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HomeMy WebLinkAbout0009 HARVEST LANE - Health 9 Harvest Lane Centerville A = 209 067 s Ow'rford® NO. 1521/3 ORA �;�� 10% t Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Harvest Lane _ Property Address David Juneau _ Owner Owner's Name information is Centerville MA 02632 March 31, 2010 required for _ every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell _ cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 -- 'B""' City/Town State Zip Code 508-428-1779 SI 12855 _ 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority \Z-,C� aL::�4c March 31, 2010 _ In pector's Signature Date 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. LIO-81au.doc•08/06 Title 5 Official Inspection Form Subsurfac L,e Sewage Di sal System ge of 15 Commonwealth of Massachusetts A ;� j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Harvest Lane _ Property Address David Juneau _ Owner Owner's Name information is required for Centerville MA 02632 March 31, 2010 every page. Citylrown 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: Tank is scheduled for pumping following inspection. Leaching chambers had no standing water and no sidewall stains. 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 structuraily 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 10-81 Juneau.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 TOWN OF BARNSTABLE L OCATION� 4Gt(V�T-LyN Sc S/I VILLAGE o,NT-2ry ALe ASSESSOR'S MAP&PARCEL RqSTAttEWS NAME&PHONE NO. i C.fL ' f 79 SEPTIC TANK CAPACITY L LEACHING FACILITY:(type) akCA.+nn be(S size J NO.OF BEDROOMS OWNER ff PERMIT DATE: C6HATE:y„ P �'3 l I I C� 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 �� 1 \ 4 4 4 k 4 4 4 4 4 \ - ' - f '- , ! r f r f r J J J f ! J ! f J F ! J f f f F f 52! ! r r f lot 4 4 4 4 4 3 m" s Commonwealth of Massachusetts 4 t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Harvest Lane _ Property Address David Juneau _ Owner Owner's Name information is required for Centerville MA 02632 March 31, 2010 - every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 10-81 Juneau.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3.)f 15 Commonwealth of Massachusetts n, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '( 9 Harvest Lane _ Property Address David Juneau Owner Owner's Name information is Centerville MA 02632 March 31, 2010 required for — every page. Cityrrown State Zip Code Date of Inspection B. Certification cont. C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or Y P 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 El ® 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. 10.81 Juneau.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Harvest Lane _ Property Address David Juneau _ Owner Owner's Name information is required for Centerville MA 02632 March 31, 2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence! of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 10-81 Juneau.doc-08106 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 9 Harvest Lane _ Property Address David Juneau _ Owner Owner's Name information is required for Centerville MA 02632 March 31, 2010 every page. Cityrrown 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)) 10-81 Juneau.doc 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 ' <ZN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 9 Harvest Lane Property Address David Juneau Owner Owner's Name information is required for Centerville MA 02632 March 31, 2010 _ every page. Cityfrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 — DESIGN flow based on 310 CMiR 15.203 (for example: 110 gpd x#of bedrooms): 330 — Number of current residents: 2 — Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): N/A Irrigation System. Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: — Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seatsipersons/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): — 10.81 Juneau.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Harvest Lane Property Address David Juneau Owner Owner's Name information is Centerville MA 02632 March 31, 2010 required for _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records:. Source of information: Tank pumped March 2007 — Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? — Reason for um in : — p P 9 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: Compliance date: 11/9/03 Were sewage odors detected when arriving at the site? ❑ Yes ® No 10.81 Juneau.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Harvest Lane _ Property Address David Juneau Owner Owner's Name information is required for Centerville MA 02632 March 31, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 — feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): — Distance from private water supply well or suction line: feet — Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): _ Depth below grade: 16"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: 10.5' long x 5.8'wide- 1500 gal.— Sludge depth: 3 — Distance from top of sludge to bottom of outlet tee or baffle 30" — Scum thickness 2 — 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 12" — How were dimensions determined? Measured — 10-81 Juneau.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Harvest Lane Property Address David Juneau Owner Owner's Name information is required for Centerville MA 02632 March 31, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, tees were intact and clear. Tank scheduled for pumping following inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum to bottom of outlet tee or baffle — Date of last pumping- Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: — Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 10.81 Juneau.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Harvest Lane Property Address David Juneau Owner Owner's Name information is required for Centerville MA 02632 March 31, 2010 o. every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): No solids or high stains present. Liquid level found at bottom of outlet pipes. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 10-81 Juneau.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 or 15 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 9 Harvest Lane Property Address David Juneau Owner Owner's Name information is Centerville required for MA 02632 March 31, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required).- If SAS not located, explain why.- Type: ❑ leaching pits number: — ® leaching chambers number: three 500 galdrywells. _ ❑ 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.): Interior of leaching chambers had no standing water or sidewall stains. 10.81 Juneau.doc•08106 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Harvest Lane Property Address David Juneau Owner Owner's Name information is required for Centerville MA 02632 March 31, 2010 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of Liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: — Dimensions — — Depth of solids — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 10-81 Juneau.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 cf 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 9 Harvest Lane Property Address David Juneau OwnerOwner's Name -------------..._._......----.-...------_---_----------------------------------— information is Centerville MA 02632 March 31, 2010 required for . --------------- ----- _._..