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HomeMy WebLinkAbout0052 HARBOR HILLS ROAD - Health 52 Harbor Hills Road � Centerville A=247--70 'ff 0 2f 0 i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 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. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information I on the computer, use only the tab 1. Inspector: v (� key to move your cursor-do not Ricky L. Wright use the return Name of Inspector key. B & B Excavation, Inc. Company Name 14 Teaberry Lane Company Address Sandwich MA 02563 City/Town State Zip Code 508-477-0653 S14595 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 and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: •v Passes ❑ Conditionally Passes El Fails C'.l Needs Further Evaluation by the Local Approving Authority iE 1 �a. r 3/12/12 ® Insoegtor's Signature Date The"ystem inspector shall submit a copy of this inspection report to the Approving Authority(Board � N of�iehlth 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. �tllr(t5ins•09/08 Title 5 official Inspectioubsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required f Centerville Ma 02632 3/12/12 page. or every 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: i I i 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND(Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 _ _LQCAT-IO.N ' SEW�,C,E PERMIT 1.10. I-W5T.ALL.E-R-5-I,LL MF-- 6--AD.DRE5S__ __ _BUILDER S___►.1.A1.A.E_ � _AD_DR.E.SS ___ __ _ _ __ _ DIaTE P-ERN IT_ 1.55UED -D.ATE._ CON'IPLI AMCE._ ISSUED: j �� �� � - 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 ' h Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information a Centerville Ma 02632 3/12/12 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 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 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 ❑ ® 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w„ 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 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. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 5 of 17 Commonwealth of Massachusetts y W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 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)] 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 I i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 ears usage d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: July 2011 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: t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 16"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good shape no signs of leakage or blockage. 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: 5.8x5.8x10.6 Sludge depth: no sludge t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts r - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle no sludge i Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour 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.): At time of inspection tank appeared to be in good shape tees present no sign of back up. 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 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. Cityrrown 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.): 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: 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 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GSM a'' 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): At time of inspection d-box appears to be in working order.No sign of carryover or leakage. Pump Chamber(locate on site plan): i Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 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: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of W Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500 ❑ 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.): At time of inspection leaching appeared to be in good shape no sign of staining or hydraulic failure.Leaching was dry at time of inspection. 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 t5ins-09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 • i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 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.): i i I t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I i Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Harbor.Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. Cityrrown State Zip Code Date of Inspection D: System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately Rear Al 35' A A2- A3= 2W A4 :: 31 ` ® o A 5 = 29` CI 61 = 25` $2 - 31 ` O 1 Iv ` (3 52" 5 = t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts a W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. Cityrrown 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: >12 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: i Hand Augered hole I I Before filing this Inspection Report, please see Report Completeness Checklist on next page. l t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 52 Harbor Hills Rd. Property Address Sue Connolly Owner Owner's Name information is required for every Centerville Ma 02632 3/12/12 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION ASP Nar,Sor Ni 115 Rol • SEWAGE # 67005- 3:)0 VILLAGE C c.n-I c r u i ))c ASSESSOR'S MAP & LOT 9 '7 0 INSTALLER'S NAME&PHONE NO. RoScH G1 14114 SO'S- N77- 0653 SEPTIC TANK CAPACITY 1S00 gcxllon LEACHING FACILITY: (type) SOO c�cL I C aMS (size) I o7•5 z x a y 'x 2 NO. OF BEDROOMS 3 BUILDER OR OWNER John 1 OCco PERMIT DATE: '7-!l- OS 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 AI - 3s� - 31 AS AZ` 21' . iA3=o�N Rcc`r 3 ` 51 • A B Pa-►�0 3 ay -ys � z O AS 09 ' .J3 =4sa ' d t. t No. aoui — c� Fee #d THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS Zipprication for 33 gpool Opaem Cong;truction Permit Application for a Permit to Construct( . )Repair( )Upgrade(V�Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. �„ F�4rbo r }t �5 Owner's Name,Address and Tel.No. Assessor's Map/Parcel E' er c e�r" 10 h n -t 14 n 4 TOC LO M..A 2-47 LO--10 SZFJarbor I-h115 Rd,ldyQnnisport Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. _RGber+G•LIfv 1;r.B ExcaVa+tC3r\ �aho - Tech En4tronrr&n+al sos- 1q-j-i -berry �Ores+da. -c ,Spg-4"17-ob53 43 Tr'iani�te. Ctrcle , 5c►nAc0lC_h 08q 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 2:1-0 gallons per day. Calculated daily flow gallons. Plan Date b 22 0 5 Number of sheets A[251de5)Revision Date Title S PoAjnQjt _Qi!5P_Q5Q I lQ n Size of Septic Tank 15 0 O Type of S.A.S. Description of Soil Nature of Repairs or Alterations'(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date 7 1 7 10 Application Approved by /2 Date 61 Application Disapproved for the following reasons Permit No. Z�uS 3�o Date Issued 7— -7 —O- F No. Y Z2-o ' Fee /W^ THE COMMONWEALTH OF MASSACHUSETTS t , PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mizp5al *pwm Con.5truction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(✓)Abandon( ) + System located at 52 V\A�,n r,Q F n.,r.a. (a1, rn �`f 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 t�li'is erm�t. Date: -� Approved by / �~^� No. -_d�OUC''- Fee' tl ' . yam , • THE-COMMONWEALTH OF MASSACHUSETTS /� * Entered in computer:le!fYes - PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE;ANIASSACHUSETTS / 01ppYicatiou for 310pooal bpotem Cong;tructiofrt permit Application for a Permit to Construct( _ )Repair Upgrade Abandon i p ( )Upg (� ( ) ❑Complete Stem El Individual Components t Location Address or Lot No.4�1 H G r bo r 1-I,1 Is VCII" Owner's Name,Address and Tel.No Assessor's Map/Parcel J U i L n A 1 U C(0 MA P 2-,-17 I-u b 15Z.H(,rbOr I-Ii11.5 Rcl tJynnni-sport Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ? Ob-eri ,C i I U� [firB �MrkVti1 Iur� C`Cho - TeCh En\ll ror,MtnIC 5Uk - -1 f �:,.. 1 i 'Teaher,.�lfu turPS4cict�ta„SU .,:�t 53 c13 T,-lan� r0u.) 0�q` 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 �_0 gallons per day. Calculated daily flow gallons. Plan Date b I Z 21 Number of sheets I (2 5►C1 P 5) Revision Date Title )r,c4 el� '7a r Size of Septic Tank 1 r-�U U Type of S.A.S.(a) Zu Ck+w„ -, Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system.in operation until a Certifi- cate of Compliance has been issued by this Board of Health. - Signed _t2± Me I Date �7, Application Approved by YZ Application Disapproved for the following reasons �r f Permit No. Svc,c` - 3 2 Date Issued - -E------------------- l -------r--' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ' certificate of- Compliadre �- THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( ) Repaired (' )Upgraded Abandoned( )by:R)(�P r, + �, 1 ITS,a=� t �, c�, i n-1 at � ..1-er ,I " has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 uu�_—?;t) dated - Installer ci.be r I Ej'! I T v Designer- -F r Ini,TP c h_ The issuance of this permit shal not be construed as a guarantee that t e1P sy em�w'hftion a designed. �, ._.._Date � �� � Inspector \`�, t ^ Town of Barnstable IKE Regulatory Services Thomas F. Geiler, Director • BARNSPABM • 9Q MASS. �679. Public Health Division V 1� Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 r` Installer & Designer Certification Form / Date: 1 V lY �Ci. 200 5 Designer: Davit( 1�. Cov y dwv �5 Installer• Ro(=H Address: %Go -7'ec� C:vi v► 1'0hVWe47t Address: J 4 -�-s&Szrr4 Le-1 43 1 o'cingle C;v. S�n�w►ic� Fares4da lz rya oaGytl On `? - -OS' JRoS•c.r4 C;lfr'oc.