HomeMy WebLinkAbout0062 GOFF TERRACE - Health 62 ,OFF TERRACE, CENTERVILLE
A=170.087
11H
UPC 12543
No, R gPosr coc+s'�
HASTINGS, GIN
r
L
1
COMMONWEALTH OF MASSACHUSETTS
W Title 5 Official Inspection Fora
a
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form. Inspection forms may not be altered in any way.
A. General Information
1. Property Information: MAP 170—PARC 087
62 GOFF TERRACE — CENTERVILLE, MA 02632
Property Address
GIRCELEY, DAVID
Owner's Name
62 GOFF TERRACE
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
AUGUST 14, 2006
Date
2. Inspector:
JAMES D. SEARS
Name of Inspector
A & B CANCO
Company Name
350 MAIN STREET
Company Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
508-775-2800
Telephone 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 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 16.000). The System: z
® Passes ® Conditionally Passes ® Fails
® Needs Further Evaluation by the Local Approving Authority
I ctor's Signature: Date: LIP
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.
*'"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 Official Inspection Form:Subsurface Sewage Disposal System
Page I of 2
COMMONWEALTH OF MASSACHUSETTS
w Title 5 Official Inspection Form
d
/p^ Vag
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. Certification (cont.)
62 GOFF TERRACE
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
GIRCELEY, DAVID
Owner's Name
AUGUST 14, 2006
Date of inspection
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: N/A
® 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:
COMMONWEALTH OF MASSACHUSETTS
Title 5 Official Inspection Form
9 C
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
62 GOFF TERRACE
Owner's Address
CENTERVILLE MA 02632
City/Town . State Zip Code
GIRCELEY, DAVID
Owner's Name
AUGUST 14, 2006
Date of inspection
B) System Conditionally Passes (cont.): N/A
Observation of sewage backup or break out or high static water level in the distribution box due to
broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass
inspection if(with approval of Board of Health):
broken pipe(s)are replaced
® obstruction is removed
distribution box is leveled or replaced
ND Explain:
® 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: N/A
® 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
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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
COMMONWEALTH OF MASSACHUSETTS
Title 5 official Inspection Form
9 C
Not for Voluntary Assessments
e^M SJe�
Subsurface Sewage Disposal System Form
B. Certification (cont.)
62 GOFF TERRACE
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
GIRCELEY, DAVID
Owner's Name
AUGUST 14, 2006
Date of inspection
C) Further evaluation is required by the Board of Health (cont.): N/A
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
indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less that 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3.Other:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
COMMONWEALTH OF MASSACHUSETTS
Title 5 Official Inspection Form
9 C
l�M Sye
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
62 GOFF TERRACE
Owner's Address
CENTERVILLE MA 02632
City/Town State Zip Code
GIRCELEY, DAVID
Owner's Name
AUGUST 14, 2006
Date of inspection
D) System Failure Criteria Applicable to All Systems: N/A
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
® ® Backup of sewage into facility or system component due to overloaded or clogged SAS
or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool
® 0 Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
® ® Liquid depth in leaching is less than 6" below invert or available volume is less than
'/2 day flow
® 0 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 surface water elevation.
® N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary
to a surface water supply.
® r N/A Any portion of a cesspool or privy is within a Zone 1 of a public well.
® N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
® N/A 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.]
YES No
® The system is a cesspool serving a facility with a design flow of 2000 gpd—10,000 gpd.
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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5 of 16
I
COMMONWEALTH OF MASSACHUSETTS
w Title 5 Official Inspection Form
d
Not for Voluntary Assessments
V y
Subsurface Sewage Disposal System Form
B. Certification (cont.)
62 GOFF TERRACE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
GIRCELEY, DAVID
Owner's Name
AUGUST 14, 2006
Date of inspection
E) N/A 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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. Checklist
62 GOFF TERRACE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
GIRCELEY, DAVID
Owner's Name
AUGUST 14, 2006
Date of inspection
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, including 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)].
