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0011 HELMSMAN DRIVE - Health
A I Helmsman Drive Centerv_ille i A= 194-078-4A UPC 2534Na L4, R • 1111�T1110�•111f r No. ®V� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for 3Bisposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. C—LM5MW DIR Owner's Name,Address,and Tel.No. Assessor's Map/Parcel i `t. 1( iWGe_M5_NW (D&j Installer's Name,Address,and Tel.No.36X'g77— W 77 Designer's Name,Address,and Tel.No.5_,0$—;Q3-0 9 77 C4L—GviDr &"71 /AGa 'ZG C1V GdN Cz =MG _L53 Ga d,1A4_S-Z- AYtt-P05 - 64WlE �► �e Type of Building: Dwelling No.of Bedrooms Lot Size aL(/ —sq.ft. Garbage Grinder Other Type of Building A&,SQEx.)r l cam. No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3© gpd Design flow provided gpd Plan Date 4— Number of sheets Revision Date Title —072j V c- <fCLk Size of Septic Tank (1600 6�)J Type of S.A.S. (A 5-00 G LL..OIJ 4—).6 - t{06Y � Description of Soil F11JE C40 a4" 56-E P4,0W Nature of Repairs or Alterations(Answer when applicable) . &J 6— 1 1&06 �lU Ll1 ti)�-; Co D'AA)C. 11� (a. C)® kL4411) t4 n,20 LL EL1--1 �: K BLS Lo 1 mt± !Y yA-j?j t1U Cr- 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 Certificate of Compliance has been issued by this Board of ealth. Signed Date Application Approved by �^ r Date ~ 10'L Application Disapproved by Date for the following reasons Permit No. 2019 — 13q Date Issued / /0 q TOWN "OF BARNSTABLE LOCATION N� �P`I N 04b—iV S SEWAGE# ;4(9 (34— VILLAGE�9`TaV_U-r— ASSESSOR'S MAP&PARCEL 9y `7 INSTALLER'S NAME&PHONE NO.Ca — 7—iR7 SEPTIC TANK CAPACITY t i OOO CALLOM S LEACHING FACILITY.(type)\A O®!-�, 04A,Rj3EwS (size) `X as NO.OF BEDROOMS— .3 OWNER yV QCeL.� b®/4&-PZJ PERMIT DATE: 4 1 COMPLIANCE DATE: V.20 l Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /`0 Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) lA Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY `A PEch C ' 0��S EP � A41 .5 ' 3 31-'l � c `5 f. C t No. C! ®� J •' Fee f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0[pplifation for Disposal 6pstem Construction i9Prmit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location.Address or Lot No, tt�jj� /�'I 7%GLM5M OV 1( 1WG_�'(SM Owner's Name,Address,and Tel.No. p Gt V/CG 00 �$.a y�-°�1v Assessor's Ma /Parcel (9`C/ Installer's Name,Address,and Tel.No.5402-If77-?8 77 Designer's Name,Address,and Tel.No.S4c6'��3'�-0 7 77 "CAV&W iD& C-+v7s Address, 'fi t:. G4V GdMC1MW :r =A)Q 53 G.v c�,/�4-C.SZ' cc'f,4S 'PE $S� Hwy Type of Building: ^ Dwelling No.of Bedrooms ra'21,klt, Lot Size .5 ;Lq-sq.ft. Garbage Grinder( ) Other T e of Buildin J Yp g QCSl1�F�th'( _ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) _ 30 gpd Design flow provided gpd Plan Date 4" {- P-to xNumber of sheets Revision Date l+ Title Size of Septic Tank (d4D0 6*LL Op ) Type of S.A.S._(A 574k> GA4.4 4w 14-kj C-L4!!ja Description of Soil F/ So(Aj ) < a 1 S 6 L 44A) Nature of Repairs or Alterations(Answer when applicable) U56 G 1 S`1AJ&' hop® 77U fytg J -;;LU b•g® ?tom goo G&J,&J ,f-l'�� [.��-eaJC—� C1�d�g�JLS 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 Certificate of Compliance has been issued by this Board of Health. Signed Date '"��"� Application Approved by � /'_ 9 12-S Date j 0`/ 5 I r Application Disapproved by Date for the following reasons Permit No. a�OI j 3�( Date Issued %n`Cq THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired OO Upgraded( ) Abandoned( )by 1^ �jc}! a j ,� at__� (. { I t�t.�d 4N . DA!VE Ut u. has-been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.909 ' 13Lf dated 1-[ /D C Installer_" P w(Da �K,►`T, f ® Designer XC. E)J&WIE' 6 #bedrooms Approved design flow ,, / gpd The issuance of this permit shall not be construed as a guarantee that the system wil)'function as designed. Date �J C' Inspector 7 (T ------------------------,------------------------------------------------------------------------------------------------------------- No. P d(?r !J �( Fee ( c THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposat *pstem Construction VPrmit Permission is hereby granted to'Construct( ) Repair(X) Upgrade( ) Abandon( ) System located at t I l�i UA<1+U Abj Oki UF— !Cr ( , and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 permit. Date � Approved by / r IYlay. I v. IU I Y d: JOA l No. 3193 P. i Town of Barnstable Regulatory Services Richard'V'. Scali, Interim Director '"^W Public Health Division ffi�9• Thomas McKean,Director . 200 Main Street,Hyannis,MA 02601 Office; 508-862-4644 lac 508-790-6304 Installer& Designer Certification Vorni Date: "10' �� Sewage Permit# 20 19—1 34 Assessor's Map\Parcel 1 R N Designer: TG Enc%trlew.ct� 5��. Installer, Gaee.wicle t:tlFtrP�tscS. Address: 265Y C(avib,2rr,/ w a�� Address: 15'5 Coy me--coal 6Free.F ho-��Apee_\ riA 07-6'19 Qn "+ 'o — 20 lc1 Gad�',c�cJe L,�l-"rrscy was issued a permit to install a (date) (installer) .. . septic system at �66 S r4avt Dr�V C- based on a design drawn by (address) 5 G Lnyth�ertn 0t , 'Try , dated A CC,( 1 , ZO I (designer) 1� 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. Strip out (if required) was inspected and the soils were found satisfactory. 1 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, Strip out(if required) was inspected and the soils!. . were found satisfactory, I certify that the system referenced above was constructed ' e with the terms of the I\A approval letters(if applicable) ��P IN o Arasq c oho )OHN 04CH►LL JR, (ln ller' Signatu CI NO 190� /STER Igner's Signature) (Affix Des' a amp Here) PL + SE RETURN TO ARN'STABLE PUBLIC HEALT DI SION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND. AS- BUILT CARD ARE RECEIVED BY THE 13ARNSTABLE PUBLIC HEALTH DIVISION. TRANK YOU. Q;1SeptioMesigner Certification Forni Rev 8-14-13.doc FIK Town of Barnstable P# 1 5 9 2-.2_ Department of Inspectional Services wuvsTas 8S.r,e, Public Health Division Dateg t639. '°rFp MpI° 200 Main Street,Hyannis MA 02601 Ad Office: 508-862-4644 ? Date Scheduled �� Time / ( Fee Pd. G D D P� M, Id Soil ui ability Assessment f ewage Disposals Performed By: I i Q(/1 ��-4 CS!� Witnessed By: I MATION, Z ERAL'1�NFORIVIATION` ; Location Address I t )ams. ru bp— 'IL�Owner's Name �tt<L!/}NQ Dak46 [�r� �l (f6WrC_Y_V,t C(� 14 E015&44 V DR. �E_P7&-ut „CAddress I 1 Assessor's Map/Parcel: i -l 4 /0_ 9 Engineer's Name JL / Engineer's Email:Al'nIM&-'OTtL (,TC.