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HomeMy WebLinkAbout0019 BABBLING BROOK ROAD - Health 11 k6pin3 grook (g8- iS3 sMEA KEEPING YOU ORGANIZED No. 12534 2-153LOR SUSTAINABLE FORESTRY MIN.RECYCLED ALMLINITIATIVE CONTENT 10% CartifiedFberSourcing POST-CONSUMER VmW www.sfiprogram.arg SFwrzvn MADE IN USA "-ET ORGANIZED AT SMEADPAW COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 ,OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 19 Babbling Brook Road 6 Centerville, MA 02632 Owner's Name: Joan Cullinan Owner's Address: Date of Inspection: April 15, 2007 Name of Inspector: (Please Print) Jmnes M. Ford Company Name:. James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 . A CERTIFICATION STATEMENT t. , I certify that I have personally inspected the sewage disposal system at this address and that the information report6d below is true,accurate and complete as of the time of the inspection. The inspection was performed bead on my Co 77 training and experience in the proper function and maintenance of on site sewage disposal systems. I a''a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: — ✓ Passes N Co ditionally Passes N e s Further Evaluation by the Local Approving Authority j ils Inspector's Signature: Date: April28, 2007 The system inspector shall su4 a copy of thl inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 Babbling Brook Road Centerville, AM Owner: Joan Cullinan Date of Inspection: April 15, 2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound;not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the.Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 Babblinz Brook Road Centerville, MA Owner: Joan Cullinan Date of Inspection: April IS, 2007 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public.health,safety and the environment: Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of annnonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 Babbline Brook Road Centerville. bM Owner: Joan Cullinan Date of Inspection: April 15. 2007 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped— _ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from-a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less.than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems.in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 19 Babbling Brook Road Centerville, MA Owner: Joan Cullinan Date of Inspection: April 15, 2007 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No _✓ _ Pumping information was provided by the owner,occupant,or Board-of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ — Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health: ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 19 Babblinz Brook Road Centerville,MA Owner: Joan Cullinan Date of Inspection: April 15, 2007 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: I Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no.): Industrial waste-holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: _ Pumped after the inspection for maintenance Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components, . pp onents date installed i g p f known and source e of informa tion: Installed on 516185-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: 19 Babbling Brook Road Centerville, MA Owner: Joan Cullinan, Date of Inspection: April 15, 2007 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other ex lain ( p ) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TAN ✓K. (locate on site plan) Depth below grade: 20" Material of construction: concrete metal _fiberglass polyethylene _,other(explain) If tank is metal list age: Is age confinried by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 aQ 1. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert;evidence of leakage,.etc.). Tees were present. The liquid level was even with the outlet invert There did not appear to be anv sins of leakage The tank was pumped for maintenance after the inspection GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Continents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. _ 19 Babbling Brook Road Centerville, MA Owner: Joan Cullinan Date of Inspection: April 15, 2007 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: . Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION B ✓OX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even m Coments(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.): No solids were present. PUMP CHAMBER: - None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 Babblinz Brook Road Centerville. MA Owner: Joan Cullinan Date of Inspection: April 15, 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why:. Type ✓ leaching pits,number: 1 -4'x 6'(600 ate_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): The leach pit was in the driveway, An H-W heavy duty ton was added(See Permit No 2007 117) The scum line was 2'un fi oni the bottom. There did not al2pear to be any signs o ailure. The cover is ?"below zrade. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer:. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 Babbling Brook Road Centerville, MA. Owner: Joan Cullinan Date of Inspection: April 15, 2007 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. 