-t was issued a permit to install a (date) (installer) septic stem at S Z 4whor P y H flS P&f based on a design drawn by (address) dated 3u0e (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. E SN OF M4 c q moo`' DAVID yGm D. (Installer's i e) 0 COUGHANOWR N Ido. 1093 �FOfSTE sgIVITAR%P� (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:HealWeptic/Designer Certification Form Y/l 0/W Notice: This Form Is To Be Used For the Repair Of Failed SepticSystems Only PERCOLATION TEST AND SOIL EVALUATION EX-8MPTION FORM I, Dkvl n C O�"G H.q-1.1L1� , hereby certify that the engineered plan signed by me dated Tuw 2Z,2P concerning the property located at Z H� Ry« R l,(„ RQJf 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 CLASS 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 deep test holes and percolation tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed 0 There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) � B) G.W. Elevation +adjustment for high G.W. ©•/1 DIFFERENCE BETWEEN A and B SIGNED7 '�- (i, ��S DATE: NOTICE Based upon the above information;a repair permit will be issued for bedrooms s maximum.. No additional bedroom .are authorized in the future without engineered septic system plans. gASeptic\percexemp.doc No.---' Fps THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........OF.....6....CLAv.-.,-,*...........*...*---------------------------- Appliration -for Bhipviial lVarkii Towitrurtion Vrruift Application is hereby made for a Permit to Construct or Repair ­an_T_ndividual Sewage Disposal System,,at) C 4a4_.,,j44,.. .. ... ............ ................ -e_.q--------_--_----------_--- Location cAddress 4 L No. --------- ----- ­- .......................................... .................................................................................................... Owner - ----- _... .................................................................. ............. .............................Address...................................................... Installer Address Type of Building Size Lot----------------------------Sq. feet D*elling—No. of Bedrooms--------------------------------------------Expansion Attic Garbage Grinder ( ) Other—Type of Building ..-------------------------- No. of persons..-_____._-______-_.____.-- Showers Cafeteria ( ) Otherfixtures ...................................................._---------------------------------------------------------I-------------------------------------- Design Flow-----------------------------------.........gallons per person per day. Total daily flow-------------------------------------------gallons. P4 Septic Tank—Liquid capacity------------gallons Length---------------- Width-.-_--..-_-__._ Diameter__.-__-._______ Depth._____.__.----- Disposal Trench—No_____________________ Width__________-_____-.__ Total Length----__--__--_.___-._ Total leaching area--------------------sq. ft. Seepage Pit No_____________________ Diameter_________-_______-__ Depth below inlet.._.__.________..__. Total leaching area------------------sq. ft. Other her Distribution box Dosing tank Percolation Test Results Performed by----------- --------- ----------------------------------------------- Date__-_----------.------------------------. Test Pit No. I----------------minutes per inch Depth of Test Pit_.._.._.__.__...._._ Depth to ground water...-___-...__._._....... r3:q Test Pit No. 2................minutes per inch Depth of Test Pit.___.__.__._-.____.. Depth to ground water-_.------_--:__._---_... Ix ------------------------------------------------------------------------------------------*------------*--------------------------------------------------- 0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------ x U ........................................................................................................................................................................................................ -------------------------------------- ----------------------------------------------------------------------- - --------- ---- --------------?