F12.o1`1 LE� LOCATIOW •85 A3r uo Sc�s.t_�-.I . cAl_ ( i�� SO bATr— Igo �lIAT1r.2. �. ¢. GGtzX'l.t^ T14AT TNG 170010�aT1�N Stlo�vl.l PLAt.1 R 1'EIZEtJC� .' 14t.(7c7uni.•t ,cc�,,��1_�s wITI� -,rt-t`: 5(v�.u►-�E: Lcrr G3 AWI? 7C'Tl',AC OP T► C -Toww E3/S.XTt t2CGlS oSTE2.v%LLr= a IJ�f��:J•'✓ll:Wi iUt:./C:`{ 1i1C: c�Fl:�esr/i �jIIGWLD APPl_1 [.A.!-JT t�k,r cU_ Ul-,L(-:1 Tc, l)r.-._1'(:c_mr,4i= 1.0T Llwa..� r �•L ` 24 Elijah Childs Lane Centerville xi Existin 1000 it Existing -Box ` New = 4 0 . v rw _ r � \ � O = wo _� Z A N ` \ N N � r 1 N �......>[. .�i Fic$.....M�7..�: ... � THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...10...........OF........6 � ................................... Appliration for Uiipniial Workg Tnnstrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _ �1�J�/t�J r�s ation-Ad re s - or Lot No. _ .... ....... � ------------------------------ ----------- ------..........................--- Owner Address L� ' .......... �`�� 1........� :�-. .................................•------------- .... �. ....-•--------.....---•----•-•----.........---•-----.....-----•--- Installer Address Type of Building Size,Lot.... -�/-_,�.� .....Sq. feet Dwelling X No. of Bedrooms_-_---_-----•��----•--•-----___-••-_____-_--Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ---------------------------•-••• •- W Design Flow_._..` . ......................gallons per person per day. Total daily flow..__._.____...5_.�...................gallons. WSeptic Tank—Liquid capacity/l'K' gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—/No..................... Width__....._._......... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._.!- ___.. Diameter....P_X.��.._ Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box (✓) Dosinje tanil ( ) ' Percolation Test Results Performed by.. ....... ............... Date.... 2_-. .T.... '. ._.. a ,_� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------0............ Depth to gr nd water........................ 9 ....-•I.I. I ._. �... -•--••_.. ...-••-•....... . I . o c , z �--` n- ] Descr' o of Soil_... ._.. L �.!' Z...!-. x - ...... . _ -�;-01; 1 -- ----------------------------•-....._..--•---.---------------•-------------- W i -----------------------------------------------------------------------------------------------•••-•---••-......--------•-------...•••••-•---•-•--••-•-••-•••••-••-•..........................-•----.... VNature 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 i ITLL 5 of the State Sanitary Code—The undersigned urther agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of/'health. Si ed —:.; .....--•••-•-•..•••. •/ `// .........._.... y // ate Application Approved By--•- >� I •...••....._---•-_.... --.y� (R ...............Date Application Disapproved for the following reasons:...................... .......................................... .............. ---•---•---•--•.............•--------:....---•--•-•----------------------••••-•--......--•--•------....---•••••-•-••••••-•-•----.....---•-•--•--•-••----•-•-••••--••••-•-••--•-••-•--•••---•--•...-•••-- Date PermitNo......................................................... Issued....................................................... Date �1 N ................ Fits.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I ' f ...................OF..................................... . Appliration for Disposal Works Tonstrurtiun thrutit 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 UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of ersons__________________________ Showers a YP g ------•--------------------- P -- ( ) — Cafeteria ( ) Otherfixtures .----•-••--•------•---------------------------•-----•-.--•••...----•••••••••-•••••••••----••••-••-......._..---..._..-----._._....----...........•-_.. w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity____._._____gallons Length................ Width................ Diameter________________ Depth................ x Disposal Trench—No.____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter___..______..__._._. Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box (�' ) Dosing to ( ) a Percolation Test Results Performed by-__ _.__ ." __.___.,* .. ; . �_______________ Date_____t _' j_ __ "_Y_... Test Pit No. 1_____________...minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to gr. and water........................ a f r —"I t Descriptio of Soil ". x ' i'z w VNature 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 I-T 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sined -----------------------•-----••------•----....._.._. .-•---•••--•- . Date ,1y 4!,Application Approved BY �1- , _ •a " -i-i ^. -•- ---- ........... Date Application Disapproved for the following reasons:........................../.........._..................................................................... ...................................•-----....••-...----------.._..__.....••------ ------------------ Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. x %rrtifirab of Toutpliatta THIS IS TO CERTIFY -., - ---.......................................................• -----•-------------aed ( or Repaired ( ) Y � � That t�he� Individual Sewage Disposal System construe. -�•} � � ; t_ t< �e f " '-s " f= do f has been installed in accordanca'with the provisions of T "'jP) 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. �„' �_____ ......... dated...... ___________ THE ISSUANCE OF .THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIO SATISFACTORY. DATE...............---------------- z-'�I11 Inspector —.,� �- THE COMMONWEALTH OF MASSACHUSETTS j} BOARD OF HEALTH i X n +� No FEE.........._. (n Permissio s°-hereb ranted_.__ _ , "'* 4 _+_________________________________ -*_ Y g ..: =: --••.................................. to Constr ct ) Re it/ (( +) an}Indivi al Sewage�'Dispospt System at No. _: .•� ; t tit- .-- � , 't.�..... f' � r Street as shown on the application f4 Disposal Works Construction Permit; No___________________ Dated....... `."_`:.... _. f/ � /,"P / Board of Health fl• �---••-•~ DATE......... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS Il-`( 3 T72J��~V .+ 1.10 GA2H�i= GRI�,.b>E1Z. f' „=-... A��J,l�.t� Gb411..'C�6j �-�••�, /�/ � �E�r-Ic Yak = 330� ISo % • 5 6.P.0. ' uSeE�7 l OOCk OGAL.. (OC7'c0 tr 4 E. SUGWa AVG-A = IcjO S.F. lj x`v SD lw=. `1,c t .o vc/r�aT�vNt, t� ToTA�- •r.>GSIGN = d2S G.P.D!. ell 33O 6. � GEf1GDl.QT�,Ot.I tzh-m Cmj 2Mtu•ov- LP-%. a If4aaaO M f!d. t ;TAT fC-,LM--T LJG .Q •�V.. ��ry►� 4:r 10, P-41 ? �, - - I1, .. TOP F•ND -IC. 1 o-'f - Z/ U �L'G• 1-04 iN SJ sofL, PIS IW Zit uav TAQK Id ?G ,c, CsQL. 9G 2 U ; PI e•; :. • STo*J� O.D - r �. a� A9 H.0 5446 LOCATIOW t K: EL85 /3 A u o s SGAL --. ( - SO pATI✓ 'd B I gI 1J0 WA t~ ; GGtzTt,F -r&4A?' TI-Ia t-dulJ'►�aTlvl�l St-�orc�i.1 Pt_A11 R�Fcczc►�e� • ti••IF:1't=�1a ;Ccan.tPt_�(S W tT'E-t T►�`: 51Z7�.<..IN� ,. LD-r �'� Y h A►.�to 5E'i"l'9ACIG V:C4u10EtitEWTS OF T64C �. -TO W U, oT= -$A21� ABLE s� � lal•BI PA'rC _�__._ G. • h i 'M :ii' 7 T1115 C7 C:;A N 1!, �..!O'I• I,",A ACV+ v�-•i AN tIJSt'�:J!✓lC_tJ"" �,Ut_�/I_�! ; ~flat:. UFI-; I-�, rji•IGbJLD A ! JT PP tl_A.►- b U. U", "" j t' I s } , a 9 y: 1s 48'-3 " a':` •,nF •'S 4 ", a da'' ,w4� :;N:. �''i:" � >'A FLAT SCREEN ' WATER r 2t x 4„INTERIOR WALE SHUT OFF ' w/R-21 BATT I,NULATIONt CLOSET J"BLUE BOARD,AND ay/ RECREATION) %"SKIM COAT SMOOTH ROAM .\ ���,• - f PLASTER. 21-9"x 12'-6 • - , r � . IV 3q 6Ti-i STOR. y.4 z$ i. .• Yn -0'x 5`-0" I i 11 ELECTRIC ,:• I1 / PAN1=L y F-CHANICAL II W F RNAC E II cn � R � fl f� M ro $ STORAGE A0 1I , 5EDROOM#3 — I I TYKE X RATED SHtET ROCK INSIbr-' 21'-9"x 12'-6" �1VH STORAGE \. i I WALL OF MECHANIbAL ROOM:. it (11)9,READS \ M"x 48" (12)7-71$'RISERS CASEMENT SEWER,W.IPE p ....., ,...g. .. r ii-•y EdRES SILL HT 67" WINDOW II �• S K-B 1 gyp - _.. -• •;: - • - - _ NO. . REVISION DATE " BASEMENT PERIMETER E)(T�RIOf WALLS TO BE 2"x 4"METAL STUDS w/OPEN CELL INSULATION AND Y'.