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
f
COMMONWEALTH OF MASSACHUSETTS
N Title 5 Official Inspection Form
a d
ye�
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information
62 GOFF TERRACE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
GIRCELEY, DAVID
Owner's Name
AUGUST 14, 2006
Date of inspection
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: 3
Does residence have a garbage grinder? Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection is 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:
Commercial/Industrial Flow Conditions: N/A
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):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 16
v
COMMONWEALTH OF MASSACHUSETTS
w Title 5 Official Inspection Form
d
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
62 GOFF TERRACE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
GIRCELEY, DAVID
Owner's Name
AUGUST 14, 2006
Date of inspection
General Information
Pumping Records:
Source of Information: N/A
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)
® Tight tank.Attach a copy of the DEP approval.
® Other(describe):
Approximate age of all components, date installed(if known)and source of information:
1999 PERMIT#99-33
Were sewage odors detected when arriving at the site? ® Yes ® No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
6y0 Subsurface Sewage Disposal System Form
D. System Information (cont.)
62 GOFF TERRACE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
GIRCELEY, DAVID
Owner's Name
AUGUST 14, 2006
Date of inspection
Building Sewer(locate on site plan):
Depth below grade: 18"
feet
Material of construction:
® cast iron 0 40 PVC other(explain)
Distance from private water supply well or suction line:
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
GOOD
Septic Tank(locate on site plan):
Depth below grade:
feet
Material of construction:
® concrete ❑ metal ® fiberglass ❑ polyethylene ® other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ® Yes ® No
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dimensions: 1000-GALLON PRE CAST
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle 27"
Scum Thickness 2"
Distance from top of scum to top of outlet tee or baffle 12"
Distance from bottom of scum to bottom of outlet tee or baffle 161,
How were dimensions determined? ASBUILT&TAPE
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
COMMONWEALTH OF MASSACHUSETTS
E
w Title 5 Official Inspection Form
d
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
62 GOFF TERRACE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
GIRCELEY, DAVID
Owner's Name
AUGUST 14, 2006
Date of inspection
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 AT WORKING LEVEL. TANK AND COVERS AT 24".
INLET TEE - OUTLET BAFFLE.
NO SIGN OF OVER LOADING OR LEAKAGE.
Grease Trap (locate on site plan): N/A
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: N/A
Material of construction:
® concrete ® metal ® fiberglass ® polyethylene ® other(explain)
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
COMMONWEALTH OF MASSACHUSETTS
a y Title 5 Official Inspection Form
d
o�. Not for Voluntary Assessments
4j Jew
Subsurface Sewage Disposal System Form
D. System Information (cont.)
62 GOFF TERRACE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
GIRCELEY, DAVID
Owner's Name
AUGUST 14, 2006
Date of inspection
Tight or Holding Tank (cont.) N/A
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 a 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
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.):
D-BOX LOCATED ON SITE, NOT DUG UP — BOX AT 4'.
BOX WAS INSPECTED WITH CAMERA, BOX CLEAN & SOLID.
NO SIGN OF OVER LOADING OR SOLID CARRY OVER.
Pump Chamber(locate on site plan): N/A
Pumps in working order: ® Yes ® No
Alarms in working order: ❑ Yes No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
COMMONWEALTH OF MASSACHUSETTS
w Title 5 official Inspection Form
d
e` Not for Voluntary Assessments .
V v`
Subsurface Sewage Disposal System Form
D. System Information (cont.)
62 GOFF TERRACE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
GIRCELEY, DAVID
Owner's Name
AUGUST 14, 2006
Date of inspection
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:
® 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.):
LEACHING IS TWO (2) TRENCHES 30'X4'X2' PROB & TEST HOLE AT FIELD.