8 o � 3 a as y� � 6 6 3 ag 10 d r Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 Babbling Brook Road Centerville, MA Owner: Joan Cullinan Date of Inspection: April 15, 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 15+/- feet Please indicate(check)all methods used to:determine the high ground water elevation: Obtained from system design plans on record-If checked,date.of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours inays Checked with.local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours naps the maps were showing gpproximately 15'+/ to groundwater at this site. i 1. This report has been prepared only for the septic system and components described herein.' This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed, written or implied, relating to the septic system, the inspection, this report andlor any components of the septic system which have not been located and inspected. 1 11 i l No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Y ZIPPYication for 3Mpo5al *pgtem Con0tructton Vertu Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ndividual Components Location Address or Lot No. /011 BAUD 05 B rm� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel cv rf,f, v.'L� r 7 m /_Qf b r1 An Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. rGon Gvm+I pul- )FOr2 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answ�er whi�n applicable) f n �n A ��VY �2 0/1. 6GO GAI � �h�ct' tS Un / �rt,v;LWAV 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 o the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar Heal . Sign e Date Application Approved by Date Application Disapproved by: Date for the following reasons _ Permit No. Date Issued a No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i/ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye applicatibn for Mi5ponl 6p$tem Cow6trUction Permit Application for a Permit to Construct( )` Repair( ) Upgrade( ) Abandon( ❑ Complete System X,�ndividijal Components Location Address or Lot No. /q BA II Aq B rO k Owner's Name,Address,and Tel.No. Assessor's Map/parcel CGnTG�V� /Q��/ —5—O An G'U(f I n alb Installer's Name,Address,and Tel.No. [ [� Designer's Name,Address and Tel.No. G4r8On BuMpU's FO 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(min.required) gpd Design flow provided gpd Plan Date Number.of sheets Revision Date Title " Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(.Answer when applicable) 14 5-70 A_.(1('.AJ V 7-00 ol-\ -mp A !/ r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in 1 accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. r� Signe r Date- Application Approved by Date 02 Application Disapproved by: ` Date v F for the following reasons Permit No. Date Issued 671 r ——————— ==—————————————————— — —._ —————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Of-AV"/ TC� on P Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ✓) Upgraded ( ) Abandoned( )by Go/4 &M>JS at 1 c,\ &>D(-1 i 6 ron v GtnT. has been con tructed in ccordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer r1 #bedrooms App veb'd d gn/.fl� _ gpd The issuance of this permit shah/j�/bot� s a guarantee that the(ystem will func io as ned. Date Inspector 1` - ----------------------------- .No. �D �` Fee 7THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS of\ Q,T Mi!5po$a1,6p$tem Cow5truction Permit �Av�r 10� Permission is hereby granted to Construct Repair (X Upgrade ( ) Abandon ( ) System located at (O r_41,Ari (Jf(M k R F and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty .to comply with Title S and the following local provisions or special conditions. Provided: Constructio must be completed within three years of the date of thisff Date �� Approved by PP V/ Q�e340 O r THE COMMONWEALTH OF MASSACHUSETTS -� 1,5 BOAR® OF HEALTH a ............. ...............--.-----....O F............................... ........... App iratiun for Disposal Works Tonstrurtiun Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: . ........... i�f, �:r.!�1. �33 < ..._&----------------------- --------------- r.... .. .% ----------------.....------ ---- Location-Address �/ _ or Lot No.. Owner Address ....... ....Z?�]`ham.....S. k�.. _ '� ... ---••............. .....,..........-------•-----------•--••--- Installer Address PQ UU Type of Building Size Lot�'_s.�_�a�_....Sq. feet Dwelling—No. of Bedrooms......................................Expansion Attic ( ) Garbage Grinder (�)o) p-, Other—Type of Building ............................ No. of persons....a 2................... Showers (off) — Cafeteria a :_. Other fixtures ---------------------------------------•----------------------•------------------------------------- W Design Flow.............................................gallons per person per day. Total-daily flow....... ...................................gallons. WSeptic Tank—Liquid*capacity#e.x....gallons Length................ Width................ Diameter................ Depth....___.._...._. x Disposal,Trench—No.�.................:.. Width.................... Total Length.................... Total leaching area..s2 //......sq. ft. Seepage Pit No..................... Diameter....____.