�� 4h2aU zXX.k-W-1 NEW CONSTRUCTIO1N REPAIR Telephone# 50'�s,;113—63-77 Land Use St " l �0. Slopes(%) 01110 Surface Stones /t Distances from: Open Water Body /yob ft Possible Wet Area )]do ft Drinking Water Well ft Drainage Way _ ft Property Line 710 ft Other ft SKETCH:(Streit name,dimensions of lot,exact locations of bst holes&perc tests,locate wetlands in proximity to holes) madd P1c,_t) Parent material(geologic)attw Depth to Bedrock `t Depth to Groundwater: Standing Water in Hole: `f Y JJ,�.J. Weeping from Pit Face Estimated Seasonal High Groundwater ](fly` 3,Cs,S. D TERMINATION FOR SEASONALYHIGH`WATER TABLE _ ` , �` Method Used a{(� �bS� � Depth Observed standing in obs.hole: ! U in. Depth to soil mottles: u� in. Depth to weeping from side of obs.hole: /as in. Groundwater Adjustment — ft. Index Well# Reading Date: — Index Well level Adj.factor — Adj.Groundwater Level ' PERCOLATION TEST Date .� me ' Observation I' r Hole# Time at 9" Depth of Perc �K ' `r Time at 6" Start Pre-soak Time @ '1 v Time(9"-6") End Pre-soak I •' !Q ht Rate Min./Inch Ca Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:Wpplication Forms\PERCFORM 2018.doc DEEP OBSERVATION°HOLE"LOG';' Hole# La_ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) aQ 4q ' C Y 7/y — DEEP OBSERVAT:ION'HOLEZOG' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) `DEEP OBSERVATION HOLE Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) DEEP OBSERVATION HOLE LOG';= Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) Flood Insurance Rate Map: / Above 500 year flood boundary No_ Yes V Within 500 year boundary No V Yes Within 100 year flood boundary No V/ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring,pervieus material exist in all areas observed throughout the area proposed for the soil absorption system? VeS If not,what is the depth of naturally'occurrin4 pervious material? Certification I certify that on 10 1,2 711 q (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience describ in 310 CMR 15.017. Signature Date Q:Wpplication Forms\PERCFORM 2018.doc ' TOWNT 7F AR'NSTABLE -LOCATION SEWAGE # VILLAGE 1 �L-tL�. ASSESSOR'S MAP & LO INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type)(1 o �� �—� f1,�(,�size*X � ► NO. OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: j . 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 11 Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility Feet '� Furnished by _ �' c scretn noA ac , g AO d� f�j 11 f p C L r / Eo k A'I COMMONWEALTH OF MASSACHUSETTS t' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 1 x� quo �Y, u»� TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR:VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ; PART A CERTIFICATION Property Address: 11 HELMSMAN DR CENTERVILLE,MA 02632 Owner's Name: BILL DOHERTY Owner's Address: PO BOX 275 BRIDGEWATER CORNERS,VT 05035 Date of Inspection: 1/14/02 x' Name of inspector: (please print) JOHN GRACI _ INSPECTIONS SEPTIC INSPEC y Company Name: Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813,,FAX 508-564-7270 ' CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is 4 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: X Passes` _ Conditionally Passes Needs Furthjr Aaluation by the Local Approving Authority Fails r sry'. Inspector's Signature: Date: 1/14/02 d The system inspector shall submit copy of this inspection report to the.Approving Authority(Board of Health or DEP)withtn,�t 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. buyer,if applicable,and the approving authority. sent to the system owner and copies sent to the a a, as Notes and Comments SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. w ****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. rI ,tom� f - `Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR,VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A .s ' 3t�r CERTIFICATION(continued) f Property Address: 11 HELMSMAN DR CENTERVILLE,MA 02632 :g Owner: BILL DOHERTY Date of Inspection: 1/14/02 `' ~ Inspection Summary: Check A,B,C,D or E/ASS complete all of Section D A. System Passes: X 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: SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE. . SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or mores stem components as described in the"Conditional Pass"section need to be replaced or repaired.The system, , , Y p _,,.. upon completion of the replacement or repair,as approved by the Board.of Health,will pass. t Answer yes,no or not determined(Y,N,ND)in the for the following statements.if"not determined"please explain. `' y n/a 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: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed `_ F i e s or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of PPO , Health): _ broken pipe(s)are replaced obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass a b inspection if(with approval of the Board of Health): u _broken pipe(s)are replaced _obstruction is removed i ND explain: n/a 1 7 V � Page 3 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A n CERTIFICATION(continued) ; . Property Address: 11 HELMSMAN DR CENTERVILLE,MA 02632 , Owner: BILL DOHERTY '. Date of Inspection: 1/14/02 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. " • fir: .: � 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: _ C _ 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 ; R k 7c 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: .r _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water ,e. 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 K` supply well".Method used to'determine distance n/a ` t y� "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 4�1+ 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. 1 a Z_, 3. Other: n/a Qj rt � ttTiiyu��„ y3 �r 'Page 4 of 11 „ s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART A _� C;yr CERTIFICATION(continued) w { Property Address: 11 HELMSMAN DR CENTERVILLE,MA 02632 Owner: BILL DOHERTY r Date of Inspection: 1/14/02 1 � 4 D. System Failure Criteria applicable to all'systems: Xt You must indicate"yes"or"no"to each of the following for all-inspections: w Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool : X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged . ; 5 SAS or cesspool r '' X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ,: _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/2 day flow 1. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nla. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. p P �'Y g f� X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone I of a public well. 4. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. k X 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 DEP7 , certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free a from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or, r, less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.]. (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 ; CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design now 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 X the system is within 400 feet of a surface drinking water supply Ni N' X the system is within 200 feet of a tributary to a surface drinking water supply . : X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped . public water supply` well t Zone II of a p r,Ta� If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered The or operator of an large Sys,tem considered a significant threat "yes"in Section D above the large system has failed, p Y under Section E or failed under Section D shall upgrade the system in accordance with 310 CMII 15.304. he system owtlt3P should contact the appropriate regional office of the Department. : R tI Page 5 of l l tv OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS � • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :u �- PART B " CHECKLIST yt I} Property Address: I HELMSMAN DR CENTERVILLE,MA 02632 � ' Owner: BILL DOHERTY `t Date of Inspection: 1/14/02 " 4. t indicate"yes"or"no"as to each of the following: Check if the following have been done.You mus Yes No X _ Pumping information was provided b the owner,occupant,or Board of Health r P g P Y P X Were any of the system components pumped out in the previous two weeks « . X _ Has the system received normal flows in the previous two week period? � _ X Have large volumes of water been introduced to the system recently or as part of this inspection? Y; a X Were as built plans of the system obtained and examined?(If they were not available note as N/A) u .1, X _ Was the facility or dwelling inspected for signs of sewage g back p • X _ Was the site inspected for signs of break out? {� X _ Were all system components,excluding the SAS, located on site? X _ 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? , ;: X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance H° 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 ; plan at the Board of Health. X _ Existing information.For example a p �`'��:• �; iy.'{,' X _ Determined in the field(if any of the failure criteria related to.Part C is at issue approximation of distance is �N, unacceptable)[310 CMR 15.302(3)(b)] � a 'a x Y Page 6 of 11 a , OFFICIAL INSPECTION FORM—NOT FOR,VOLUNTARY ASSESSMENTS •'' ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r r� SYSTEM INFORMATION . Property Address: 11 HELMSMAN DR CENTERVILLE,MA 02632.. Owner: BILL DOHERTY ; Date of Inspection: 1/14/02 FLOW CONDITIONS f RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual); 2 DESIGN flow based on 310 CM 15.203 (for example: 110 gpd x#of bedrooms):220 Number of current residents: 1 ' Does residence have a garbage grinder(yes or no):NO y' Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] ` Laundry system inspected(yes or no). NO , Seasonal use:(yes or no): NO "rr Water meter readings, if available(last 2 years usage(gpd)): n/a t Sump pump(yes or no):NO . Last date of occupancy: n/a s F � } COMMERCIALANDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a ' Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no):NO , Water meter readings,if available: n/a g , ?p a Last date of occupancy/use: n/a t' OTHER(describe): n/a GENERAL INFORMATION _ Pumping Records -# Source of information: n/a Was system pumped as part of the inspection(yes or no): NO w um A If es volume pumped: n/agallons--How was quantity pumped determined?n/a ' Reason for pumping: n/a `3 TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool ='y Overflow cesspool "t ,zt4 _Privy 0 r no if es attach previous inspection records,if any) 1 system es P f Shared ( Y S (Y ) Y _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 3 _Tight tank Attach a copy of the DEP approval Other(describe). n/a Approximate age of all components,date installed(if known)and source of information: ; 1984 Were sewage odors detected when arriving at the site(yes or no): NO �. s}lryaf' i {,� Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 HELMSMAN DR CENTERVILLE,MA 02632 ' Owner: BILL DOHERTY ` Date of Inspection: 1/14/02 ti t 1Y iV'. BUILDING SEWER(locate on site plan) Depth below grade: 18" ?: Materials of construction:_cast iron _40 PVC Xother(explain):20 PVC w . Distance from private water supply well or suction line: n/a `. .. Comments(on condition of joints,venting,evidence of leakage,etc.): : TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" fill'; Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a u If tank is metal list age:n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8 6 H 5:,T. W:4 10 Sludge depth:2" ` F ^ Distance from top of sludge to bottom of outlet tee or baffle:32" W. ' '?= Scum thickness: 1" 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: 17" ` How were dimensions determined: MEASURED Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related Z.,a to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. l r: locate on site plan) GREASE TRAP:_( p ) �. r. Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a 3 Dimensions: n/a Scum thickness: n/a r Distance from top of scum to top of outlet tee or baffle: n/a ; Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related. L`x; to outlet invert,evidence of leakage,etc.): n/a ?, 32ti �,! v �'ij• r� Page 8 of 11 y; OFFICIAL INSPECTION FORM—NOT FOR,VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � � PART C SYSTEM INFORMATION(continued) Property Address: 11 HELMSMAN DR CENTERVILLE,MA 02632 ` Owner: BILL DOHERTY Date of Inspection: 1/14/02 '1=` TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) ; Depth belowgrade: n/a .: Material of construction:_concrete_metal fiberglass polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day ;`s Alarm present(yes or no): N/A ' Alarm level:N/A Alarm in working order(yes or no): NO Date of last pumping: n/a '�e Comments(condition of alarm and float switches,etc.): n/a on site plan) DISTRIBUTION BOX: X(if present must be opened)(locate zti Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into::. or out of box,etc.): ; D-BOX IS STRUCTURALLY SOUND. `" 4„Lr PUMP CHAMBER:_(locate on site plan) .?'� ,` w� 15 Pumps in working order(yes or no): NO . Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 4 ` T n/a } a R� + W+ A R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 4'b ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: I I HELMSMAN DR CENTERVILLE, MA 02632 u Owner: BILL DOHERTY Date of Inspection: 1/14/02 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) ; If SAS not located explain why: n/a A. ;. Type 1000 GAL 6' X 6' leaching pits, number: 1 ;' n/a leaching chambers, number: n/a - ~ . r n/a leaching galleries, number: n/a I n/a leaching trenches, number, length: nla F� i n/a leaching fields, number: nla F' n/a overflow cesspool, number: ` p n/a innovative/alternative system n/a Type/name of technology: n/a * S ' F r Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THERE IS 4'OF LIQUID IN IT NOW.BOTTOM IS AT 9' WITH 1' OF LEACHING LEFT.RECOMMEND MOVING TREE. s CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a 9 Depth—top of liquid to inlet invert: n/a ' Depth of solids layer: n/a Depth of scum layer: n/a { Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO s Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): k. n/a rt� 1 PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a " ' Depth of solids: n/a level of ponding,condition of vegetation,etc.): Comments(note condition of soil, signs of hydraulic failure, le J�q •a n/a k , q b,M1Ji r� d Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1, PART C SYSTEM INFORMATION(continued) Property Address: 11 HELMSMAN DR CENTERVILLE,MA 02632 Owner: BILL DOHERTY { F Date of Inspection: 1/14/02 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. ;. 3, A IiY:laT �i'. zy ?fit. AA 13 " F 4C s: b 1�p1 i • Page 11 of I 1 ,t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 HELMSMAN DR CENTERVILLE, MA 02632 Owner: BILL DOHERTY Date of Inspection: 1/14/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+FT. ' s I ,F r � r 37`r 11 3 • �-\ COMMONWEALTH OF MASSACHUSETTS _ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION a TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:. q. Owner's Name: RECEIVED Owner's Address/// Date of Ins, ection: / //, p ���' JAN 2 9 ZOO( Name of Inspector: (please print)__P �. 1C)f ,,� TOWN OF BARNSTABLE Company Name: Z, L . ��el C HEALTH DEPT. Mailing Address:. ._O Telephone Number: /., 9,39 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at-this address and that the information reported below is true, accurate and complete,.as of the time of the inspection. The inspection was performed based on nay 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 Needs.Further Evaluation by the Local Approving Authority F�ls Inspector's Signature: Date: / S/Ot4 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection.and under the conditions of use at(fiat 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 I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART A . CERTIFICATION (continued) Property Address: Owner: o-ozA, Date of]nspec ion: Inspection Summary: Check A,B,C,D for E/ALWAYS complete all of Section D A. System Passes: 1 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 meta l and over 20 ears old or the septic lank(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 boa.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: Page 3 of 1'1 OFFICIAL INSPECTION FORNI - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYST�,M INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ,C& oc/ Owner: Date of lttspec ton: 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 wliich:ivill protect pudic 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 an),)determines that the system is functioning in a man tier that protects the public Health,safety and environment: _ The system has a septic tank and,soil absorption.system(SAS)and the SAS is within 100 feet.of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and,the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet.of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100.feet but 50 feet or more from a private water supply well". Method used to determine distance` "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A-copy of the analysis must be attached.to this form. 3. Other- 3, Page 4 of 1 I OFFICIAL.INSPECTIONFORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ' a. v ,cJ Owner: Date of Inspec ion: ~/o,/i;!�� l D. System Failure Criteria applicable to all systems: You must indicate "yes"or"no"to each of the following for all inspections: Yes N q L Backup of sewage into facility or system component diie to4overloaded or clogged SAS or`eesspool _ 1, Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or / clogged SAS or cesspool _V Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 1 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 priory 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 coliforrn bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the.presenee of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria p are triggered. A copy of the analysis must be attached to this form.] �U (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the,failure. E. Large Systems: To be considered a.large'system the system must serve a facility with a-design flow of 10,000 gpd to:15,000 gpd You must indicate either"yes"or"no"to'each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system js 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 LI 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 1,1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHLCIMIST Property Address:d Owner: p Date of Inspe Lion: 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. w,"Were.any of the system components purnped out in the previous two weeks Has the system received normal flows in the previous two week period? _lave large.volunies 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? _V"' _ 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 plau.at the Board of Health. Detennined in the field(if any of the failure criteria related to Part Cis at issue.,approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page g 6ofll . OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFAC:F� SEWAGE-DISPO,SAI.J,SYSTEM INSPECTION T,'ORM PART C SYSTEM iiN.I+ORICIATION Property Address: ,Q -'a-7A P ;CIA Owner: Date of 7nspec • n: � fi Cg 1 r7.,Ow CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(acnial): , DESIGN flow based on 310 CvIR 15.203 (for example: 110 gpd x 9 of bedrooms): 000 Mimber of c►irrent residents: Does residence,have a garbage grinder(yes or..no).�/,,7- .Is laundry on a separate sewage system (yes or no)LZE0.[af yes separate inspection required] L;aundry system inspected(yes or no)..