-------_-------- -------- U N/atu of Repairs or Alter ions,—Answer when applica e.-- g. ...... u -0' - ---- - -------------------------------------------------------------- ............. greement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has boelNssued bb the boat 00f . S19*2d Date Application Approved By.... ��Ouzo.. ---------------------- ------------------ Date Application Disapproved for the following reasons:------------------------------------------------------------------------------------- ..................... ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued-_------------------- ................................. Date ------------ -------—------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............OF*.... ................................................ (Intifirate Of T11mittiatta THIS IS TO CERT FY, That the Ine 5vidual Sewage Disposal System constructed or Repaired by._.. 7A - ------------------------ ...... - -­---­....................................Ir........................................... ------------ - Iristallq, at., / l............f-----------S........... ------ ------------­-------------*.. ................... has been installed in accordance with the provisions of Article`XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit f--7--_-------- dated ............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ ...........OF.............,4 4 .......................................... N ............ FEE.."'�' ...................... 11mitrurfian Vrrmit .............. ............................................................................... Permission is hereby granted.._........ . .....�L to Construct -or Repair an Individual Sew-age Qj"sposal System .41 .......... .......C---—----- ----- ... at No..... ......... a Street as shown on the application for Disposal Works Construction Permit No-.- ......:: ... Dated__ . ... 7 (_ 1--') ................ ........ .... '......................./---------------- _/ ----------------- ...................................... Board of Health DATE.__. ............... ............ FORM 1255 11OB11S 8, WARRIEN, INC_ PUBLISHERS No. `Z`. � Fsa .................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Cr ti�✓ti./............OF.... ... ,�:* .l .. . ..--...... ................. Appliratiun -for Ditipmal Worko Tutuitrnrtion Vrrnift Application is hereby made for a Permit to Construct ( ) or Repair ( an ridividual Sewage Disposal System at Location-Address o No. -- - ..................... -: ------------------------------------------ ........................................... ................................................... Owner .............................•-•---•--------Address Installer Address Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) per-, Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures --------------------------------- Mons per person per day. Total daily flow------------------------------------------.-gallons. W Design Flow--------------------------------------------g� P P P Y• Y WSeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter.......--------- Depth................ x Disposal Trench—No. .................... Width.--.__-___-___--_--. Total Length-................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area------------------sq. tt. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY-----------------------------------------------.......................... Date............... --------------------.-.. Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ f1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ---------------------------------------•-•-----•--------•--•---•----------••--••-----•-------------..................................................... 0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------ X U --•------------------------•---•----------------------•--------•--•-----------------•----•--------••---•------------........................... ------------------------------•---------•------ w .......... ..................... -•...... It UNatu e of P.epairs or Alter dons—Answer when applica �' �q/` ..cz�.P� / f'/ r1 f r ti f '' - " " -f. _- ------------------------------------------------------------------------- greement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b n issued b the boar of h. j ,, Si ed, iy ,�' =�== = Date Application Approved By._ .. ------ --- ------------------------- "` Application Disapproved for the following reasons:................ -----------------------------._.-.-----•----------_---..