NO SIGN OF OVER LOADING.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
COMMONWEALTH OF MASSACHUSETTS
w Title 5 Official Inspection Form
d
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
62 GOFF TERRACE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
GIRCELEY, DAVID
Owner's Name
AUGUST 14, 2006
Date of inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A
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, damp soil, condition of vegetation,
etc.):
Privy (locate on site plan): N/A
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
COMMONWEALTH OF MASSACHUSETTS
4 Title 5 Official Inspection Form
a
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
62 GOFF TERRACE
Property Address
C E NTE RVI LLE MA 02632
City/Town State Zip Code
GIRCELEY, DAVID
Owner's Name
AUGUST 14, 2006
Date of inspection
v sketch of the sewage disposal system including ties to at
Sketch of Sewage Disposal System: Provide g p y g
least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where
public water supply enters the building.
i
I
I
I
i
i
I
LS l
r
3 IV
-r;tli Fnrrn .;u6sLrthre Sewege Disp,,al 5rs:em.
f
COMMONWEALTH OF MASSACHUSETTS
4 Title 5 Official Inspection Form
a
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
62 GOFF TERRACE
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
GIRCELEY, DAVID
Owner's Name
AUGUST 14, 2006
Date of inspection
Site Exam:
Slope ,
y
Surface water
Check cellar '6
.0 jrA c.1-//
Shallow wells
N a Tir/t,
Estimated depth to NO ground water: 8'
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:
TEST HOLE 8' NO WATER.
TEST HOLE 4' BELOW BOTTOM OF LEACHING.
Title 5 Official Inspection Form-Subsurface Sewage Disposal System
Page 16 of 16
/ TOWN OF BARNSTABLE
LOCATION SEWAGE#
-PILLAGE C ti 7- ASSESSOR'S MAP&PARCEL
INSTAbEER NAME&PHONE NO. V16 t X N C d
SEPTIC TANK CAPACITY S .E PrL /ti S,,0 eC 71ati
.LEACHING FACILITY: (type) (size)
'NO. OF BEDROOMS
OWNER G/�CFL f f
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
3 Y'
- fo
ro
�u
UQ
0�1 -
U � C'G A-2 EL£Vq-TfON 12I(�N•T •ELF VatTIO tiJ
vq �^
FRI-_
J 'Ip!a ThesedmWinge'MmPreparedfryCaOzdHome
Improvement for the ine of Copt m Home Impovement EEL P l A n n r 77 0.t
n.4,tpef r•;'.V rorlreetury Artynm idling these �l "�
an
f-F7=T £LEViF�77 o.t1 w+vr1��-•rn r,L'vcrEv rdemt•ng ccrtotWrtis, ecaair�y"�•'i7 arwrovmnl puwnn
anwrwc.. .:I r,rn•• •nv to Wail,nd etas evading
mdae pna irm jneyt,.t_r.lase dravnngs.Ceprsa Home -W
Improvement I.,,Pnisanyreepofurolely for any and all 8 y SNAxaa� nna.
problerlre zilch erep lrom the ta of these dmwBpe by t) 7�b'•667y
Mya1e othectryAn ampbyPee 81n6mnCaytae ai oew.ra haws
G�pladHaopfnpedwnwflE Fare CA?i771 AnAig 9 738 9yr'/ /arj
a
�J
ro
s �
C C
' * I
I
i
�tt _
c�•iY S' ---y +�lF
�S Ru3H s
vf.nw
JZ
'1114
� r
t i O
ry
L
r) >gg
Z vF A
p Lc i ti r
x
L
v•o' S-8• v- •
m
bs
i•
A 2 i
DL�Mmu
�& E
• °"Psi L�
r
l rye•/- - 5' - .
k-9
I�
a-L
n
Y ®y
I I-I
E r
tz
o -
L
p=
y X
n vl
ap _
"s-
r
t
3=8•r_ Oor X z
aa= el--Sr, a /r irw
r
s
- R �
NEW
x
ExrST ExrsT Ex•S>•.
b
r, GIRT —
m r
9-9'arr- E gaI ,gym EeoP�A r
Ih LAuy�Pws =nfl4 msdD
_ S 0RTS NFW_ iOL�O pN PZN�
rn Ey15T. MI Ro.
