HomeMy WebLinkAbout0010 FAIR OAKS ROAD - Health 10 Fair Oaks Road
Centerville P
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UPC 12534 '
ljS!LU53_L0R •
HASTINGS,MN
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
LRE-1
2004
RNSTABLE
TITLE 5 DEPT.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION (�
Property Address: 10 Fair Oaks Road MAP - `a
Centerville, MA 02632 OC o o
Owner's Name: Joan Rook PARCEL 1 __
Owner's Address: LOT
Date of Inspection: March 3, 2004
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
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 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:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: March 6, 2004
The system inspector shall subm 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
****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.
Title 5 Inspection Form 6/15/2000 page i
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 10 Fair Oaks Road
Centerville, MA
Owner: Joan Rook
Date of Inspection: March 3, 2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
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.
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:
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:
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:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 10 Fair Oaks Road
Centerville, MA
Owner: Joan Rook
Date of Inspection: March 3, 2004
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
"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:
3
Page 4 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 10 Fair Oaks Road
Centerville, MA
Owner: Joan Rook
Date of Inspection: March 3, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either`yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for 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.]
No (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 System:
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
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- I WPA)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.
4
. Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 10 Fair Oaks Road
Centerville, MA
Owner: Joan Rook
Date of Inspection: March 3, 2004
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant, or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS, located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 10 Fair Oaks Road /
Centerville, MA
Owner: Joan Rook
Date of Inspection: March 3, 2004
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: 2
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)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records_ 1
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed 8129186-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 10 Fair Oaks Road
Centerville, MA
Owner: Joan Rook
Date of Inspection: March 3, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 20"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
• Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 10 Fair Oaks Road
Centerville, AM
Owner: Joan Rook
Date of Inspection: March 3, 2004
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
• Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 10 Fair Oaks Road
Centerville, MA
Owner: Joan Rook
Date of Inspection: March 3, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -6'x 6'(1000 gal.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
The pit had Y of water on the bottom. The scum line was 3'6"up from the bottom. There did not appear to be any signs of
failure. The bottom to grade was 86". The cover was F below grade.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
9
• Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 10 Fair Oaks Road
Centerville, W
Owner: Joan Rook
Date of Inspection: March 3, 2004
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.
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10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 10 Fair Oaks Road
Centerville, AM
Owner: Joan Rook
Date of Inspection: March 3, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +/- feet
Please indicate (check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked date of design plan reviewed:
Y �P � g
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately
25'+/-to groundwater at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
I
TOWN OF BARNSTABLE
LOCATION ® �Al
r04 SEWAGE # �6" G
VILLAGE (,2✓4r-"VA ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. 6�
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) P�7- �o X (size) U►!b
_ NO.OF BEDROOMS 3
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 leac 7 facility) Feet
Furnished by
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No.-&&..SS? d Fas....
THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH
.W.0 f..........OF......... ..AW. /.. . ... . . ..
o V' Purkiun for Disposal Work Tons#.rudiun rrrmit
\ Application is hereby made for a Permit to Construct ( or Repair ( ) an In ividual Sewage Disposal
System at: � R
................__.... V1.2
n-...dress ...._... .. ... ... ....... -- -- ------------ .
................_..__ L:. ... e. ........... ..1�, ... ° ` .........._........__..._.�.....
• ow Address
Installer ��� q.
Address �-�
Type of Building Size Lot............. ..........S feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Gar age Grinder ( )
aOther—Type of Building ............................ No.. of persons............................ Showers ( ) — Cafeteria ( )
aOther fixtures ................................ .... ...................................................... ..
W Design Flow...........1_. .O....................gallons pe -lsaa p fr gay. Total daily pow............*S:5 -............. long{
WSeptic Tank—Liquid capacity ...gallons Length4� 0.... Width....+... Diameter................ Depth- VID...
x Disposal Trench—No. .................... Width..- .-.-........... Total Length............... Total leaching area._.._..._--.... sq. ft.
3 Seepage Pit No----- Diameter...._...... Depth below inlet.............. Total leaching areassq. ft.
Z Other Distribution box�� Dosing tank n
a Percolation Test Resin Performed by......... ........... , JK Da
te......l Z.�._ ,...