___.Date ._.._......... .............................. .......................................................................................................................................................................... Date PermitNo......................................................... Issued........................................................ Date f HYANNISPORT, MA { PLAN REFERENCE CONTOURS "" FNtM z = i PLAN BOOK 103 PAGE 127 EXISTING - - - - - - - 40 i A a, =w ASSESSOR'S MAP: 247 MINIMAL GRADING PROPOSED J 00 o�< LOT: 70 LOCUS $ o 0 w 3 O C O<W + rtoS N O OHO >_ _ Q` \Z mNN Q "Wir N N 42 LOCUS MAP w I NOT TO SCALE LL O N wN !t Z � �N � O T l6 ' _42 N Lu < � U J (� W 1 ARE - 8550 s{ +- 0 & < � o ► LEGEND d o LU < Z w Z o WATER 1500 GALLON O o O o o GATE O SEPTIC TANK 3 4 ^ WA TER ` �+ 24 r, ► D-BOX O �' rL L I'NE �, Q J Vt o o ► TEST PIT J� tn • O Z " o�`o ICO lij a• 4'C p 5-0 12.7 ft EXISTING O >LL `l► Qj n-j Q oW Z o CESSPOOL (UOr W Zw G V '�0 ^ UTILITY POLE ca =oN NEB_ w'- co m P'9 VEp p -'� p a R/vFyi,A Y 1 TREE Q 7 -NUMBER REFERS TO DIAMETER P ► IN INCHES. LETTER DENOTES TYPE O-OAK M-MAPLE P-PINE In .LU 24 ft x 12.5 ft x 2 ft z w � O Z LEACHING GALLERY �. J �� m J � PLANwSEWAGE DISPOSAL SYSTEM PLAN LLo SCAL E: I in = 20 ft , -TO SERVE EXISTING DWELLING o BENCH MARK No °- JOHN & DIAN O: CO n- F �, Ln LU TOP OF WATER GATE ESN OF M4 tO ELEVATION - 42.91 ���P sStic 52 HARBOR HILLS ROAD T. MA o ° BARNSTABLE GIS DATUM off° DADVID �� ECO-TECH ENVIRONMENTAL O No. 1093 LL v " COUGHANOWR N 43 TRIANGLE CIRCLE SANDWICH MA 0256 l� a o --� Ed _ 508 364-0894 H C> e IST �- VITA /2, ETE-2077 DUNE 22. 2005 1/2 j y1� °'� THIS PLAN IS TO BE CONSIDERED A DRAFT PLAN UNLESS IT J OS BEARS THE STAMP AND SIGNATURE OF THE DESIGN ENGINEER (' ORIGINAL PLANS INTENDED FOR SUBMITTAL TO THE BOARD - OF HEALTH WILL BE SIGNED N BLUE AND STAMPED IN RED. SOIL TEST LOG ' DESIGN CALCULATIONS DATE OF TEST: JUNE 20. 2005 SOIL EVALUATOR: DAVID D. COUGHANOWR. RS WITNESS REQUIREMENT WAIVED - NO VARIANCES SOUGHT DESIGN FLOW: 3 BEDROOMS X 110 GPD - 330 GPD NO GROUNDWATER ENCOUNTERED SEPTIC TANK:330 GPD X 2 DAYS - 660 GALLONS TEST PIT I PARENT MATERIAL: PROGLACIAL OUTWASH ELEVATION - 41.40 •- PERC AT 56 in : 2 MIN/INCH IN C SOILS INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) DISTRIBUTION BOX: USE 3 OUTLET D-BOX. DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING SOIL ABSORBTION SYSTEM: A 24 ft x 12.5 ft x 2 ft LEACHING GALLERY CAN LEACH 41.40 0-3 0 WOOD LOAM 7.5 YR 2.5/2 NONE FRIABLE Abot - ( 24 x 12.5 ) - 300 of Asdw - ( 24 ; 24 12.5 ; 12.5 ) x 2 - 146 sf 3-7 A SANDY LOAM 10 YR 4/3 NONE FRIABLE A t o t - 446 s f 7-32 B LOAMY SAND 10 YR 4/6 NONE LOOSE Vt 0.74 x 446 - 330.04 GPD 38.73 32-140 C MEDIUM SAND 10 YR 6/4 NONE LOOSE USE A 24 ft x 12.5 ft x 2 ft GALLERY. Vt - 330.04 GPD > 330 GPD REQUIRED 29.73 GROUNDWATER ADJUSTMENT EXISTING GROUNDWATER LEVEL BASED DSSTABLE DEPARTMENT RECORDS.G S LEACHING GALLERY 500 GALLON DRYWELL DrENSIONS AND DETAL INDICATEDINDEX WELL W MIW-°29 CONSTRUCTION DETAIL USE H-�0 LMT ZONE C READING DATE MAY. 2005 DRYWELL UNIT 8 RISER LTO WITHIN SIX INSPECTION READING 6.4 STONE '-6'x 4•-10-x 2'-9' .. . INCHES OF FINAL GRADE ADJUSTMENT 0.9 2 f1 EFF. DEPTH AND INDICATE LOCATION ADJUSTED GW 13.9 24.0 ft ON AS-BUILT PLAN 0 NOTES oN 0 34 00 1) GARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN N o cv O�aoQOpoopp 00��0 in A LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM. dpppc:3E:3 00 2) ALL L p O 00 o p po 0 •� . INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS _ pp 3) ALL COMPONENTSS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15) 3.5' 8.5 8.5 3.5' 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES 24.0 �� NOT TO � )2 in BEFORE EXCAVATING FOR SYSTEM. SCALE 5) EXISTING CESSPOOLS TO BE PUMPED. COLLAPSED. AND FILLED, OR REMOVED 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE 7) LINES EXITING D-BOX TO RUN LEVEL FOR 2'-0' BEFORE PITCHING DOWN SEWAGE DISPOSAL SYSTEM PLAN 8) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK -TO SERVE EXISTING DWELLING 9) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM, J O H N & D I A N A T O C C O 10) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. 52 HARBOR HILLS ROAD HYANNISPORT. MA 1 1) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE._ ON A LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH EC',O-TECH ENVIRONMENTAL SIX INCHES OF CRUSHED STONE HAS BEEN PLACED 70. MINIMIZE UNEVEN SETTLING 43 TRIANGLE CIRCLE SANDWICH MA 02563 ETE-20771 JUNE x22. 2005 2/2