___._...... Depth below inlet.................... Total leaching area..................sq. ft. i Z Other Distribution box ( Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date..........---------------------------- x Test Pit No. L..Z/Z,___minutes per inch Depth of Test Pit...L,5:.1...... Depth to ground water---V.6.- f14 Test Pit No. 2_A/2—minutes per inch Depth of Test Pit----/_S,_./..... Depth to ground water......YLC!?v4z P ......-...................................................................................................................................................... 0 Description of Soil........................................................................................................................................................................ W U ------------------•----••----.......---•-••-•--•---••-.......__.........-----------•..............--••-----------------•------------••-.......--•-•----•-----------------......---•-------------------- 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 TITLE4 5 of the State Sanitary Code—The undersigned further agrees not to place the system in o era ' until a Cert sate of Compliance has een ed by the board of health. ff Signed... `- - Date Application Approved By......... -------------- --•••----� . Date Application Disapproved for th following reasons-............................................................---------•-----•------•-..-.................... r --------------•-•-----•--•-•-------------.....--••----------...............-----------.......--------•--------••.....---•-------------•---•-----•--------•-----------•--------•--...---•------------_... Permit No..... S �------------------------- Issued.........!•• --- ....Date...... Date 140......................... FE:I3............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................................OF.............................. ........................... Apptiratiou for Roposal Works Toustrurtivit "pautit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: .................................. ............ Location Address or Lot No ............................................... ......................................... ............................................ �res. ...... .................................... Owner .Ls Installer Address Type of Building Size Lot.............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder 114 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria 04 04 Other fixtures ...................................................................................................................................................... WW Design Flow................''"--------------------*----gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid.capacity............gallons Length________________ Width._.__.._______-_ Diameter._.__._.._______ Depth________.___._.. Disposal Trench—No..................... Width_______-_-_-____.___ Total Length____________----..__ Total,leaching area....................sq. f t. Seepage Pit No._______-s---------- Diameter..................... Depth below inlet_.-__.:_.______.____ Total leaching area..................sq. f t. Z Other Distribution bok,( ) Dosing tank ( ) 4., . . Percolation Test Results Performed by...................................... Date........................................ 7---------------------­------ P4 Test Pit No. 1................minutes per inch Depth of Test Pit__.__.____________._ Depth to ground water_._._.____-_.._____..... 44 Test Pit No. 2................minutes per inch Depth of Test Pit-_.._._____.________ Depth to ground water_..____..._.________.... P4 ............................................................................................................................................................. 0 Description of Soil......................................................................................................................................................................... ..................................................................................................... U ................................................................................. :VW --------------------------------------------------------------------------------------------------------------- 4 '"...­*.......... ---------------------------------------------------------------------­*---------------- U 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 TITLE ': 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. Signed...................................................................................... ................................ Date ApplicationApproved By.................................................................................................. ........................................ Date Application'-Disapproved_roved-for the following reasons:............................................... 1�pp ............................................................ .......................................................................................................................................................................................................... Date PermitNo......................................................... IssuedL................