` cuENr: a GYPSUM BLUE BOARD w/ "'SKIM PETERCUSKIE Residence t COAT OF PLASTER, 24 Elijah Childs Lane Centerville MA 026329 E 1/4"-1' DEEP WELL EGRESS TITLE. BASEMENT ^ SCALE: 0" " Basement Floor Plan I _ REMODELED BA - ENT a....':.: a \AfiNDOW WELL W/ ' ' � FLOOR PLAN = '815kWE4'DOME COVER. _ - DATE:MARCH 21,2017 _ - - - - - MICHAELA.JIMERSON,A.LA. ARCHITECTURE&INTERIORS > 193 Horseshoe Lane IL .. .. ., 4' Centerville,MA.02632 - . 508 775-4264 - --• - - - majarch@comcast,net �r Rod&Shelf Y 5 WALK-IN CIO o CLOSET 11 GUEST. (5)12"Deep, I I BEDROOM Shelves I II r, Ord +.zv «�r�urYia I I HIGH BOY I I MAST DRESSER I I BEDROOM II DN a C WJ Z LINE ABOVE 4 2A U N o OU ro 8 ' xU" ermount DRESSERwl MIRROR C e Dp Soaki n a�of y, I I Rod&Shelf r ( m ) ( ® ) _��__________________ WAI-K IN 48 Al ' x 3 f- II I 1 CLOUT / ss I E sed _ I 1 how M xy - NO. REVISION DATE - -- � CLIENT: I PETERCUSKIE Residence 24 Elijah Childs Lane 1 i Centerville MA 026329 SCALE: 118"=V-0" Pro posed I st F Qor Plan TITLE EXISTING CONDITIONSTIONS �_^,: � . FLOOR PLAN ' DATE:MARCH 15,2017 MICHAEL A.JIMERSON A.I.A. ARCHITECTURE&INTERIORS 193 Horseshoe Lane ` Centerville,MA.02632 508 775-4264 majarch@comcast.net li ------------ ASSESSORS MAP : NOTES: 1-EST HOLE LOGS* 9\1 PARCEL: -71057 SOIL EVALUATOR1) The installation shall comply witli'l'itle Vaii(I 'l'owil ollm%ft3oard of FLOOD ZONE: AIV77 : I lealth 1�egtilatioiis. WITNESS : 719nd -11hm"11-7 verify the location of titililies, sewer inverts and septic hall ver REFERENCE: 2) The installer s DATE: 17, 1-7 .11110144*/ / .-I npoimits prior ior to installation and setting base elevations. *r PERCOLAT (ON RATE: Af/A/,//A/. I - cgs 3) All gravity septic piping to be inch Sch 40 IIVCat 1/8"perl'oot. 'Ilielilst two feet out of the d-box to the leaching shall be level. TH-2 4) This plan is not to be utilized for property line determination nor any other ...... purpose other than the proposed system installation. e-4 U04 ( in 5) All septic components must meet Title V specifications. --- 1 6) Parking shall not be constructed over I I 10 septic components.1 64t4 0 7) The property is bounded by property comers and property lines. -40/z 8) The property owner shall review design considerations to approve of total LOCATION MAP ....... design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shalt be deemed"-\777" approval of the design flow by the owner. 9) 'Flie existing leaching or cesspools shall be pumped and filled with material per Title V abandonnient procedures. Those within the proposed SAS shall too— be removed along with contaminated soil and replaced with clean sand per Title V specs. -A 011 10)System components to be 10 feet 1rom water line. Sewer lines crossing the -111N6 water line shall be sleeved with 4 inch SCI 140 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service line. The line is to be sleeved as arorementimied and maintained in place. SEPT I C SYSTEM DE*S I Gil 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. FLOW ESTIMATE 12)Tlie installer is to take caution in excavation around the gas line if such exists. Ll I BEDROOMS AT I I GAL/DAY/BEOROOIA GAL/DAY 13)Tlie installer slialLverify,(he location, quantity and elevation of the sewer lines exiting the dwelling prior to the installation. SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting 'I'itle V requirements. MOGAL/DAY x 2 DAYS J GAL USE 100()GALLON SEPTIC TANIVUJ 4alwWL (11Z� AULD OF -7, DAVID 1 0 1 B. L 2 1107 S I DE AREA: -A 6,1 AREA: 35 S T BOTTOM 2-5 7, t ql -SEPT I C, SYSTEM SECT ION 10 OF Or �bUW 0 Xt 4 Mir /ILJI, L D--Uu d 4B,t�l - SEPTIC TAIII s( 4� �L �0 —2-5 >e)Z 71 S I TE AND SEWAGE PLAN L -H 0 o C,A U/GIA-H 64M,D lz� PREPARED FOR : 60� �,�5rz m C 4- SCALE DAV I D B . MA! 301144- DATE: DBC EIAV I RONMEIATAL DES I GHS EAST SANDW I C11 . MA DATE HEALTH AGEN'r ( 508 ) 833- 2177 k1