Tlpx
r' �•� 2rS --� p<�� d• Z� m I R
IC,ncr- a g fi �k mZ�
opw_
I X
4
Ias-o•exr,r J
LiDQM£7C M 6.�6LE r2 EA l2
��monp r pAW
x e 6F r r r
O (D'Po
24
gaE
t x
7-31 7-5'a"EXrST. -(�"ExrST
A EkrsT. MATcAl MATCH
O
A A
tl
o
I
L
iE rocw j. .�
D
x i el i;j� v x)c r
2 W x t ` p U L3 j a Njt�jp��o 6�
Y a . o v r
�LDc
r Y
1 a
>F
A a
R r b
�tl7op,w Ala:
T
-a'a"EXrS7tN6 1 1 ?o K CJ4 tl k
n: y 2 � r D o03�GW0i �
ILI
n m 2 r _w Lai X sd it ih%ADc�
tlCnnky
rrt o
JD Ai IA�
l , `
d O
r o a I @I
e/kro + I It y o ! G I e
rN m p� A I o I g Y�2r dX -
r 1Yy p
b " r 6-8•�o a•ox8 n ` G-8'na� ? u m' ' �`�
E nees r c e s P I Z• �i
In -I t J
jo' �I ECG , � x• x nix f E
�o+} A�ay o anima �� mtio a
m c
5a � u
b" y
A my \ „ � N y '
m
No. Fee Sv
THE COMMONWEALTH OF MASSA(HUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0[pprication for Mi5po5a[ *pgtem Construction Permit
Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No.6,1 60(f Owner's Name,Address and Tel.No.mM(��z/
Assessor'sMap/Parcel 4:70 —06, �!��M�,� /��a�C
Arog
Installer's Name,Address,,and Tel.No. 8PIA•<fi(/0tT4f Designer's Name,Address and Tel.No.
06 TR6z0P uR. v1'�
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Buildings No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 334 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil 0-6 a keng� `?atl wsou_ X`k l W, 4 rr Nature of of Repairs or Alterations(Answer when applicable) L.(590.77%� 60 7
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 nv' rental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued this o of H
Signed Date j a
Application Approved by Date
Application Disapproved for the following reasons
Permit No. 3 Date Issued l— 2 S—
Z Y t
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS,.
application for Di-qpoga[ *pztem Conotruction Permit
Application for a Permit to Construct( )Repair(V/)Upgrade( )Abandon( ) El Complete System El Individual Components
Location Address or Lot No.6a 6OFf 7t9A/7— Owner's Name,Address and Tel.No. �n y�v Dgnn
Assessor's Map/Parcel /_/G -OP
q ( &� Ul/`�. /-J _ fU - Cgo o
N
Installer's Name,Address,and Tel.VoU i9. RJIV/II/C!G1``�'.C•(: Designer's Name,Address and Tel.No.
,)D ma7op GiR. ingRsr�NS f u 5
Gam' g
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 .7,?0 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil 0 CU060& 2) 4 -3a"'sG,9-SDfL.. ��lV, ME.0!GmS.4 7
Nature of Repairs or Alterations(Answer when applicable) l70�C 1FXaZ /
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 Env' ental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued this o d of
Signed Date 62
Application Approved by 912 Date l—ZS
Application Disapproved for the following reasons
Permit No. /�S—3 Date Issued---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( )
Abando ed( )b
at �Z �e rr�C� , �� has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated /—2 s' t g
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the s ill functionyasL1 ned.
Date """"" sA i�r' Inspect
— —
/ ( — ----------------------- -----Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migozar 6potem Construction Permit
Permission is hereby granted to Coss ct A. /)Repair( Upgrade( Abandon( )
System located at G z6G
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 this t.
"s
Date: �, �/ Approved by Q-� -
w
+ 7/98
NOTICE: This Form Is To Be Used-For the Repair Of Failed
Septic Systems Only.
s
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
0�of m , hereby certify that the application for disposal works
construction permit signed by me dated l '�� , concerning the
property located at IQ 60fic meets all of the
following criteria: x
• There are no wetlands located within 100 feet of the proposed soil absorption system.
