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HomeMy WebLinkAbout0019 GINA COURT - Health '19 Gina Court 1 Centerville A = 210 193 iE No. 42101/3 ORA 0 10%, J ® © © m iYI.:.-:ems 4N•w'ia�:. ;:' -..:�.am-��.... 1�. .. ..:...:.....v.f:.... :.....�. ._—_..: 'hWyil _ ASSESSORS MAP N0: Z l O Commonwealth of Mass.chw4etts � PARCEL N0: 1 ,15 W Title 5 Official Infspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Gina Court Property Address Gary Blondin Owner Owner's Name information is required for every Centerville MA 02532 JULY 18, 2009 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: vl key to move your cursor-do not Carmen E Shay use the return Name of Inspector key. Shay Environmental Services, Inc. ,Q Company Name 185 Ashumet Road Company Address m Mashpee MA 02649 City/Town State Zip Code 508-539-7966 3080 Telephone Number License Number B. Certification 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 and4— a"intenance of or4-qIite sewage disposal systems. I am a DEP approved system inspector pursuan6;� Section A.3412iif Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ FAils, ❑ Needs Further Evaluation �by the Local Approving Authority OF Sq o � o CARMEN yNa. ' E. 7/18/09 v SHAT- Inspector's Signature Date TIT. The �F5 MS The system inspector shall submit a copy of this inspection report to the Ap rity (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. ****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. u � l 6 19 Gina Court,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 19 Gina Court Property Address Gary Blondin Owner Owner's Name information is required for every Centerville MA 02532 JULY 18, 2009 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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: 24" effective depth availble per stain line. System passes. Risers on tank, d-box and SAS. 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 19 Gina Court,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Gina Court 4M Property Address Gary Blondin Owner Owner's Name information is required for every Centerville MA 02532 JULY 18, 2009 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B System Conditionally Passes (cont.): Y Y ( ) ❑ 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: 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. 19 Gina Court,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Gina Court Property Address Gary Blondin Owner Owner's Name information is required for every Centerville MA 02532 JULY 18, 2009 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ElBackup 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 '/z 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. 19 Gina Court,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Gina Court Property Address Gary Blondin Owner Owner's Name information is required for every Centerville MA 02532 JULY 18, 2009 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well 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. 19 Gina Court,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �N 19 Gina Court Property Address Gary Blondin Owner Owner's Name information is required for every Centerville MA 02532 JULY 18, 2009 page. City/Town State Zip Code Date of Inspection C. Checklist 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: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 19 Gina Court,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Gina Court Property Address Gary Blondin Owner Owner's Name information is required for every Centerville MA 02532 JULY 18, 2009 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No. Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 19 Gina Court,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Gina Court Property Address Gary Blondin Owner Owner's Name information is required for every Centerville MA 02532 JULY 18, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1-23-02 - BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 19 Gina Court,Centerville•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Gina Court Property Address Gary Blondin Owner Owner's Name information is required for every Centerville MA 02532 JULY 18, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan). Depth below grade: 2.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leaks, plumbing properly vented Septic Tank (locate on site plan): Depth below grade: 6 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 6' x 10' - 1500 gallon Sludge depth: 16" Distance from top of sludge to bottom of outlet tee or baffle 15" Scum thickness 4 Distance from top of scum to top of outlet tee or baffle 4 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured 19 Gina Court,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Gina Court Property Address Gary Blondin Owner Owner's Name information is required for every Centerville MA 02532 JULY 18, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition,Inlet Tee in good condition outlet Tee in good condition Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 19 Gina Court,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Gina Court GSM Property Address Gary Blondin Owner Owner's Name information is required for every Centerville MA 02532 JULY 18, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert D-Box Present 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.): Liquid equal with outlet inverts. Two outlets present. No significant solids carry-over noted Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 19 Gina Court,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 19 Gina Court Property Address Gary Blondin Owner Owner's Name information is required for every Centerville MA 02532 JULY 18, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1 -25' x 13' x 2' ❑ 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.): Inspection Installed. No Liquid in SAS -24" effective depth availavble 19 Gina Court,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Gina Court Property Address Gary Blondin Owner Owner's Name information is required for every Centerville MA 02532 JULY 18, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 19 Gina Court,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form s� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 0 ;c e a 19 Gina Court Property Address Gary Blondin Owner Owner's Name information is MA 02532 JULY 18, 2009 required for every Centerville page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. u -,i V Ole i 19 Gina Court,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Gina Court Property Address Gary Blondin Owner Owner's Name information is required for every Centerville MA 02532 JULY 18, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam.- Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: No groundwater at 12' feet per soil log feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: refer to plans on file 19 Gina Court,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 lopCOMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION rllq -dl0 -/fl perm,4 _ ;,00a - 03/ TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: G!� GT Owner's Name: Owner's Address: / C i — c Date of Inspection: ( Name of Inspector: lease print) otr /"o l �� 45 Company Name: —.*I0 — %&- M ailing Address: D p ol. � rn A ®X6�a Telephone Number O'8 c f4f- -11 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�Passes ection 15.340 of Title 5(310 CMR 15.000). The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority F ils Inspector's Signature: Date: 6 0 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system 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 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address• Gi V1,� G Owner: V/ ? Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A=1have sses: ot 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 enfiltration 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 obstructedpipe(s).The s stem will pass inspection if(with approval of the Board of Health): y y broken pipe(s)are replaced obstruction is removed ND explain: Title Tno..nntinn x'.,...,!./T;Mnnn 7 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 ,^ Oa c�T-L Owner: Lja--I A vt& f Date of Inspection• p C. Further Evaluation is Required by the Board of Health: Al 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 15303(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: T41a jnonon*in..v-- </1 GMAAA Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: / 9 trt N A t✓ vl ✓r � pd 63� Owner: !/ ✓1 Date of Inspection: b 0 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes Nq. ✓ Backup of sewage into facility or system component due to overloaded or clogged SA or cesspool S _✓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 sspool _ quid depth in cesspool is less than 6"below invert or available volume is less than%:day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed of tunes pumped pipe(s).Number _ _ 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 conform 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 pp provided provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Xesno system is within 400 feet of a surface drinking water supply system is within 200 feet of a tributary to a surface drinking water supply system is located in anitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped ne 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. T;tln Z ✓ ' Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B Q CHECKLIST Property Address: 1.7 1 h^ G / ✓✓ Od-�32 Owner: M Date of Inspection• 0 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes — Pumping information was provided by the owner,occupan%or Board of Health ere 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) v 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: Z�no ��xisting 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)] Title ;Tnonw fin"Rnr Ali crone 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C q / SYSTEM INFORMATION Property Address: 19 6:f q G T e 1-v e A OoZ 6 JeZ Owner: a � Date of Inspection: p P OW CONDITIONS �e �"►i RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): vZ DESIGN flow based on 310 CMR 15.203 fore le: 110 �0 ( example: gpd x#of bedrooms): Number of current residents: oZ O c�j0o vs Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):AV [if yes separate inspection required] Laundry system inspected(yes or no):AP Seasonal use:(yes or no):XIV Water meter readings,if available(last 2 years usage(gpd)): �� s Sump Pump(yes or no):_&V Last date of occupancy: r COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203). and Basis of design flow(seats/persons/sq$,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 Source of information /�i r��p f, _ O Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP�F 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/Altemative 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 al`omponents,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 'e'V Title i inano..ti.... C,.«..•ti�e�nnnn (� Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Q SYSTEM INFORMATION(continued) Property Address: G`] — 4ev-Lglte Owner: tM G Date of Inspection: 6 p�' BUELDING SEWER(locate on site plan) Depth below grade: o?6 // Materials of construction:_cast iron _ PV _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:�Q Material of construction:_�_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) 1��> Dimensions: Sludge depth: 3 �— i Distance from top of sludge to bottom of outlet tee or baffle: d 2 Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: C Distance from bottom of scum to bottoF pf outlet tee or baffle: How were dimensions determined: P'o/e k g C, o% i c Comments(on pumping recommendations,inlet and oil et—tee or baffle condition,structural integrity,liquid levels a elated to outlet invert,evil a of leakage,a s .): Co,. ,,, . /l/d e GREASE TRAP:I�(iocate 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.): Ti+1a Tncrwrtinn 1.'nr... �/1 GMAAA 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: !il C�x 6 T_ Owner: / e U"a✓J� Date of Inspection: 0 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: aaIlons Design Flow: aallons/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: (f if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 401./'? a L_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or o)��f�x,etc.): �v�� �s /Py Sod r /yo Le, PUMP CHAMBER:& (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: f4_ G Owner: Date of Inspection: G SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: (J _ Soo ::q !