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF,,,HEALTH a .ley'r F.,1WA ...........OF............. ..... ....................................... THIS IS TO CERTIFY, Tha�4,h e Individu . .......................I Sewage Disposal System constructed or Repaired by..................... ........... • ............ ......................... ..................................................... .. I In t I at.. ... .... ...... ................. .... ....... ..... ... ... ................................................ . has been installed in accordance wit the provisions of TITLE 5 oy The State Sanitary Code as described in the I application for Disposal Works Construction Permit No------1 4............. dated............/.......Z_Je-7-...f.,. ..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE A S A D CONSTRU GUARANTEE THAT THE SYSTEM WILL NICTION SATISFACTORY. DATE... — ---------------------------------------- Inspector................... . .... ...... TTS THE COMMONWEALTH OF MASSACHUS TTS BOARD/OF HEALTH I I ......... ..... ...............'OF.../4— ..................... ................................ No......................... FEE........................ Permission is hereby granted.________.... ....................................................................... to Constru t or�Re air an Indi J.d al Sewa D*s sa4syst� it ....... ................. .............. ......................................................... Street as shown on the application for Disposal Works'Construction Permit Dated______ _....... ....... ... ........... .... ........... eZ, Board of H e DATE.............................................................................. FORM 1255 A. M. SULKIN, INC., BOSTON r ' � ` e�l "��-y ��.,nl -, ,i 11.1/.• c-afi• .'�•/�-_''� .+-. N��. �• t6 A-1 ✓E �+Rlif7l: i / J� /vy �_ ." :.•_.. f'1'J t.ai ... � 1 .�` ��T/jl M�+`�'7'•iCL"' t•i A-r 1_4oi-tsr /z FC-L-'r RGcJi1`+ r/1U/+9 EX/ 17 li//t7 - J w, Fuur�Dr9'na,� -- 6 �� ./�,-. _.•:-: T//t:: F` 7 f CT rrn/h.LL--ACE+/✓G "IT- 3 73 1 it c, �S`/Dgvq t 1 /-7 un tt t$7fN6 _q •� � - t j W9_ s, a`r GAvtD C g, , 00�TC� f N V 17 - r— 01 o `otv P � � y �s' ra s�• _ 4- - • s fu Q N i 8c%2.7./ 1. 0 T 22 I 1" OF Miss 45; ooa�' 02. AL RTi ORSE GO Y No.10951 v/S of-_f 7Z 0 OF C6Nr;17701 LEGEND FS��0NAU�a EXISTING SPOT ELEVATION Ox CERTIFIED PLOT PLAN EXISTING CONTOUR --'.0 --- boa aaA FINISHED SPOT ELEVATION�WUCE icy' ``U7 2� �� �BL/N � 2ac��c R4 Q� vim \"s 4 FINISHED CONTOUR 0 CErc/TC F /_<. t. APPROVED , BOARD :OF HEALTH �. �� Q d gR.Dy6,i fL�✓i5E3 /7. /98y DATE AGENT s SCALE+ / '"= 40 DATE 12 / y _ _ (tLDREDGE ENGI EER/NG CO. INO cv 7 l CLIENT I' CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO. Oo BUILDING SHOWN ON THIS PLAN CIVIL t LAND CONFORMS TO THE ZONING LAWS ENGINEER �,�URVEYOR DR.BY OF BARNSTABLE , MASS. 712 MAIN STREET CH. BYE I NYANNIS, MASS. SHEET OF �- A E at'G . I r,r% "URVEYOR LE/�CN/NG PIT Ahe' MORE 7",",IAl /.Z '®I•"L,= . /© r'T. /•ot/N. SRA O49,0 /A ?4 *,01A M F 7,ER CONC-R.F TF C•0 J,,e 4'i'VC o/P� SWALL QF ®�DUaNT TO 41rA G0E. 6. ,v 7,4 CONCRCrL �/ MIN. PITCH hNEAVY CAST /ROiv C0Ve•-`R S,�/.�1 L pE c SF. ,DR/VJF1VA Y -- 2% W/N. CO/V C.eE TE (��:_.°: �y .4 oE COVER CLEAN S'A;r .' I I4. 4' GIST Q 2`LAYER-'/e` I O� P/TGN 000 GAL' D/57; o• �� 1 / • • • • • i ► p' •q� WASNL-D SJ�NE SEPC TANI� TI , / 1 . • 4 BOY , 1 1 $ • . • • • • .. _ ; : • •DGPTN •o: WA5W FP STONE' zs- i lot • • • • a • • o •�r PREc A5 r SE 9G/•" I MVCR7' C'L rE✓.4T/Q.V J / • . • • • • • • • ► P/T -OR "V I L! y y,v Gip . • s C;Ci v Z,r,o /.V AL'•RT AT ot/JLDJNG 26,o FT, P/TC..q,-l c f7y e G ITT: GJAJN. /N4 ET SEPrAC 7.4,VK Z t RT, I Z FT. PIAM. ri C SEE 7A0VL AYION•� .JuTLET SEPT/C 7*i4)v/4 ZS-e- FT. - /.,VLkTOJSTR/OLIT/ON, BOX ZSY FT. SECTJON OF GROUNL7 14G4TER Ti4�lL,E (M�-K • IS. r = 0✓TLtTD/5TR/OU'Y`1,ON DQX z.S.'Z FJ► INLET LEACNIAW fp/T 2S:0 Fr SE�/AiS.= O/SROSA 1. SYS7-&,W 'T�{01JLAT/DN I' LEACHIlVew PIT ' SCALE %s me / o~ D/MEN.t/ON A—2.o X77 D.ES/6JY CR/TER/�l Z D/MtNS/CN C.�_F77 "�.KC9,+tGED/ POSAL UN/r SO/L LOG �1'. 7-A4 Z�rr//` A7-Eo F'J-O*V ZZO GAL./0AV SOIL 7-F57-•)0/ $0/1- 7 7-##,2 SD/L T.EJT UA/0.5e )F LL`ACNlNG P/TS 1 �`ELC'Y. 27.I .w4jr4 A4T4- OF SOIL TEST I L -3 le ID 4.-ACHIACl PEft PIT ITb-0_519 lrT v/a.: RESULTS h 17-Al SSED JY •'��c"- ='rr�nf Ls�+CN/NG PER P/T r1 3.! $q. pT O�Z Pelf C0.4AWON RATFM/IDS//AICN LCACN/NG AREA ?GY SQ fT. A 1eCO3 A7-/oN RA7-,F A-2 Iy/N /NC. S �rt�EL,EA CIII v.S ARE^Z Lt4 SQ. FT, AA r 7Z�r 2970 +4 OVI , ORS No. 10951�Q ELD.RED a-v EIYCr/NctR/Arr G,.,.7 f / f��.tr' ' + •c \No rST_6P 7/2 MAIN ST, A Y.��NN/y /�•> .t_� . __ ` f' ONAL��'• nro Gnov/vD ✓'47&R .,VCOUA,;r rEO CI /.ENT � . GMO UNU Pv,4 TES r9 T- .FL EN, /Z, -.- TOWN OF ARNSTABLE LOCATION AT r6o SEWAGE# 1$LLAGE Ct/�lX r,/AU ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �� 1 yx�� (size) �*00 NO.OF BEDROOMS OWNER C t/J 4n 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 rn Spcc;r1no"\ I i L A, ' o ► oa A Q ► � U3 38 ; 3 as y3 3 as L0'CAT10N SEWAGE PERMIT NO. VILLAGE INSTA LLERR'S NA ME: i / ADDRESS S U I L D E R,,, OR OWN ER DATE PERMIT ISSUED 8 DATE COMPLIANCE ISSUED - A r® � I �, L