0 There are no private wells located within 150 feet of the proposed septic system.
• There is no increase in flow and/or change in use proposed.
• There are no variances requested or needed.
• If there are any wetlands located within 250 feet of the proposed soil absorption system,the
observed groundwater table is 14 feet or greater below the bottom of the leaching facility.
• I understand that the attached Title V Calculation Chart may only be used for the design of a
septic system if the existing naturally occurring soil is classified as Class I(sand or loamy sand)
in the most hydraulically restrictive layer included within the five foot zone beneath the proposed
soil absorption system. If the soil conditions are not Class I within this above described zone,a
professional engineer or registere s-nitarian is required.
SIGNED : DATE:
LICENSED SEPTIC SYS STALLER IN THE TOWN OF BARNSTABLE NUMBER
Please complete the following:
A)Elevation at top of ground in the location of the proposed soil absorption system
B)Elevation of groundwater
[Attach a sketch plan of the proposed system. Also if the licensed installer possesses a certified
plot plan,this plan should be submitted].
q:health folder:Cert2
sock
/000
6o"X�'Yl af L.&O 7P&*'I
r
otw y TOWN OF BARNSTABLE J
LOCATION o LSEWAGE # ;)
VILLAGE ASSESSOR'S MAP & LOTS "'O f7
INSTALLER'S NAME&PHONE NO. A1Y
SEPTIC TANK CAPACITY AP
LEACHING FACILITY: (type)
NO.OF BEDROOMS
`BUILDER OROWNER-1 °M f mod/
PERMITDATE: �'y� —9 COMPLIANCE DATE: 7
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 f leaching facility) Feet
Furnished by
/ s
r t
1 F
ff } !
LO ,CATCON b� SEWAGE PERMIT NO.
VILLAGE
N i�OK v tile- f f7D D
INSTALLER'S NAME & ADDRESS
NAR (Ail,C',L� �
B U It D E R OR OWNER
DATE PERM T ISSUED
DAT E COMPLIANCE. : ISSUED
AA/7
No.................�0.... Fizz......2..:,s.....-r......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
._ 7... OF.....1.�. ._�..�.. .. !L---..�'...........................
Appliration for Uh4p a W urk�i C omarnrtiun 11amit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Systemat n...Tc� L a C /..............�- -•--------•-----....••---......-�--• -------•-•--•--•--•-------•-•--•-•......--
Locat• Add re Tor Lot f o.
s� Own �p �Jnd ess
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.............. ............................Expansion Attic ( ) Garbage Grinder (�)
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures .................................
W Design Flow.............110......................gallons per person per day. Total daily flow...... 0....................
WSeptic Tank—Liquid capacity.(o-®Dgallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet....._.._._ Total leaching area..................sq. ft.
Other Distribution box ( ) Dosin tank ( ) 0�
aPercolation Test Results?ate.Performed by-- 9"�Y�.. .�.'..... .................................. Date---`� �_.�[ -_ ..........
a Test Pit No. 1�..._�___.____minutes per inch Depth of Test Pi�-----------------• Depth to ground water_-___---_____---__----_.
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----- ___-____--_-____
�+ ----•------•----•---------------------••-----------4••-------------------_----...--•--..... .......----.......
Description of Soll.W.C. 1- �! w - .1�,t ..........f?....................�1 � (e6v� �1-1�
..................4.. / ..... ------•--•-••-----------------------••---•-••-----••-•-------•----•--------------•-----------••--•---------•..........................---••---•-
W ---•-•---•------------••-----•--••-...---••-•---------•-•----------•••--••-•----•....-•-------•--•-•-----•-----•--------••--•---------•----•-•----•---•----•--••-----•---------••-•--••--•--•--••-•-••--
UNature of Repairs or Alterations—Answer when applicable................................................................................................