/o leaching chambers,number: — �-- leaching galleries,number: leaching trenches,number,length: 540 We leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,ling,damp soil,condition of vegetation, etc.): ow i, f -level of ponding, ` ' aTM-� CESSPOOLS:/�(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: ` Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 TC-1 N a C j __ N e--L, P, Z Od AO. 2, Owner: VW A Date of Inspection: 9c,457 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Loc`te all wells within 100 feet.Locate where public water supply enters the building. C,W Ill�i 10 .r r j Cy 30 .0 , �� a 3 a" r 6e(o,/ 6,r� T;rla Iq rncnartinn r^rm An Siinnn 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFA CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Q SYSTEM INFORMATION(continued) Property Address: / C7— o-c.?j Owner: 1M it t�,f Date of Inspection: 6 p SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indi (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: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must desc ' f how you establis 'the gh g and water elevation: `� � R Gc ,e,. K Tif1A i Tnennrtinn Fnrn,�/1 G/'lnnn 11 No. 1 Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLEa MASSACHUSETTS Zipplication for Mis;paaf Opotem Conotruction Permit Application for a Permit to Construct( )Repair p()Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. G t p/4 e-o u iL T Owner's Name,Address and Tel.No. Assessor's Map/Parcel Q_Q�V vt kk l�Aly/L4 P /�0 e MN Address,and Tel.No. Designer's Name.Address and Tel.n, �G X,i*��*� •erg l/ /� I'� r rc,Cj a'�r 96 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 13 G Co P D gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank C)U Type of S.A.S. CS Description of Soil Nature of Repairs orAlte.S''ons(Answer when applicablee1 ` f L >--Ju Sb0 GI k G h 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 Certifi- cate of Compliance has been issued by this and Health. ?/0 Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued t ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired k )Upgraded( ) Abandoned( )by at / has been constructed in 4ccordance with the provisions of Title 5 and the for Disposal System Construction Permit No.n 12 PJ y dated I Installer Designer The issuance of 1hispermit shall not be construed as a guarantee that the sy wfl, unction d si . Date � �O 2 Inspector: -- ,. --------------------------------------- Fee �d THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLEa MASSACHUSETTS ;Diopoml 6pelem Construction Permit Permission is hereby granted to Cons ct( )Repair )Upgrade( )Abandon( ) System located at 'S G 1 rZ0 tlu Vl E c k. D Q r A l,A 4 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of is pe Date: `� ,l C)" _ Approved by _� l �- G,'`l L l�Ate..✓ f \, SOLE LOGS NOTES: %TOR: Amy Von Hone, R.S. 1.VERTICAL DATUM: Assumed Unwltnessed 1/18/02 2.MUNICIPAL WATER is AVAILABLE. 3.SCHEDULE 40 PVC PIPE TO BE USED THROUGHOUT SYSTEM UNLESS )N RATE: C2 min./inch OTHERWISE NOTED. 4.ALL PRECAST UNITS TO CONFORM WITH AASHTO: H-10 EL, 100.77 TH-2 5.PIPE PITCH-1/4'PER FOOT UNLESS OTHERWISE NOTED. 6.ALL CONSTRUCTION DETAILS TO BE IN CONFORMANCE WITH MA.ENVIRONMENTAL ford CODE (TITLE V) AND LOCAL REGULATIONS. 99.57 7.CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR TO CONSTRUCTION. YRS/8 97.77 Y6/4 bbles SZ77 entered SEPTIC SYSTEM DESIGN FLOW ESTIMATE (Existing 2, Design for 3) 3 BEDROOMS AT 110 GAL/DAY/BEDROOM=660 GAL/DAY SEPTIC TANK Not d,aW d for Garbage 1Xsposal a0a prc 330 GAL/DAY x 2 DAYS m 66o GAL USE 1000 GALLON SEPTIC TANK. Existing-Contractor to verify min. 1000 gal. tank. Replace with min. 1500 gal. If undersized or damaged. SOIL ABSORPTION SYSTEM Class I Soil Use 2 - 500 gal. Precast Chambers with 4' of washed stone, 251 x 13'W x 2'D SIDE AREA: 4(25'+13)C0.74) = 112.49 gal/day BOTTOM AREA: (25')(13)(0.74)= 240.5 gai/day TOTAL CAPACITY = 352.98 gal/day SEPTIC SYSTEM SECTION Cover wlthM 6' EL. 100 to grade lYA 1 Cover 12' To Grof T.D.F. EL. I01.76 over xkhln 12• t0291 to grade N 2'1/8'-1/2' Washe it 6r - 3/4 -1 1/2' Washed g�' 93 97.0 c 10, 14' 6'su 00000000000 Add Gas 00000000000 Baffle 96.8 96.0 0000000000 oaa000 97,05 ELEV ELEV Use 2 - 500 gal. ELEV 1000 D-BOX 96.33 Precast Chambers wit GAL 96,5 OB-5 ELEV 4' of washed stone SEPTIC TANK 3.3% slope ELEV watertest L6Y slope EL. (Existing to for levelness <25'L x 13'W x 2'D) °`"'3 remain - see �n note above) ANNY mw WARNER ZHOFMgS No.3872 �aNHONE oiG SITE AND SEWAGE PLAN • •/ ,9#1068 Q y �M LOCATION: 19 GINA CQURT 7aDZ CEN TER VILLE, MA PREPARED FOR: RDN'S EXCAVATING 61ANDA DEPEDRQ DATE HEALTH AGENT V H SCALE, 1� DATE, l�C associates 370 Comlf Road Sandw/cn,MA 015B3 SEPTICSYSTEMOES/GNS 508.8330041 ASSESSORS MAP: 210 TEST f ori4 PARCEL: 193 SOIL EVALU. R°p Route 2g FLOOD ZONE: X Town of Bourne (Above 100 Year Flood Zone) WITNESS: REFERENCE: Pt_, BK. 290 P6. 57 DATE Ra ,;;,: PERCOLATII 0 �d Pia TH-1 17cus Sandy A/F1L1 LOCATION MAP Loom sandy B It Loan 36 Perc at 601(botton) Coorse CI E: . sand 20X Ct lab• No Water Eno In m N x0.00 0\ �fl�� coc O �� HYDRANT'62 (' 99.98 V G 40 a q9 24 99.63 99.31 PKISET 99.29 99.55 9,39 6 GRIAINU9 Lot 10 0g d� 15,021+/- So. FT 100.24 a 120b� 0,34+/- ACRES Paved GROU .19 ND0 100.85 Map 210 drive I$0.30 Parcel 193 GROIN a�k� 100.35 ]a 00.37 100.45 Fc 100.71 1 100.80 k19 100.70 TOF=101J6 BENCHMARK, 100.38 Dryer Vent EL. a /Garage �101 I 100,53 12I A Ip�ck x 100.86 i 9A 102.41 GROUND 101. BM DRYER V T 0 101.42 4IN O 100.33 � yr 2 ' Exist -Box 2 0'9 to be replaced. LOL.36 99..66 8' x 0, v Scale, 1'=20' a, i 01 x 100,77 GRDI '44 4 fT TH-1 0' 20' 40' 60' IOL37 Fa Red Leach Pit �01, to D 02.3 2 , ..,.