�V— Seasonal use: (yes or no) (y.. Water meter readings, if available(last 2 years usage (gpd)): Sump pump(yes or 110): P' Last date of occupancy:V( [.hB -►� G /��7. GCY�✓c t?�2eC11�� COMMERCIkU NDUSTRIALIVj-- Type of establishment: Design flow(based on 310 CMR.15.203): gpd Basis of design flow(seats%persons/sgft,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:. C Was system pumped as part of the inspection{yes or no V If yes, volume pumped: gallons--How was quantity pumped determined? Reason'for.pumping: . TYPE OF SYSTEM _ /Septic Tank,distribution box,soil alisorption 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 mainienance contract(to be obtained from system owner) _Tight tank `Attach a eopy'of the DLP.approval _Other(describe): Approximate age of all components, date installed (if known)and source of information- �& 'e We're sewage odors detected ralien arriving at the site(yes or no): — Page 7 of 11 OFFICIAL INSPECTION FORM:—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 11'roperty Address: 9 C, /i✓f/Ir� Owner: Poem, az�5xe, Date of Inspec iou: BUILDING SEWER(locate on site plan)�60- Depth below,grade: Materials of construction:_cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage;e °:): SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction:✓oncrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: V''—(n Distance from top of sludge to bottom of outlet tee or baffle: �j G Scum thickness: 5' Distance from top of scum to top of outlet tee or baffle: �! Distance from bottom of scum to bottom of outlet tee or baffle:_ How were dimensions determined: AM6&22C Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels /a�related to outlet invert,evidence of leakage,�tc,): ,O GREASE TRAP flV ate on site plan) 5 Depth below grade: Material of construction: concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 Page 8 of I 1 OFFICIAL:INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION(continued) Property Address: s Owner: Date of Inspec ion: ` ,S TIGHT or HOLDING TANK .(taril<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 BOX: _JZ0f present must be opened)(locate on site plan) Depth of liquid level above outlet invert:O4-) ,r! Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of tea°age into or out of box, etc.): PUMP CHAMBER:: (locate on site±plan) Pumps in working order(yes or no): Alarms in working order(yes or no):. Comments(note condition of pump chamber, condition.of pumps and appurtenances, etc.): 8 i Page 9 of I I OFFICIAL INSPECTION FOIZAl—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspe ion: / SOIL ABSORPTION SYSTEM(SAS):. �ocate on site plan, excavation not required) If SAS not located explain why: Typed I t/leaching pits,number: leaching chambers,number: leaching galleries, number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool;number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil;condition of vegetation, etc. '011): 1 a �ik &Y,4- _Zlee,ll - 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 sctrtn layer: Dimensions of cesspool: . Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding;condition of vegetation,etc.): PRIVY:. -locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): 9 Page 10 of l 1 OFFICIAL INSPECTION FORM—=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ;Q. l • j / %�P/,�C� h) /x-fPA/121VA/zo "A Owner: p ` / Date of Tnspe ion: SKETCH OF SEWAGE DISPOSAL:`SYSTrN[ 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 pub lic water supply enters the building. �Y jtp p ' o1°tl Cf (19 . s 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: v � p Owner: Date of Inspection: / /~ SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water ZZ 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: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: f1, 11 Permit Number: Date: _ Completed by:- HIGH GROUND-WATER LEVEL COMPUTATION e r Site Location:_ Lot No. Owner: T ����� �J��©�� Address: -: Address: :;. Contractor:_ i Notes: STEP 1 Measure depth to water table tonearest 1/10 . .............................................................................. .Date month/day/year STEP 2 ,Using Water-Level Range Zone � and Index Well Map locate site and determine: (� Appropriate index well.................................................... � OWater level range zone ..:.................................................. STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... month/year S T EP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 23) I F6� determine waterdevel adjustment ...................................:.............................................. i STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water I levelat site (STEP 1) .......:...................................................................................................:.. igure 13.—Reproducible computation form. 15 r Y fa F f r 5 l 4 l Town of Barnstable Health Inspector Office Hours pFZHE 1p��O Regulatory Services 8:00-9:30 Thomas F.Geiler,Director 1:00—2:00 &UMST"LE, : Only 9� MAW. ,0r Public Health Division Thomas irector 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT— SEPTIC QUESTIONNAIRE 1. General Information: Address: / ��L hfS�tA� Map IW Parcel 0 78 Name: /'/ 'l� e`� l'�' . Dow&-.a Phone#: C. 2 2 7/b 2a. How many bedrooms exist at your property now? 17' 2b. Are you planning to add any bedrooms? :6�-6 If yes, how many? 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 2d. Please include a copy of the floor plans for the entire property- showing the existing rooms in the home plus the proposed amnesty apartment and/or addition. Please label each room clearly on the plans. 3. Is the dwelling connected to public sewer? YES or NO 4. Location of dwelling is WSIDE or OUTBID a Zone of Contribution to public supply wells? 5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 6. Is a disposal works construction permit on file? YES or 6a .If yes,how many bedrooms were approved according to this permit? Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms? YES or NO 8. Is there an engineered septic system plan on file at the Health Division? YES r NO 9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO -------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY TO BE SIGNED BY A HEALTH INSPECTOR/AGENT ONLY The Public Hea vi • a no objection to 3 bedrooms at this ro e ?.� Signed: �' Date: � Inspector(Print):- `d`vk,,,z A r. Q;/health/wpfiles/amnestyapp I THE COMMONWEALTH OF MASSACHUSETTs -Iq I tj BOARD OF HEALTH ............OF....... ............................. Appliration for Disposal Works Tons trwtion prrmit Application is hereby ;qade for a P r1rlit to Construct *<Or Repair Spy-p t an Individual Sewage Disposal re a LCr_ 4 ....................................a okion,Ad a A................................................ or Lot NO. 4�;Y&...J&L-.