---------------------------••----•--•••-•••••-•------••------•--•---•-----•••-----•................••-•--•-----••••-•--•-•--•••----••-----•-•-•----•---••----•---•-••••--•--•---•------------....----•-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI`:i.;;:. 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.
Sigd--•-- -------------------------•-----------------------•-••-..._..._..---•--•-- ................................
ALL
�� Date
Application Approved BYCEO �- ------------------------- --------------
Application Disapproved for the following reasons_............_.................................................................................................
-------------------------------------•--...----------------------------------------------------••-•••---••-------••••-_._...-•-•--•--•-•----------•----
...........................................
Date
PermitNo......................................................... Issued.......................................................
Date
L J
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ApplirFation for DiiposFal Workii Tonitratrtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System a;.y f- �....� : ....................................•..... ._ - .............
Locat Addre .. a. or Lot o.
'....../W0417'r--------------------------------- .r. .1. . r... = --.... .cS...
Ow .. r d ess
i. '- ..................... ..... �'"� '� . ' _ +....1
Installer Address
d Type of Building Size Lot............................Sq. feet
aDwelling—No. of Bedrooms---------- -----------------------------Expansion Attic ( ) Garbage Grinder (C))
p l Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a4 Other fixtures ............................
W Design Flow............ ......................gallons per person per day. Total daily flow--____�..:3... }.__.................gallons.
WSeptic Tank—Liquid capacity. Q-90gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area................__`Sq. ft.
Seepage Pit No_______________ ___ . p w inlet__._......,,.Total leaching area..................sq. ft.
( ) i __ ( ) - 1
r K /
.____.Diameter.... . ..___. eft below
Other Distribution box Dos>n tank C�
a Percolation Test Results 1H�-Performed med by �` ` Date {........
,� Test Pit No. 1 i..............mmutesper inch Depth of Test Pit.................... Depth to ground water.........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----- ._..............
a ................................................... ....................Y......___.._..--"V-----•---_. _..._.__ .............._.... ........__.._._.
O Description of Soil.11t! D 1?:f l ...... .Slt+j-"-_` �/ '.. Q 1!�` 14!l &A-1.)--
x ��1
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 TIT i E 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.
Siged.-•----------------•---------••--•------........_...._.............................. ..........................
Date
Application Approved B Date
Application Disapproved for the following reasons--------------------------•------------------•-----. ............................................................
••-------------•---•-------•--•------••-----•----------------------•••-•••-•---•-•..........---•--•-•---•---•-•-----------------••--••------•---•-•--------•-•---------•--•-------•--------•----•-•-•---
Date
Permit No.......................................................- Issued_....................................
=
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
VIN
- *
i..t�.11 ..:. ............OF.. c ''J... .. .. ^.4-:....: .....................
(9rrtifirate of Tontph anrr
THIS IS TO CERTIFY}That the I dividual Sewage Disposal System constructed ( ) or Repaired ( )
by .y I. S. . '. 4) 1 ►-----•--- ------.__•------------------ -----------------------......-......---------------------------------------
at �� -�• e {.. 1-_----.._.1. - .Sa. I Installer Gam -----------------•.........................-----
has been installed in accordance with the provisions of T j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit �'o____ _________ .,�� __..__.. dated-.-�/-. _��°=._?`�,___._._....:...
THE ISSUANCE OF.,THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.... .... 7 - Inspector{.. C--........................
- J
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..w.. ......OF..... ... ../ ..............................
Cq n ...........I... ""���
'��`• FEE. ..........
Diopogaal or.4 Tomitrnrtion antit
Permission is hereby granted..... Q!'!�..............V.._. _
•-•-----------------------------------------------------------------------------------
to Construct ) or Repair ( an I vldual Sep age Dispos -System
at No....._.,�.u_ .._/.: _.. " ,.tr.. 5,: c.-..,.,T 12a.._... .....C-..................................
Street 2y 7l
as shown on the application for Disposal Works Construction'Bermit o Dated... _...._.._..................:.....