•102 a 103.1 Stockade 103.1 f@ 102.90 102,74 S 77'34.53' V ' Oct-29-01 08:28 BARNSTA3LE HEALTH DEPT 5087906304 P .02 st2::0i NOTICE: This Forll>rr Is To Be Used For the Repair Of Failed j Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM Aiz�e Ar S hereby certify that the engineered plan signed by me dated 1'2-2-42— ,concerning the property located at meets all of the following criteria: • This failed.system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling, •. The soil is classified as.CLA SS I and the percolaron rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preti.rninary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when. applicable] Please complete the following: Al Gl/�� 1�/J/> A) Top of Ground Surface Elevation (using GIS irforrnatior.) B) G.W. Elevation +adjustment for nigh G. Y. _ DIFFERENCE BET"TEEN A and B SIGNED : (� DATE: /",.7-2 d2. `dOTIC.E Baled upon the above information, a repair penmc -.4111 be issued for bedrooms er 1 in", imam. No additional bedrooms are author:�ed in &ie future without en,i,�e_.ed septic system plans. q:hoilh(older:percemp { r Fee�11_// THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for Migpooal bpftem Construction i3ermit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. '17 6,pj;A Cci v&T— Owner's Name,Address and Tel.No. Assessor's Map/Parcel Q--Q-Vl k,- /t 1\j�_ Install s Name,Address,and Tel.No. i Designer's Name,Address and Tel.Np ru G a t 90 13" l/(0`1 /y/lgs��---t Hi 3 a c� c cs 4-u c /l D Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow V Co `� gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. CS Description of Soil Nature of Repairs or Alterations(Answer when applicable S�h, �- J-'-'y S� J� i�� E ��rn bah Jrw� 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 Certifi- cate of Compliance has been issued.by this and Health. Signed Date I/ A Application Approved by JL Date Application Disapproved for the following reasons Permit No. �a' b3` Date Issued 1 INo. Fee 1 ` f f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes V PUBLIC HEALTH DIVISION.-TOWN/OF.,BARNSTABLE, MASSACHUSETTS ' Zipprtcatton for 30t.5po5ar Op5tem Conttructton Permit Application for a Permit to Construct( )Repair X\Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. C I wh C u v n T' Owner's Name,Address and Tel.No. �Q.V--k'Vt Assessor's Map/Parcel { Inst�, js Name,Address,and Tel.No. Designer's Name,Address and Tel.No. l�(S'/V)si < X C.q C,i,i- //W Cj �`� /� ! rU Ci to f Type of Building: Dwellings No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) -Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design,Flow V G (2 D gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title ` Size of Septic Tank Type of S.A.S. �Q'\ Description of,Soil Nature of Repairs or Alterations(Answer when applicable F Iv Sc<) i�40-, 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 Certifi- cate of Compliance has been issVA by this R°ard Health. Signed -1 Date /a /U Application Approved by O- Date Application Disapproved for the following reasons T Permit No. Date Issued 1 ,7`3/oQ - { v THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )RepairedX )Upgraded( ) Abandoned( )by at -s1 C cClt � /VA i has been constructed in cordance with the provisions of Title 5 and the for Disposal System Construction Permit No. _ dated (>� Installer Designer The issuance of this,permit shall not be construed as a guarantee that the syste w�1unc_t}ion aides'g ed. Date 1t 26/1)2 Inspector ,,li,VV, F --------------------------------------- Fee THE COMMONWEALTH OF MASSACHUSETTS - PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mtgoar *pgtem (Construction Permit Permission is hereby granted to Constpact( )Repair�� )Upgrade( )Abandon( ) System located `r\. E v t 1 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of t1fis pe "t. Date: �/ Approved by 7� �LL i 1 TOWN OF BARNSTABLE LOCATION � -SEWAGE VILLAGE ! .ASSESSOR'S MAP & LOT alv��y j INSTALLER'S NAME&PHONE NO. ® - 77 SEPTIC TANK CAPACITY LEACHING FACILITY: (type)(� `// '(�/t�d .S"' (size)K2 X t� NO. OF BEDROOMS BUILDER OR OWNER VJPryyi4I} 9eP, ,.J A PERMITDATE:. a COMPLIANCE DATE: J 01) 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 ching Facility ( y wet ds exist within 300 feet aching fa ty Feet . Furnished by j s- Oct-29-01 08:28 BARNSTABLE HEALTH DEPT 5087906304 P . 02 NOTICE: This Farts Is To Be Used For the Repair Of Fabled. Septic Systems Only. PERCOLATION TEST ANC SOIL EVALUATION EXEMPTION FORM I, ,0/!AZf / S hereby certify that the engineered plan signed by me dated 1'22 a2-- _,concerning the property located at j i/IAZg 4Z1,P—T?— meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no corntnerciai or business uses associated with the dwelling. •. The soil is classified as.CLH.SS i and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct prelirr,.inary tests at the site without a health agent present.. • There is no Increase in flow and/or chance in use proposed • There are no variances requested or needed. • The bosom of dae proposed leaching facility will net be located less than Fourteen (14) feet above the maximurn adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method wher! applicable) Please complete the following: A) Top of Ground Surface EeyaEion (using GIS information) B) G.W. Elevation +adjustment for high G.W. _ DCFFERENCE BET-+v'F_FN A and S SIGItTD : L DATE: /" 2 dam. 74 NOTICE 'Baked upon the above information, a repair perm[ -';will be issued for_ bedroo-ns unaximum. No additional bedrooms are author.ced in th, future withouteno.ineered septic system: plans. _ q:hnilh folder:percexrnp TOWN OF BARNSTABLE. '���' LOCATION SEWAGE# R40 9, O V C VILLAGE ��� 1� � ASSESSOR'S MAP&PARCEL ArQ - I Q 3 INSTALLER'S NAME-&PHONE NO. SEPTIC TANK CAPACITY. I Spa Cr Ol LEACHING FACILITY:(type) (size) ;KAE l NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 5 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 _T bO TOWN OF BARNSTABLE 6-E. �.. .,LOCATION AF 19 Q /Z:;t_SEWAGE C '0.31 VILLAGE .ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 77 SEPTIC TANK CAPACITY LEACHING FACILITY: (type)( ��d l .S' (size) X �� NO. OF BEDROOMS BUILDER OR OWNER Vi Puy 0 N PERMITDATE: I a 0 2 COMPLIANCE DATE: J U�— Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �j' Feet Private Water Supply Well and Leaching Facility (If any wells exist ,w` on site or within 200 feet of leaching facility) Feet Edge of Wetland and ching Facility ( y wetlands exist within] )feet aching fa ' ty Feet Furnished by - S L �,n� cl, V 1 Commonwealth of Massachusetts Executive of Environmental Affairs HP Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 19 Gina Court. Centerville, Ma. Address of Owner: Richard Jurkowski. (if different) 30 Musquash Rd. Nausha,N.H 03071 Date of Inspection: 05/24/96 Name of Inspector: Michael DeDecko Company Name, Address and Telephone number: Atlantic Environmental P.o Box 2384 - M ashpee Ma 02649. Tel : (508) 4771420 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 Passes ---- Conditionally Passes ---- Needs further evaluation by the local Approving Authority ---- Fails Inspector 's S ignatur . a ,I Date: 05126196 The system Inspector shall submit a copy of this inspection report to the Approving Authority 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 or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 Gina Court. Centerville,Ma. Owners : Richard Jurkowski. Date of Inspection: 05124196 INSPECTION SUMMARY: Check A, B,C,or D A) SYSTEM PASSES: - I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below B) SYSTEM CONDITIONALLY PASSES: ---- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determinate (Y,N,or ND). Describe basis of determination in all instances. If "not determinated", explain why not. ---- The septic tank is metal, 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 conforming septic tank as approved by the Board of Health. ---- 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 --- 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 n 'J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address : 19 Gina Court. Centerville, Ma. Owner : Richard Jurkowski. Date of Inspection : 05/24/96 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ---- Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health , safety and the environ- ment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETYAND THE ENVIRONMENT: ---- Cesspool or privy is within 50 feet of a surface of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. ---- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. ---- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. ---- The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: -- I have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. --- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 Gina Court. Centerville,Ma Owner: k .Jurkowski. Date of Inspection : 05/24/96 D) SYSTEM FAILS (continued) -- 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 over- loaded or clogged SAS or cesspool --- Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary to a surface water supply. ---Any portion of a cesspool or privy is within a Zone I 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 ana- lysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. { SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 Gina Court. Centerville Ma. Owner: Richard J urkowski. Date of Inspection : O5/24/96 E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above : The design flow of system is 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: --- the system is within 400 feet of a surface drinking water supply --- the system is within 200 feet of a tributary to a surface drinking water supply -- the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compli- ance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please, consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 19 Gina Court. Centerville Ma. Owner: Richard Jurkowski. Date of Inspection: 05124/96 Check if the following have been done : -x Pumping information was requested of the owner , occupant and 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 the 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 sep- tic tank was inspected for conditions of baffles or tees, material of construc- tion, dimensions, depth of liquid,depth of sludge, depth of scum. --x The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods -x The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. •s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 19 Gina Court. Centerville Ma. Owner: Richard Jurkowski. Date of Inspection: 05/24/96 RESIDENTIAL: Design flow : gallons Number of bedrooms : 03 Number of current residents: o Garbage grinder (yes or no) : t­� Laundry connected to system(yes or no): yes Seasonal use (yes or no) : tea Water meter readings,if available: Last date of occupancy COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow : gallons/day 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: Other: (Describe) ............................................................................................................ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: .................................................... System pumped as part of inspection(yes or no):....t:O........ if yes, volume pomped: .................... gallons Reasonfor pumping :............................................................................................................ sy SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19 Gina Court. Centerville, Ma. Owner: Richard Jurkowski. Date of inspection: 05/24196 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) ... Other (explain)........................................................................................... APPROXIMATE AGE of all components, date installed (if known) and source of information .4t&....A��.....1°tl`1............................................................................................................ ................................................................................................................................................ ................................ Sewage odors detected when arriving at the site : (yes or no).....N�... SEPTIC TANK : ... (locate on site plan) Depth below grade: ...!.k: i Material of construction: ... concrete ......... metal ........ FRP ........ other (explain) ................................................................................................................................................ Dimensions: .5.x . ... Sludge depth :...I.'(........ Distance from top of sludge to bottom of outlet tee or baffle:......33.................. Scum thickness :....2.."............ Distance from top of scum to top of outlet tee or baffle: ............1.0 ......... Distance from bottom of scum to bottom of outlet tee or baffle :....t!:t,':............... 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.)...................... o...N ..�c c Q.u,�nQ.�.c ., ` �:.4 ..f�.�.aT.. .. a► F;aT:"��z:s. a �..J ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19 Gina Court. Centerville, Ma. Owner: Richard Jurkowski. Date of inspection: 05/24/96 GREASE TRAP: ....... (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FRP........other(explain).... .......................................................................................................................................... Dimensions:............................... Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee 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, etc.)........................ ................................................................................................................................................ ................................................................................................................................................ TIGHT OR HOLDING TANKS:....11 .... (locate on site plan) Depth below grade:.........,..... Material of construction:........concrete........metal.........FR P..........other (explain).......... ................................................................................................................................................ Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee, condition of alarm and float switches, etc.) . ................................................................................................................................................ ................................................................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19 Gina Court. Centerville Ma. Owner: Richard Jurkowski. Date of inspection: O5/24/96 DISTRIBUTION BOX:..RCS (locate on site plan) Depth of liquid level above outlet invert:..iyi.v . ?� Comment: (note if level and distribution equal evidence of solids carryover,evidence of leakage into or out of box, etc.)... ...fix..- ...Q�... ,4...'s... ?►sT.�t. !G ... .ucQ..(..l�?ca. .V.� � .q3p.!.A.. ....CFV. c�--� ................................................................................................................................................ PUMP CHAMBER:.....Q (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.).................... ................................................................................................................................................ ................................................................................................................................................ SOIL ABSORPTION SYSTEM (SAS):....Q4. ...... (locate on site plan,if possible; excavation not required, but may be approximated by non- intrusive methods) if not determined to be present, explain: ................................................................................................................................................ ................................................................................................................................................ Type. leaching pits, number: ...v ..Io?� leaching chambers, number:........ leaching galleries, number:........... leaching trenches,number, length:..................... leaching fields, number,dimensions:................... overflow cesspool,number:.......... Comments: (note condition of soil , signs,of hydraulic failure, level of ponding, condition of vegetation, �►. i.l....0 ...tX?. M. AWWI 5. . ...A��.Sy s .�-t. .�'`.°� � I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: 19 Gina Court. Centerville Ma. Owner: Richard Jurkowski. Date of inspection: 05/24/96 CESSPOOLS:....) b.... (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: ..................... Indicator of ground water: .................... inflow (cesspool must be pumped as part of inspection) ................................................................................................. ................................................................................................. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) .....................................................................................................................................I.......... ................................................................................................................................................ PRIVY : ..... (locate on the site) Material of construction: ................