�;.......... Address IL.Q.50..........6.f--D.At.!................... ................. Installer ....".Lc.............................. Type of Building Address U Size Lot. _..11-4...Sq. feet Dwelling—No. of Bedrooms.._..._... 3................... .....Expansion At tic (00 Garbage Grinder 1:14 ....Other—Type of Building ........................ No. of persons..................... PLI ....... Showers Cafeteria Other fixtures ............................ DesignFlow.............. per --------------------------------------------*----------*---------------*-------*.................. ------------------------------gallons er person per day. Total daily flow................................... .....gallons. Septic Tank—Liquid'capacity.iOI20gallons Length................ Width......_..._..... Diameter................ D e*p'"t'h x Disposal Trench—No............ ....... Width._.._............_.. Total Length........... Total.leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter--.--.-------------- Depth below inlet...... _ Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( -) Percolation Test Results Performed by........ ....... ............... Test Pit No. 1...........:....minutes per inch Depth of Test Pit-------.-.--------.- D . Date.....4=17m$!4....... Depth to ground water:..........._........... 3� Test Pit No. 2................minutes per inch Depth of Test Pit...-.......__...._..m................ Depth to ground water--...................... D �4 -..................�4. ......... ..........................................................................................................................Description of Soil.....4- ........ 4ft... ................. . ..... ......."AILS&..... -----------*-----------*------- 6hAybN.....6ALA ---------------------------------------743.....4fVt#4".*......SAA..To ----------------*......------- Nature of Repairs or Alterations—Answer when applicable......................................... ..........M-................................ ............... Agreement: .................................................................................................................. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance I with the provisions of'JITLF, 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 health. Signed .. . .... ...... ............... Application Approved By....................................... ... ......... .. . ......... -------------------&a,te,---------Application Disapproved for the following reasons:.......................... .................................................................. .................................w.................................................................................................................................................................... Permit No.................................................. Issued..........._.... Date Date 1 Lr= %.0,wr low -TZ 1- NO SCA►L.I-- SCALE 4d V A.-r r-- gS %0W C.OMPU�!S WITO-THS G-.. SlPSUW Lot ot 4 A ?&A 0 Tow*N 0:VI-MIt I r.-, CT 4tNo UJWtvff A-OCA-Irel> WITHI T & PL,&.I W •CF?p-q4 Myt f SA-K+r=V-9 - INC. RF.eaISZ6.266`LAUCO'SuMYrCYol,S `T%Al!S PL&IQ 1'5 KI Orr B N5 rz D Old AN I W,5TV-u u 9-V L,Y � -r q Pe wc>-r mr- ur,6 0 TCP 0 f!"T F—�V�I W S L. H F—d5 P P I e-A,W'r, LOCATION II PROPERTY LINES /VIAY NOT BE ACC RATE STANDARD LEGEND, NOTE:not all symbols will appear area map STATE APPROVED 4�:� GOLF COURSE FAIRWAY ZONE 2 BOUNDARY �/ X EDGE OF DECIDUOUS TRt;FS ------- ------ WP WELLHEAD PROTECTION MAP 19 - -- EDGE OF BRUSH W OVERLAY DISTRICT GP-- _ I # 80 1- - _ X ORCHARD OR NURSERY GP GROUNDWATER PROTECTION 0", - AP, OVERLAY DISTRICT AP 14 o—V—V--V EDGE OF CONIFEROUS TREES AQUIFER PROTECTION r 1 , MARSH AREA AP - AP OVERLAY DISTRICT 8 P 19 EDGE OF WATER 194 # .102- -_ _ _ _ = DIRT ROAD OI 12 0• Lt�'' �, DRIVEWAY MAP I ILA J E- PARKING LOT O �11�J�� PAVED ROAD #4 # — - — DRAINAGE DITCH I\� I94 — — — — - PATH/TRAIL X 0 063 PARCEL LINE #26 ' MAP 326 E'—'—' MAP# 021E-- PARCEL NUMBER 94 I #367 — HOUSE NUMBER 7 #25 9 2 FOOT CONTOUR LINE ' 0 E9 10 FOOT CONTOUR LINE 19 Elevation based on NGVD29 MAP 194 MAP ;/4.9 SPOT ELEVATION 0 078 0 # i I `1, STONE WALL �s -X—X— FENCE RETAINING WALL P MAP 194 RAIL ROAD TRACK 080 © STONE JETTY # 19 MAP 194 SWIMMING POOL 0 81 PORCH/DECK ,CY �] ❑ BUILDING/STRUCTURE P 194 O DOCK/PIER # \ Q HYDRANT MAP 3 ��\ 6 VALVE OO MANHOLE 3 MAP 193 M 94 o POST 0" FLAGPOLE 372 T O W N O F B A R N S T A B L E G E O G R A P N 1 C I N F O R M A T 1 O N S Y S T E M S U N 1 T .a SIGN ® STORM DRAIN N PRINTED SCALE:IN FEET *NOTE: Planimetria,topography,and **NOTE:The parcel lines are only graphic representations DATA SOURCES: Planimetria man-made features)were interpreted from 1995 aerial hotogmphs by The James vegetation were mapped to meet National of property boundaries.They are not true locations,and W.Sewall Company.Topography and vegetation were interpreted from 1989 aerial photographs by GEOD UTILITY POLE TOWER ❑ W1 0 50 )00 Map Accuracy Standards at a scale of do not represent actual relationships to physical objects Corporation.Planimetria,topography,and vegetation were mapped to meet National Map Accuracy Standards 4 LIGHT POLE o ELECTRIC BOX s 1 INCH=100 FEET on the map. at a scale of 1-100'. Parcel lines were digitized from FY2004 Town of Barnstable Assessor's tax maps. FLOORPLAN an Lane. Fite No.: 02010047 Case No.: :&Trust Co. State:MA Zi :02632 Encbsed •12' 38' Porch 14' _. ---------- Balb Bedroom Kitchen kitchen ; 2 6' ' 1 Car6 arage '26' Bedmon Bdih living Room Cbset 38' ----14'----= FborPlan N Otto Scale SKETCH CALCULATDRS Al Al :38.0 x 26.0= 988 A Fist!bor 988 A T0talLiemg Area 988.0 r--, t`/�c�Po Scfl 0 kL -23 V U� Q 444AJ O 2 1 - LOCAYIC3N ®F PR®PER-TV LINES MANY N ®-' BE ^CCIJR^-FE STANDARD LEGEND-, NOTE:not all symbols will appear on a map STATE APPROVED GOLF COURSE FAIRWAY ZONE 2 BOUNDARY +� ' 1 EDGE OF DECIDUOUS TREES ------- ----- WELLHEAD PROTECTION MAP 19 WP OVERLAY DISTRICT EDGE OF BRUSH WP GP-_ _ ,I #80 ORCHARD OR NURSERY GP GROUNDWATER PROTECTION 0", o AP, OVERLAY DISTRICT AP 14 V—V—T-V EDGE OF CONIFEROUS TREES AQUIFER PROTECTION J , MARSH AREA AP---------;--- AP 8 _____ --------------- OVERLAY DISTRICT P 19 — - -— EDGE OF WATER 0 P 194 # 102' _ _ _ = DIRT ROAD OI 12 DRIVEWAY MAP 19 IE-- PARKING LOT 0 PAVED ROAD + ##43.8 # — — DRAINAGE DITCH PATH/TRAIL xx 0 P 194 063 