Test Pit No. 1...�—.__....minutes per inch Depth of Test Pit.... Depth to ground water... .. _...
44 Test Pit No. 2................minutes per inch epth of Test Pit.................... Depth to ground water........................
O Description of Soil•• ,�„L fit_.... � P. ..�. . .... {.. '__l {. ....L E ....
.................. .. ...........................
Uw ......-•---.......•-----•--•...............••••--....................._....---•----.........---•--...........•••--•-•••-....--;--.....---..._.........................................••.......:........
Nature of Repairs or Alterations—Answer when applicable...............................................................................................
•..........................................••-•---...............--•-----....................------...._.........-------•---•----.................__.................. ...............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of,I'LZ 5 of the State Sanitary Code—The undersigned f ther agrees not to place the system in
o on i Ce tilicate of Compliance has been issued h bo rd o ealth.
Signed...................... ...... ........... ....................................... ...... Zte
t/ '.....
Application proved y................�.r........�..�_�Zlvf�`'---........:...................-•---..._ .. ...� 2cmGr........
Application Disapproved for the following reasons:....................................................o........................................ ..
Date
PermitNo..... -- ..................... Issued........................................................
Date
Z THE COMMONWEALTH OF MASSACHUSETTS
i BOARD OF HEALTH
No 7ti�:a............... ...........................................OF........... ......................................................� ............. .—'. v. ...
Fay.
T,��j
Permission i .hereby granted........... .
•. :•---••...•..... �'
to 'Construct Repair (� ) a Individualn� � Sewage Dispo�sal�System
atNo......:....................•--....................................:-.... ........................ ........... ......................-•-•...................................
Street
as shown on the application for Disposal Works Construction Permit N,o.S6 Dated....Ih �A?G
g
DATE...........•----•- 19oard of Health•• ............ ...•---....._............
.f
7--7- 7—.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HKALTH
?A4 ......................
.OF........... A&i"3...........................
.................... .... ....I...........
(gerfif irate of Toutphattre
THI�S�TO CERTCFYp Individual Sewage Disposal System constructed or Repaired
by................................................!qv-.1...................................................................................7 ..................................
Installer—
� (,Z
at......... ........................ .....................................
............................. �n.....C ..................................................................
has been installed in accordance with the provisions of TITLEE 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 FUNCTION SATISFACTORY.
DATE........... .................. Inspector...... .............a:.......................................
...... ...........................................
No...2..: ...(n Frns.....�— ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0F.......irImo"
............... .
Applikation fur Uftivosal Work Tons#rur#ion Permit
\ Application is hereby made foi,a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
-----------------------
I ......Loation Address . f
................_..._ ..I :.......... _ . ..(.o.r Lot No ��•�-
__..._.............».»_«._.....
Address
a ........................... flJ, Instal ....._ Address ....... 4....
Type of Building Size-Lot-- ,.,.Sq. feet
Dwelling—No. of Bedrooms..............��...........__..........Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building .........:.................. No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures ...................................--•K. ......---.......••--•.................•---•..................---•-•..........-•-.................
uyt+�+R
W Design Flow---........�..k. ....................gallons per-person,per day. Total daily�f ow--..•-.-.-..��- ••-...--•..-gallons
WSeptic Tank—Liquid capacity ..gallons Length? 41!.... Width:.'�'a. ... Diameter............... Depth.... t.( ..
x Disposal Trench—No..................... Width.................... Total Length............... Total leaching area................. sq. ft.
3 Seepage Pit No.........I.-----.-.: Diameter....19........ Depth below inlet.......��?...... Total leaching area?�?(0 a. sq. ft.
z
Other Distribution box`(4)N Dosing tank i
Percolation Test Results—•� Performed by Date....._1 /
a GI 4... W...,_..................y .._..r...............
Test Pit No. I...4=.......minutes per inch Depth of Test Pit....f�-=��*.._. Depth to ground water......
44 Test Pit No. 2................minutes per inch Depth of Test Pit................•... Depth to ground water........................
O Description of Soil.... .......���.�............./�-"..'"'_�r �. . .0 �•� �� .���.:._..
y 1 --
U ------------------------------------------------------------------.I......... ......,....--- �,t""
.....................
UW •......................•-----...........------------------------------------....................--------...----•------•------•.------...........----....-•--•-....---•-•........._......................