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) . ................................................................................................................................................ ................................................................................................................................................ _'4A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : 19 Gina Court. Centerville, Ma. Owner: Richard J urkowski Date of inspection: O5/24/96 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100'. �41 ;�N(' 31 `-I9 - L k L � LI 5�► �y Uo 0 3 O � DEPTH TO GROUNDWATER: Depth to groundwater: �3.4?.feet Method of determination or approximative: ....................................................................................... ................................................................................................................................................ n r Fiz ..1..................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH �oW(1-.-........._0F............. c� -- Appliratiun for Uiipnual Workri Tunotrnrtivit ranfit Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal steal at: Lv,� � \O ---... .n a.... C ' ......;... ............. -.._..... ..... --....... I O . Location-Address rn\� �� S or Lot •o. • ./..........��... . .. . .--.=� -- .......................... ..... ... ..... ` I Owner 3 Ckr- C\ Address, ��— a ' --------------V.e. cis....... - r .. Installer Address d Type of Building Size Lot--- 024 Sq. feet U Dwelling—No. of Bedrooms........ 3.............................Expansion Attic (110) Garbage Grinder (00) aOther —Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------•---------------------------------------------------------------------------------------------.---•-- W Design Flow...............\.\9....................gallons per person per day. Total daily flow...............33 0..._............gallons. WSeptic Tank—Liquid capacityJ400:gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... AAidth.................... 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 ( ) ~' Percolation Test Results Performed by............ . 1 ___.. � Date._... � a�_._.... 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........................ -----------------------------•-----........-----•------------------.......--------------------------......................................................... 0 Description of Soil------..O=a....... 5� ------------------------------------------------•----...-•----------•----- x ----•--•---•----•------•--•--------•---ate 7------------5 `�a'`1------....:; 'Y4 v. 1 V ................................................... UW ----------------------------------------------- ----- --n'`t -.------------mac r,c 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 iITLL 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. -Y ate Application Approved .... ' .4..................................................................... _.t- ,' .... Date -Application Dis rov for a following reasons---------------------------------------------------------------------------------------------------------------- ....................... ----•- --- ---- ------------•--------------------------...... Date PermitNo......................................................... Issued-....................................................... Date • No AA------- ... Fm33..)�._............_ • THE COMMONWEALTH OF MASSACHUSETTS y BOARD OF HEALTH ...............OF............. �.�..C .................................. Appliration for Uiipotittl Works Cron rnr ion Permit Application is hereby made for a Permit to Construct (A or Repair ( ) an Individual Sewage Disposal System at: L Location-Address { '7 or Lot No. ` ...................3 3 r :. ..—`•.........�...... �7�.1._1.'.'.._._.... ���tA S Cl�_. ...�lam ?. ..5�-............--................ W `— \ Owner V CA(_ C1 \Add�res \ 3 _ .�� n ........................... Installer Address 2. Type of BuildingSize Lot_1_ .:_0_?G)_..__Sq. feet Dwelling T eoof Building .......................••••No. of eExpansion Attic 0o ) Garbage Grinder (Uo ) g— aOther—Type g ............................ persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .................................. W Design Flow..............�...........................gallons per person per day. Total daily flow.._........... ................._....._gallons. t4 M Septic Tank—Liquid capacitylR92..gallons Length................ Width................ Diameter._._ s.I.......... Depth........ .... Disposal Trench—:�T W o..................... Width.................... Total Length.................... Total leachingarea.................... ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. it. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by...__..__ Ems._)K K. : ....................77 Date..... .......... aTest 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........................ •---•-•••-•-----•••--••-••••----•---••••••-••••---•-••••-•-••••-•-•.....................•--..._.............................................................. O Description of Soil - = --------................................................. -------- •----••---••�...V.....'�-......--------------------.....---------------------------------...........--- .� ctimc. UNature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------------------------------------------------------------------•----•---------------------------------------------....._..-------------------------------••••••.._.....••-_.._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i s y g g p y of the State Sanitary Code— The undersigned further,agrees not to lace the system in operation until a Certificate of Compliance has been issued by the board of health. Si ed---.....:.c?��: :•---�__.:••- ................•••••. ' ate ApplicationApprove .._.. :.... <r" 1..---•.............•-------------------------.........................--PP PP f ------------- Date Application Dis prd forthe following reasons---------------------------- ------------------------------------------------------------------------------------ C�/ r Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................OF...........�).C ....... .......................................................C. .. �ertif iratr of Tomplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (4i ) or Repaired ( ) �� �Ut "-\ � �t �� by ............