--- --- every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. \ \ \ 1 4 52 3 t.. Harvest Lane �.+ Commonwealth nwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 9 Harvest Lane Property Address David Juneau Owner Owner's Name information is required for Centerville MA 02632 March 31, 2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 20+ 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: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 25 and topo map shows property at el. 50. , 10-81 Juneau.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 N 15 T #' Q®TIQN 1 F � STCIL WAM *'VEIL WAM R N,��e��S�" ANC MA O;W 30111 0 I 00 k rouAT oil ML cis, t ow�� 1 F a I 4 1 -do. U i M { F TOWN OF BARNSTABLE �► LOCATION 9 I�4�!/e�l L ti� ACAGE#0 0—DG VILLAGE h`�trrt l!-� 17��tT_ASS SOR'S MAP & LOTL" AVYA `=INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Q A LEACHING FACILITY: (type) 3A"bQ Q0t1 0"Welk (size) NO. OF BEDROOMS BUILDER OR OWNER G PERMITDATE: � COMPLIANCE DATE: II 14,? 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 . rroN t � � a � V v r + N Fee THE COMMONWEALTH OKMASSACHUSETTS Entered in computer:/ ' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpplication for Migogar *p!tem Cow5truction Verna Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) CPIC,omplete System El Individual Components Location Address or Lot No.y Owner's Name,Address and Tel.No. (/►�t/el J' Assessor's Map/Parcel �®�� 0/ NII„ Installer's Name,Address,and Tel.No. 1. Designer's Name,Address and Tel.No. 775- 0 G 3 5— �, �� . �S Type of Building: �/�,S2� Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(/mot,) Other Type of Building r ✓ _ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ��� gallons per day. Calculated daily flow 7 y� gallons. Plan Date 2 aq- 4?9 Number of sheets Revision Date Title ld Y Y A Size of Septic Tank /_,U�d Type of S.A.S. (:S 64 Description of Soil 12�& ab1 ,_ Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and naintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the E 'ronm tal Code and not to place the system in operation until a Certifi- cate of Compliance has been issue Hea Signed "Date Application Approved by Date Application Disapproved for the following reasons Permit No. -°' AXY, Date Issued ~' Fee Z�Z THE COMMONWEALTH OFF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pprication for Mopo.5ar *veu Y Com5truction Vtrmit Application for a Permit to Construct(✓Repair( )Upgrade( )`Abandon( ) [P<-omplete System El Individual Components Location Address or Lot No.-7 Owner's Name,Address and Tel.No. { 10 Y� (A� r Assessor's Map/Parcel1. Q/^ i �� 1✓�n�a Installer's Name,Address,and Tel.No. ` Designer's Name,Address and Tel.No. 77�_ /h^7 3 - �Qn / V Type of Building: Dwelling No.of Bedrooms ` Lot Size 7 sq. ft. Garbage Grinder(/eta Other Type of Building .vim_ No. of Persons iShowers( Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow, 7 t`U gallons. Plan Date l Z--J i - CI 1 -Number of sheets / Revision Date Title ' Li r 5AJ111A-11YY1&1 Size of Septic Tank / '5 gtjJ Type of S.A.S. Description of Soil _ QAA �i Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The under ' ned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance,, the provisions of Title 5 of the E ronm tal Code and not to place the system in operation until a Certifi- `` :cate of Compliance has-been issue ark of Hea Signed _..._ Date Application Approved by I r Date �✓' A�! Application Disapproved forrihefollowing reasons Permit No. y Date Issued z - -kiE=MMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO C.RTIFY,th the On-site Sewage Disposal System Constructed( 6-1 Repaired ( )Upgraded( ) Aband ned( )b at `�/4 Lt< has been constructed in accordance `i with the provisions of Title 5 and the for Disposal System Construction Permit No 00/ dated ./,­ G� Installer Designer The issuance pf his permit shall not be construed as a guarantee that the syste V functio a designed. i I Date ® Inspectors i7 -----`r No. �!