Nature of Repairs or Alterations—Answer when applicable...............................................................................................
.............•-•---.---•----•--••••-•-....................-•--••..........----•..............----............----------•-------.....-•---•------...---••••-----...._....................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'ITAU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
o rton it Ce ificate of Compliance has been issued by,the board oflhealth.
Signed.................��'.................. :::..............•••. ......... ....
Application proved y......
............................................................................................ ..---• ...
••--••..................•.................r Date
Application Disapproved for the following reasons:..................................... ..........................»..
...--•--•-•..................................................................0...........---.............--.:_.........................-•-•••--•-•............_.......................................«
Date
Permit No...... ... ..................... Issued..........--••-• .........._..........Date
.......
Data
ASSESSOR'S MAP NO. PARCEL
LOCATION„ s /- S WAGE PERMIT NO.
ZVO CL A G E
INSTALLER'S NAME & ADDRESS
'�)-Lje U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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•� TOWN OF BARNSTABLE
LOCATION 10 SEWAGE #f`
VILLAGE CLA P-EVA. ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) P�-r ' �o X (size) UVb
NO.OF BEDROOMS 3
BUILDER OR OWNER �0/4e1 gab
PERMTTDATE: 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
G on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leac 'ng facility) Feet
Furnished byrT;�Zre
P
A aR�
it l
A 6
a
a 3o 3�
3
SECTION — SEWAGE �'
12 SEPTIC TANK - - "D"BOX - -LEACH I / ���
TOP OF F/D�NI I� 1, 37
(MSL)• ..2.,OF Ile TO 4:•• / /
Cab:Z JWASHED STONE / / 35
/ 37 5;r
40
IN- o /
OUT• IN �/
2 ��T IN•
TANK �'13 2✓�.6o U %-1 \1
SEPTIC
o /
ELEV.
ELEV. ELEV. ELEV.
ELEV. ELEV.
O WASHED STONE-T4 All
"
t
TEST HOLE LOG --12
TEST BY. -T1 ICJ oj!'l
TEST DATE I2-�3 �/✓ WITNESS 3
DESIGN
BEDROOM HOUSE
ELEV. ELEV.
I�G `.
G DISPOSER DISPOSER • �� / I �:
p . PERC RATE 2 MINAN. -- OT 43 I o 26 V
2Q S FLOW RATE'.�3 (GAL./DAY)
SEPTIC TANK. .
REQ'D SEPTIC TANK SIZ E to®sue
0' LEACH FACILITY Tf(o = PJ�4 I 0
G SIDE WALL. 0 I Z 5) - 4 G/D.
BOTTOM C = -7 8, S /�o} = 78� G/D.
TOTAL Z6�.�1 SF = �.�= 6��' '!.!If-�C� "
VA
USE: , � LEACHING p�� �'�Ef — �
WATER ENCOUNTERED
UNLESS OTHERWISE NOTED) i`34 _ •2��
NOTES': c
1.DATUM(MSU TAKEN FROM +''1 d �`- Ih QUADRANGLE MAP
2.MUNICIPAL WATER �� AVAILABLE i �� \� I ! 2
3.PIPE PITCH:11:"PER FOOT
4.DESIGN LOADING FOR ALL PRE CAST UNITS:AASHO- r�0 -44 q ;i
—( �0� (� ram. 7.
S.MINA GROUND COVER OVER ALL SEWAGE FACILITIES:(1)FT. °'• y
{ M�
6:PIPE JOINTS SHALL BE MADE WATERTIGHT E H.
7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. O,IA
STATE ENVIRONMENTAL CODE TITLES
ILi X
Of
S. Tye S P�.A�J FOL-?t1� .7 � :.
���,c o.��.r:a._.o.'7•-+ou�.� - Z I�� ��� LOCUS•. �A�
aliM
- _ RECi:.PRO SIGNAL ENGINEER I � -
._
W
PREPARED FOR: -1� :�E t:� �b►h-�'Q o n cape ���� eet n� ��. f ►s E�
. CIVIL ENGINEERS �
---tw LAND SURVEYORS
(EXISTING) ........... BOARD OF HEALTH
REG. N YOR
SCALE:
(PROPOSED) 04 CONTOURS �I I
12
A Yam . DATEI'