•-••••.... -..................................................................................................... Installer at................................................................................................ -------- has been installed in accordance with the provisions of TI i'LE j of The State SanitaZ4GUA as escribed in the application for Disposal Works Construction Permit No.' "+ .x_, _ ................... da.te �":..__.._._..___... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASANTEE THAT THE SYSTEM WILL FUNCTTI N SATISFACTORY. /� DATE--------------------------- �� -•---•-------------•------- Inspector...... THE COMMONWEALTH OF MASSACHUSETTS y� BOARD OF HEALTH >t.r..............OF...............,. .t.. ......... -c -. -----------....... FEr►�..`.�..A*............ Uiaposal Vorkv Tonatr ion "permit Permission is hereby granted......jp.. `1��......••••.- 4_<Z t�r............................................................... to Construct (�} or Repair ( ) an Individual Sewage Disposal System at No..-- -........... •_.... ' n -r.!��t.:�� ....__...-- .�'�'i:.' k----.-------•--•--- Street as shown on the application for Disposal Works Construction P ,mit '_ :.f�.._. ated.. .7.d-............ zr v .............. �t --........-----•---.................._ DATE. eF. .... ( _.f. y ......_............ Board of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS L_Iga), r USv - lGc)cn- tsAL,. o0o (9,aL• JWr-v`iNLi ��� � /� S• 1 t . -) SF 2.S • :t77S G-P.D. X 'P.vrr0,(A ,�szt la= C-10 TC"VAl- '�ES1GtJ = d25 G.P.D. rpTQL �����r t=�w - 33DbPv. Gt�f'CDL&TI0LJ CZQTE : CIQ LMIQ' 01Z �m.3 eY �2 •a _ � . •fit ��1� � PQ� T uZ. Tr. 97-0 g 3AXTEA PiJ.'�et}48 CA 1 nT4 �Ch� • �C7i UZ.Da y...,➢➢D"� err' ,.-,00�'n 99 EL<9Q• ...�•i../.. mom'-�,-�a� _. 4.• .: Y Q 40/4 wf Q Pp� t oar i�v A /, SamoV . 4'PP,e vt.;r. 1W. 64L. 'box 5� � So-ric iav �4V_ r Z (000 1 IWV1w. 't• SA�1D� Ga�. 2 9a •A rs42A VOL FtTLw4 aS w1r43 •i I f, •('lz 7 WAS"E_VD I =raN� EL=90 } sotjD 1 C T1�l�U _ 1�LC>-r PL.A.1�1 LoC.ATIot- CCNTBzVtc. A �ffi /2 tJo SGra�.�- 5CA1,t (}L 40 ,,ll N° GUa7731Z" Pt A,4,.{ R r_s^c t�.C►J c:1✓. Gl:tZTt{=�{ 'Ct-(AT T14G f: }Vw -tloo 5tAo4vW tl�,t,LaW C(a1r%PLgG W tTt-1 TW-1 : 51DE Ul-tE: LOT I (� Awa vGQutcekA—=,I TS ot= TNt_ •�o w►.� at= BA�r�STa�!.� - Pam. �rC. 'Z40 �b • �1 uATc _IZ 2 64 tr3 A XTCte. <; V_v_Gl,Ttt:irU L_A4J_lp Tt-t15 ht�At-a t!, WOT QoASC'o 1064 AW osTEevtL_Lr= o ti,tAs=„ 1(-4-,M?;J!✓tC:t4i /Ut_.�r_�{ ;� '('ta�. UFG•;�T , eo4ouL-n Apr;pt_1C.A.h1T_ �Wik i if.. ' J1M 1 tI � Tu I�C.CCt_M�WI_ 1..O'�C �1N� L U-sC► - rt' � l Yv ` / 0 6 LOCATION SFT ! G E PERMIT NO. VILLAGE 1 INSTA.LLER'S NAME i ADDRESS BUILDER OR OWNER - j- 5i irr� DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 4F L I�. t ' TEST HOLE LOGS N ASSESSORS MAP: 210 }TES: PARCEL: WITNESS: Unwitnessed 193 SOIL EVALUATOR: Amy Von Hone, RS, Assumed 1. VERTICAL DATUM: h r a R Qa Q �$ Route FLOOD ZONE: X Town of Bourne (Above 109 Year Flood Zone) 2. MUNICIPAL WATER IS AVAILABLE. Gina et iQ/n st REFERENCE: PL, BK 290 PG, 57 DATE: 1/16'/02 3. SCHEDULE 40 PVC PIPE TO BE USED THROUGHOUT SYSTEM UNLESS Rou 28 PERCOLATION RATE: <2 Mtn✓inch OTHERWISE NOTED. R aye 4. ALL PRECAST UNITS TO CONFORM WITH AASHTO: H-10 4 'z, Ord P e�y -cY^' TH-1 '.EL, .100,77 TH-2 5. PIPE PITCH - 1/4" PER FOOT UNLESS OTHERWISE NOTED. errs LOCUS A/FrLL 6. ALL CONSTRUCTION DETAILS TO BE IN CONFORMANCE WITH MA. ENVIRONMENTAL Sandy Loom 10YR2/1 CODE (TITLE V) AND LOCAL REGULATI❑NS, LOCATION MAP 14' 99,57 7. CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR TO CONSTRUCTION. Sandy B 10YR5/8 LOAM 36' 97,77 Perc, at C1 2.5Y6/4 60'(bottom) Coarse Sand 20/. Cobbles 156'1 BZ77 No Water Encountered LO SEPTIC SYSTEM DESIGN . x 0.00 n� FLOW ESTIMATE (Existing 2, Design for 3) c oc C� 100.6B HYxNT 99.98 G 3 BEDROOMS AT 110 GAL/DAY/BEDROOM =660 GAL/DAY �- �11 '�1`'P SEPTIC TANK Not designed for Garbage Disposal ox, 0.00 �Q` •• w prc � 99.31 PKTSET.24 330 GAL/DAY x 2 DAYS = 660 GAL 99.63 99.29 USE 1000 GALLON SEPTIC TANK Existing-Contractor to verify Min, 1000 gal. 99.55 tank, Replace wlth Min. 1500 gal, if undersized or damaged, -0--99.39 SOIL ABSORPTION SYSTEM Class I Soil Use 2 :- 500 ga i.--Precast- _Chd r bers with a, E GROUND.19 4' of washed stones 25'L x 13'W x 2'D Lot 15,021/1SO, FT, 100.24 x 10019 SIDE AREA: 4(25'+13')(0.74) 112,48 qal/day �2a 0.34+/- ACRES Paved GROUND 100.85 Map 210 drive BOTTOM AREA: (25'X13')(0.74)= 240,5 gal/da y GRouN°D°30 Parcel 193 v `\- 100,35 t = �/ w� TDTAL CAPACITY 352.98 gal/da y 100,37 SEPTIC SYSTEM SECTION 100,45 Pch 100,71 EL, 100.0 Cover w/thln 6' 100.80 #19 100,70 to grade Min. 1 Cover 12' To Grade TGF=141.76 T�D.F� EL, 101.76 over within 12' 100.38 BENCHMARKS to grade Mln. 2' 1/8' - 1/2' Washed Stone t Dryer Vent EL. 102.41 I Garage /s /h9 f4 9e93 E3/4 - 1 i/2' Washed 97 0 (tone of 377 chamber) 101 i Deck 10 14 6' sump- Deck ❑aa❑❑0❑❑❑❑❑ 100,53 0 12I A Ip ^ cti x 100,86 Add Gas aaaaaaaaa❑o 96,8 ❑aaoaaaoa❑aa❑ 94.0 3 101. 99, 102,41 M GROUND Baffle 96.0 ❑0aaaaaaaaaaa BM DRYER V T 101.42 41N O 100.33 ^ 97,0514 ELEV ELEV Use 2 500 gal. , � ELEV 96.33 Precast Chamk)ers with 6,23IOOQ GAL g6,:2D�-BOX B-5 ELEV 4' of washed stone SEPTIC TANK 3,3% slope ELEV Watertest 1,6% slope EL, 87.77 Exist, -Box (25 L x 13 W x 2 D) 2, 00.9 to be replaced. for levelness Bottom (Existing to of TH-1 1a1.36 98.66 8' x 0 OVINOFMASo remain - see 0 x .44 �°�� TERRY g��� note above) ��fA X 100.77 GROU 4 AN, ��NOF/ygs Scale 1'=20' r rT WAR `R P s N� ✓ TH-1 N°o.38721 � 9py ` NH G SITE AND SEWAGE PLAN 0' 20' 40' 60, 10L37 k balled Leach Pit NDl / �� S� L�o J`rPot- o VON HONE 68 102.3 2 �' ....:.102 a 103.1 r �.��,SO�p 103,17 fe =_-'- 7/ sq�l LOCATION: 19 GINA OUR ade � � d I tack ae-�� � � " S GEN TER V L L E, MA 102.90 102.74 77,3�,53 w �rZ,� Z.. --� PREPARED FOR. RL7N'S EXCAVATING WANDA DEPEDRL7 DATE HEALTH AGENT VH SCALE 1 „ = 20' DATE, associates 320CotuitRmd Sandwich,MA 0.2563 SEPTIC SYSTEM DESIGNS 508.833.0041