Grp-ter �-----------------------
7 , ;. Board o Ith
DATE. -= -------- .�I...................................•---•--•-•-_.....
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
i
/V
q ez 9
� p
1 V �
I
Zor 4�7
46.so /86 DWAFil
�4
18
0 21�
Pir
SYS7W-"'7
i IVo72 �Z�I�A�-iows I�r4sEb oa'
1
i CERTIFIED PLOT PLAN
LOCATION
SCALE ./ =30.�. . . . DATE .Ai?/4.
PLAN REFERENCE . 4`7 G. l-o.T. ' /7.4 s
��S T7O.v Z Lu.yB T. pi/44s
I CERTIFY THAT THE
SHOWN ON THIS PLAN IS LOCATED ON THE GROUND
AS SHOWN HEREON AND THAT IT CONFORMS TO THE
p SETBACK REQUIREMENTS OF THE TOWN OF
. . . . . . . . WHEN CONSTRUCTED.
7 '`~� D,� DATE 5�Wl4t L3 117,9
PETITIONER: /�/ rv.cJi S �95 5
REGISTERED LAND SURYLINOR
N59345
TOP OF FOUNDATION
CONCRETE COVER
CONCRETE COVERS
As
•'a 4' CAST IRON T '
• PIPE (OR 12 MAX. 12 MAX.
! 4°ORANGEBURG(OR EOUIV.) Aft
EQUIV.)— MIN. PIPE-.MIN. LEACH
' PITCH 1/4"PER. PITCH 1/4"PER.FT. 'PIT .
PRECAST .
o o
v' ICI a ...
-LEACHING
` 0 EL..Y..WFf INVERT INVERT ? . e•;' PIT OR
SEPTIC TANK GIST. • ''s EQU1V.
INVERT EL:.•¢Za4 . . BOX EL4Z 3 : �. �:�.
/ooa. .. .. GAL. INVERT c� •••
EL4 -'�� INVERT' ;, W W 0: .a 3/4 TO I I/2
�: WASHED
W „ STONE
L5
PROR LE OF GROUND 'WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE
� ELIIAR
SOIL LOG WITNESSED BY:
DATE�� ! L 1.�. TIME.�'�v 41 . .� G. •�1 • . . . BOARD OF HEALTH
TEST HOLE 1 TEST HOLE 2 Tj?fa!7. �; ZC � !a,�, ENGINEER
ELEV. . 5 1E,Lo. . ELEV. .. . . . . . . . .
DESIGN DATA :
5408-950i4L NUMBER OF BEDROOMS 3. .
TOTAL ESTIMATED FLOW . . . GALLONS/DAY
BOTTOM LEACHING AREA SO.FT. /PIT
�tsDiw� SIDE LEACHING AREA SO.FT./ PIT
GARBAGE DISPOSAL ./YP4 �.(50% AREA INCREASE)
TOTAL LEACHING AREA SQ:FT
/ ,/ PERCOLATION RATE ,S.T?S/.A•v+ .?w4: MIN/INCH
LEACHING AREA PER PERCOLATION RATE �` �.. SO.FT.
!'1�p. .WATER ENCOUNTERED
NUMBER OF LEACHING PITS . O!?-W1W ?Z!/o.
APPROVED . . . . . . . . . . . . BOARD OF HEALTH
ter- OFs"�.#-- o.��tC Siam, /SG .10A.3
DATE . . . . . . . THOMAS E.KELLEY COS
AGENT OR INSPECTOR ENGINEERS—SURVEYORS
346 LONG POND DRIVE
// SOUTH YARMOUTH,MAS �OF
o''Q r17 02664
E.
r: Y �� KELLEY
. (j /"",Gs/y�•S / �` 1 i:c - " r': V ,A No.24260 O co
/�fO .0 v, /(/�, `a�! s t /'L•/ A9oaFSG/STEP���``�
S�ONAI Fa
PETITIONER : , is � u Yv c;;jtN