✓ ` 1/�� Fee / —THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS migonl Stem Construction 3dermit } Permission is hereby gjanted to Construct(,/)Repair( )Upgrade )Aba ion( ) $ System located at Aa 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�errriit., Date: 1 01)d Approved by ) v TOWN OF BARNSTABLE �� LOCATION I Q�I/cTl L--art SEWAGE#aM—®6 VILLAGE�� CVO 1� _ASS SOR'S MAP & LOT— Lo INSTALLER'S NAME&PHONE NO. L SEPTIC TANK)CAPACrMN Q n LEACHING FACILITY: (type) 'rOd L1t�� �Jrv�cll� (size) ��y NO.OF BEDROOMS BUII DER OR OWNER + Ana pie- PERMIT DATE` GU 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 N � a d i own of Bal-IISti ale l' N 1)cllarinlcnl of Ifeallh,Safely, and Environmental Services �n t� Public Health Division Dale Q 307 Main Slrcet,I lymmis MA 02001 , IIA nrrerA III Y- rlAss. • �' 1639-- Dale Scheduled ` � �� � _ 'lisle � '®C� if Pd. � Soil Suitabillip Assess/\ eni fol, Se►vage .Disposal I'erfonnell fly: © Witnested fly: c��J�� yy� 111A,1 LOCATION & GENERAL INI?ORMATION Locnlion Address zwl�' Owncr's Name :zl> Address Assessor's Mar/Parcel: t Y a. I ,�J (�, I:ngincci's Nnnsc v NMV CONSTRUCTION "� Itf 'Alit Telephone 11 2,�'•0 3 S 1-111d Ilse �Co Slopes(I".) o —3 Surface Stones 7 l m " Distances from: Open Wtdcr Dolly _11 Possible\Vcl Arca ,U If Drinking Water Weil fi Drainage Way II I'loperty Line CIO-- II Other II S ICI I C11: (Street name,dimcusions Ulm.cXaCI locations()[,test holes&perc tests,locnlc wcllnnds in proximity to holes) �a I i r Q %a Q I'arenl malarial(geologic) a% 'lei ®r4�� Jdl Depth lu,lledsock n Depth lu Groundwater. Standing Waler in I lolc: Y1(YQ, Weeping from Pil hnce � Estimated Seasonal I ligh Oroundwnler pE'I'I:RMINATI.ON FOR SEASONAL IIIGII,ti'V `fI�l2.'I'AIILL Method Used: Depth Observed standing in obs.hole: in. Depth to soil nlooles: Depth to weeping From side of ohs.hole: in. Groundwnler Adjustment Il. _ Index \Veil Il .. nradinp Dnle: _ Index \Veil level. _ Ad.j.Factor.— Adj.Groundwnler Level I'I;RCOI.iATION TPS'I' ii�il�.loZ i Time 11 30 Observnlion I lule!1 Or Time 111 9" Depth of Perc 6 ?� 'I Ime nl 6" Slall I'rc-soak Iimc rr J time(9"-6") _ I:od Ple-soak IL d (late Min./Inch el a Site Suilabilily Assessment: Site Passed V Site Failed: Addilional Testing Needed(YIN) Original: Public IIcalth Division Ohservalion I We Dain To Ile Conlllleled on liacit j Copy: Applicant 40L '. 1,0 G* Ucplh limit Soil I lot izoll Soil Tex(lite Soil color So I )Illcr .St., I-I� (USDA) Mililling (Slillcillic,NIMICS,llouldcrCs. -Cmn lil�cl I M--Nd hm)Lc-D- lo Yt ---------- Sy -------—------ DEEP OBSERVATION HOLE' LOG Hole I)CpIlI hoof Soil Holi7.oll Soil'I*cxllllc Soil Color Soil other Soll"Ice(ill.) (I IS DA) (N f III Ise I I) N10111ilig (Shuclurc,Slimes, lloolducs. to S- ,,S- 6- DENT0118VAOIATION 11OLE, LOG hole II Depill hoill Soil 11olizoll Soil Tuallte Soil Color Soil 011icr Surface(ill.) Molding (Sifochlic,Sloocs.llooldcics. Giant) DEW'T 01188AVATION 110.1-X1 LOG Role I/ I)CI)III flool Soil horizon Soil Texiolc Soil Color Soil 011ier Surface(ill.) (USIM) (NIIIIISCII) Milling (Sl I licl lire,Slopes,i I oilldcl cs. lu­'.0;vcl) RmUnsinimKq—Rafe Mal). AI)ovc5OO),c;ir flood boundary No Yes Within 500 year boulithily No Y c s Wilhin 100 year flood boundary No Yes Minfluff-Unbu-all y Occurring ill jn(crial I)oCS at least four feet of naturally occurring pervious material exist in all areas observed 011oligholit file arc;) proposed for tile Soil absorption SYSICIll'? If 11011, what iS the depth of naturally occurring pervious fll;l(Cl ial'? I certify that oil (dale) I have passed the Soil evallialior examination approved by the I kpal 11TIC11( of F.11vil-ollillell(al Protection and ON'( the -IbOvc (Mullysis was parorn)c(l by ole collsisleill \vi(l] the icquired ainhig, cxl)ci lise and cxl)cl'icllcc described ill 310 CM R 15.017. sigilahlic --W1rbugLa-w ka,J, TEST HOLE LOG DATE: J>GC. /3 SOIL EVALUATOR: -Al, O:Gcv y 3:4C" — WITNESS: , /S Lo T" OAS PERC RATE: 0.7, a60Pr,4s- s3,9 3' io ye 3 3• /o .e s a L•.5 . 7. C � QED. C SAnI.I� Z sy g/�i 5.7 Z,Sy Y(, -- �a wAT'El2 E�c/cou_.c 1TE.P6a . DESIGN DATA //// DAILY FLOW:(y)BDRMS.z 110 GPD=yTQ GPD 15 SEPTIC TANK: yyOGPD z 200% GPD USE:/,Soo GALLON PRECAST SEPTIC TANK ol� LEACHING FACILITY P USE: .S v T zS CAPACITY: ` s7 , fl t . \ n� SIDEWALL: t37...G, TOTAL: 0AAA4440 ` , . H OF 444 O� DANIEL L C'y BRAMAN N CIVIL V No.326S6C y NOTES: RUMBA 1. ALL PIPE TO BE 4"DIA.SCII 40 PVC. 7$11 2. PIPE TO BE LAID LEVEL FOR 2'OUT OF DISTRIBUTION fsS BOX. ' tSS,pc1P �ONAI 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN 17 3 g Q 6 OF FINISH GRADE. 'V0 yy 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A 1-�� _q 4) GARBAGE DISPOSAL. S. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE. 6. INSTALL GAS BAFFLE IN OUTLET TEE. 2"[AYEROF""PEASTONE OVER 314".1 112"WASHED STONE ALL AROUND TOP OF FOUND. ! - Ss�3 @ EL. .58.oO SS v o S s5�to S7.03 3 S. SEPTIC SYSTEM PROFILE SITE ^� SEWAGE PLAN GENERAL NOTES FOR 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR �flr TO ANY EXCAVATION OR CONSTRUCTION. _. ��j�/T�fZ�//G L SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH PREPARED FOR 310 CMR IS.00:TITLE V, 3. THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE 7 l DETERMINATION. 4. ALL DISTURBED AREAS TO LOAMED AND SEEDED. F DATE: 2 j / SCALE: 0 5. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY REQUIRED INSPECTIONS. WELLER & ASSOCIATES FT[ 1645FALMOUTH ROAD CENTERVILLE, MA. 02632 EL: (508)775-0735 FAX: (508)775-0754 l A L'Dvnlrrt<1 1RV. 6 - «, s8,zs 72 4100, 37 oe ol t J i f - -i 1 TEST HOLE LOG DATE: 1OGC. /3 �F'37 SOIL EVALUATOR_/W, O�ac .ylst/,Gs� WITNESS: 4/n efitiZ>/ ,4.ti/ OtJE,/2L�9`� O/57i�✓cT PERC RATE: . 0-7 45 3y /oyi?3 I. /o e 3 (j G. 5, L•5 . �oY, g f3 QED. C .SA,va itl�I�, SAn/.I� S c Z'sy �� y No wATE/2 ��c/Cou,c)TE,�6� DESIGN DATA DAILY FLOW: (el)BDRMS. a 110 GPD=`/7'o GPD h� SEPTIC TANK: WoGPD a 200%=,Zgo GPD USE:/Sa o GALLON PRECAST SEPTIC TANK as LEACHING FACILITY p Q�I USE:CT)-5"k8, S.+r Z took ore 28 CAPACITY: / SIDEWALL: J�3XZXO,�y=/37,�. BOTTOM: /3'X 33,SXo,,7y -30Z,3 / TOTAL: --7 y �� > AH OF MgsJ` 41G�o CIVI NOTES: RU wiOA sn a1. ALL PIPE TO BE 4"DIA:SCH 40 PVC. "`+ 3 791 �2. PIPE TO BE LAID LEVEL FOR VOUTOF DISTRIBUTIONBOX. s rcrC�� S/ONA 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN 6"OF FINISH GRADE. - 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL. 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE. 6. INSTALL GAS BAFFLE IN OUTLET TEE. 2'LAYER OF 3/8•PEASTONE OVER 3/4'-1 I/Z'WASHED STONE ALL AROUND TOP OF FOUND. EL. s7 SO 18' 14" C O So Sy zS S5!oo s"�35 ' y�3s SEPTIC SYSTEM PROFILE TE - SEWAGE PLAN GENERAL NOTES FOR 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR TO ANY EXCAVATION OR CONSTRUCTION. ! C�~��� C i ���• 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH PREPARED FOR 310 CMR 15,09;TITLE V, 3. THIS PLAN 1S NOT TO BE USED FOR PROPERTY LINE DETERMINATION. DATE: Z? / 1� SCALE: 1-9-s/Yd TE,a 4. ALL DISTURBED AREAS TO LOAMED AND SEEDED. Zo o Z 5. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY - — REQUIRED INSPECTIONS. WELLER & ASSOCIATES 1645 FALMOUTH ROAD CENTERVILLE, MA. 02632 TEL: (508)775-0735 FAX: (508)775-0754 APPROVED BY: C,�/y,0, o s� .b- o� C - y.3 said v N nb � \• 0 q N 44 0