PARCEL LINE Uj #26 MAP 326 F- MAP# 021E-- PARCEL NUMBER 94 #367 — HOUSE NUMBER #25 9 2 FOOT CONTOUR LINE - r/ Lg 10 FOOT CONTOUR LINE M 194 MAP 194 __-_ y Elevation based on NGVD29 0 078 t MAP ;<4.9 SPOT ELEVATION # 0� 0 # I I 1 STONE WALL V y # / -X—X- FENCE RETAINING WALL rMAP 194 RAIL ROAD TRACK 080 STONE JETTY MAP 194 SWIMMING POOL �CY 081 #9 PORCH/DECK I ,O' P 1194 0 BUILDING/STRUCTURE O DOCK/PIER HYDRANT - = A- _ P MAP 3 B VALVE OO MANHOLE 372 MAP 193 MA _94 O POST O'P FLAG POLE T O W N O F B A R N S T A B L E O E 0 6 R A P N 1 C 1 N F O R M A T 1 O N S Y S T E M S U N I T 0 SIGN ® STORM DRAIN N PRINTED SCALE:IN FEET *NOTE: Planimetrict,topography,and **NOTE:The parcel lines are only graphic representations DATA SOURCES: Plonimetrics(man-made features)were interpreted from 1995 aerial photographs by The James a TOWER vegetation were mopped to meet National of property boundaries.They are not true locations,and W.Sewall Company.Topography and vegetation were interpreted from 1989 aerial photographs by GEOD UTILITY POLE w i 0 50 100 Map Accuracy Standards at a scale of do not represent actual relationships to physical objects Corporation. Planimetrics,topography,and vegetation were mapped to most National Map Accuracy Standards ;: 1 INCH=100 FEET* I"=I OO'. on the map. at a scale of 1"=100'.Parcel lines were digitized from FY2004 Town of Barnstable Assessor's tax maps. 4 LIGHT POLE o ELECTRIC BOX tA eir Town of Barnstable p Health Inspector oFTHe tp�Y Office Hours do Regulatory Services 8:00-9:30 Thomas F. Geiler,Director 1:00—2:00 &MMSrABLE, « Only qj s639• �0 Public Health Division �E��na'ta Thomas irector 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT— SEPTIC QUESTIONNAIRE 7 1. General'Information: 1 Address: / �G'Gti1S�lA� �`� .,j.,:NU Map IfX Parcel 078 Name: .� l`� °r��'� Phone#: o'-3 C- 2 2 7/6 2a. How many bedrooms exist at your property now? Z 2b. Are you planning to add any bedrooms? �`5 If yes, how many? / 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 2d. Please include a copy of the floor plans for the entire property - showing the existing rooms in the home plus the proposed amnesty apartment and/or addition. Please label each room clearly on the plans. 3. Is the dwelling connected to public sewer? YES or NO if the dwelling is connected to public sewer;skip questions 4-9 below: 4. Location of dwelling is INSIDE or OUTBID a Zone of Contribution to public supply wells? 5. Is the dwelling connected to an ONSITE WELL or to PU�WATER? 6. Is a disposal works construction permit on file? YES or 0 6a .If yes,how many bedrooms were approved according to this permit? Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms? YES or NO 8. Is there an engineered septic system plan on file at the Health Division? YES , r NO 9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO -------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY TO BE SIGNED BY A HEALTH INSPECTOR/AGENT ONLY The Public Hea vis* a no objection to bedrooms at this propert . Signed: �' c - Date: '� d Inspector(Print): 9kwA A_ Md Vmr, Q;/health1wpfiles/amnestyapp //�� � 'i � �µ� � ;�L������ t(d`� � � � � �___--.. Town, of Barnstable Health Inspector Office Hours �oFtti Regulatory Services 8:00-9:30 o� 1:00—2:00 w Thomas 1F. Geiler,Director Only 9 `�'� Public Health Division i639• ArF p M►►'�°i Thomas irector 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fat: 508-790-6304 AMNESTY PROGRAM APPLICANT— SEPTIC QUESTIONNAIRE 1. General Information: Map Parcel 4 7 8 Address: Name: A /l//.1.4 l�/ . Dow&-rL,0-"7 Phone#: 6zoo s C. 2 2 7/b 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? S If yes, how many? OF 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 3 2d. Please include a copy of the floor plans for the entire property- showing the existing' rooms in the home plus the proposed amnesty apartment and/or addition. Please label each room clearly on the plans. 3. Is the dwelling connected to public sewer? YES orRON NO 4. Location of dwelling is WSIDE or OUTBID a Zone of Contribution to public supply wells? 5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 6. Is a disposal works construction permit on file? YES or 6a .If yes,how many bedrooms were approved according to this permit? Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms? YES or NO 8. Is there an engineered septic system plan on file at the Health Division? YES r NO 9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO -------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY TO BE SIGNED BY A HEALTH INSPECTOR/AGENT ONLY The Public H��O. no objection to bedrooms at this�rJo eSigned: Date: 7 '� Q', Inspector(Print):— n Q,/health/wpfiles/amnesryapp IN, LO CAT low SEWAGE PERMIT NO. VILLAGE C f-&7F�/� v/cam INSTALLER'S NAME A ADDRESS _ AK/i g � BUILDER OR /OWN IR J ..'m rr/� DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 4 �� � � �� y , � �` � �' i �� � ` - 1 .. No.... .`1..'. F:ss............._... THE COMMONWEALTH OF MASSACHUSETTS as a l a,q BOARD OF HEALTH ....... ...... ............................OF...... `I -K�. T �C .............................. ApplirFation for Uhipvii al Worka Tun rudinn frrutit Application is hereby rylade for a P rmit to Construct ( _50"or Repair ( ) an Individual Sewage Disposal Sy te m at: .....1Y YISP . . L�'� y........... .......... .... -• �..................................... .................................................. Lo tion-Ad ss or Lot No. ........ . .,.._..s1_iL1l..L r - Owner. Address .0 d .A.�. ........ �_�.�=•--•--------------- ------•--.....---- .� ............................ Installer Address Q Type of Building Size Lot. Y....g.i.4.-..Sq. feet U Dwelling—No. of Bedrooms.........._ .._____..Expansion Attic (00 Garbage Grinder (OLW A4 Other—Type of Building ............................ No. of-persons............................ Showers ( ) - Cafeteria ( ) Other fixtures ................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.W.Gagallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area..__.....--........_sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........ ...... ............... Date..... . -/ ........... a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ( Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' •••••-•-••••-•••--------•---••......••••-------••-•-•••----------------------•--••-•-----•----------......................................................... ODescription of Soil--- dr-3....... #A ......*vAU-114M................................-........................................................ U �p 11 W ---•-•-•----•----•--- ----------------A'�.eZ-----�_ �r_Q.---•- .�t. . 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 iITL U 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 health. Signed.. /1h L11- --- -- ---- ------- --------------- ------ .I Date Application Approved By........................................ ... . -----••--• � -. A � - Date Application Disapproved for the following reasons:........... •--••-••••-• ................................................... ----------------•--•-----......•------••......_.........................................................I••---•------••----••-••----------.....-•-•--......--••••••••._...------••......•...••------•--- Date r PermitNo......................................................... Issued....................................................... Date No.... _ r....... Fss.............................. THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH OW .............OF.....�iql')� ('�C, ,�...........................--- Appliration for 11ispos al Works Tonstratrtion Prrutit Application is hereby made for a Permit to Construct (�r Repair ( ) an Individual Sewage Disposal S stem at >"V YYtS(`tom tJ �. . NZ P.v i L 1-&_ �i ....- - -•- _.......... -------------------------------------- ...................................... ................................. L cation-A Tess o Lot o. ........:� s .:....�-rn -`----------------•-. ..........------------••.......... ....�............................................ Owner Addr ss Installer Address � UType of Building 22 Size Lot-_-----4-- ..._--�-`4-----Sq. feet I—I Dwelling—No. of Bedrooms.........:3.............................Expansion Attic (NO) Garbage Grinder (J,0) a04 Other—T e of Building No. of persons............................ Showers YP g --------•------------•------ P ( ) -- Cafeteria-(---.) 04 Other fixtures ----------------------------------------------------------•---------•-----------•-----------•------------...._-•--- --- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity Agbg.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. ft. Z Other Distribution box ( ) Dosing t nk ( ) / ~' Percolation Test Results Performed by------------ ?:.`........�....y r................ Date....'![-_=..�... �-&-1 ,4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--_-_-_____-_-__..-____. fit Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -------------------- ------------......... ..-----------------...----------------- ---------------- --------•-------------------------•------ D Description of Soil....�...31......:.--0� s� S b ( f- x ------------------ -.''1....__ . ra_ ✓ . U ----------------•---------------_----In!�-----�-----'-----®------------- a h----------------------------- ------------------------------------------------ ............... 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 f health. Signed-- =--. .-�M -` ... -- ------------- - _.... ........................................ at Application Approved By------------•--------------•---•-...-•------------ ..... ------- -------_�---- -�----.....--- Date Application Disapproved for the following reasons-----------------------------------------------------------------•-----------...------------------........-•---- ----------------•----•------...-----•-----•-•-------•--------------------....---------•---•-••------.....•------------------------------------•---------------------------------•----------------------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS �` BOAR�Dy OF, 'HEALTH ..........`. ;.0 t-?.N.........OF....F �J-..N.�J.. .�r. ,r............................... Trrtifiratr of ToutpliFanrr THI�51IS TO CERTIFY, hat the Individual Sewage Disposal System constructed or Repaired ( ) "_. T ('_!_!•-?_ ...... ''S..---.....-•----••---------------------------------------------------•-------------------------......----...-----------•-•--..... Installer - `.(7t at.! A- VYY` _(h�.A±�?..._ .................... N.`t-�.... U-�-l.!;n ' has been installed in accordance with the provisions of TI r 5 he State Sanitary Code as described in the application for Disposal Works Construction Permit No.__ ' ...................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................•••--......._��.�-L=..?__jb_..:._.....---------.•. Inspector......•..-......��------......------......-------------------•-•--....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �' 11 ...........................................OF..................................................................................... .ter. No......................... FEE........................ Elisposatl Works 'U'lonstrudion amit Permission is hereby granted.................. ---------.......-------•----------------------...... •---.......... -........ -............ .--•--------- ...... --------- to Construct ( ) or,Repair ( ) an Individual Sewage Disposal System atNo............................................................................................................................................................................................... Street as shown on the application for Disposal Works Construction Permit yo..�............... Dated.......................................... ...................................•--------------------------------....-----.....-------•--•---------- Board of Health DATE................................................................................ FORM 1255 -A�.-M. SULKIN, INC., BOSTON �,I►�GLG- FAMILY - 3 BCOROOM ►JD 6ACZBAGE (�cza►.IDFcz 3 �_ r no*mLY FLOW a 110 x 3 = Z306.Po SEPTIC TAKJK = 33ox15o'/• = �497G.P R IG� -1�, I U56- 100o /II.� ^�� o% Prr_ V6fC SPoSn� a� S VG.VV AQL-A - t�cs.r: I �? I1p .37 150 5.t~ X Z•5 = 5 j� C -• I BOTTOM ASZEAa . jO 5.F-, 7I��1 Lam+' «, So S.F x I. o 5o b.Po• • A / ,00 'TdTAI- DESIGNs .4.25 G.PD. `•r, �// I TOTAL. DA I L,e F%-C>W = 330 G.PQ IPZCP Ile PSZCOLATION RATE = 1"W VAIN ohLG S r /PT 0 F A. ell A tzffA Q L� p it T6��T I •3Z� � I , TOP FWU=WOLr- d In+v III 1 DUST. INV. c.sAt�G 110.g 3 Bu�c Ilo.(e Gon�zre I000 INV. •re►NK Gam. (l p ii �jAltiD� LC•AGtI �� �,ql/� PIT INV. INv. 1 WITW 110Z IID.d 1,/3/4.1/Z WASNGD i Mtn 6TvN6 SA'J� I J1 CEfLTIFIGC PLOT PI-A-W PR.OFIL1~ LozA IOhI Gam,, v,�Lc3 q�WAT I NO SCALE 5CALE t3n-- � P L-A t�.l REF fEfZEN GE 1 C S Q•T%F Y 'f N AT THE . N6REOW GOMPUY!S VATN'THS SIC6LIW� LOT' 4A ' AWD-S�'TQe►GK R.6QVIT2.EMtGN`r> �IoPTNfr- Taww or— `�3t�.2, TA c3 AWD IS T' A2t�.(v2 �IurA.c.H LOCp►TEDc,rWITNI T 6 GLOODP L&IM bATEr> ~ D I►T E�� , (l Cy, � BAxT6iZe myt- INC. REG 1 S'T EQ6�'1Au D S u fCv 6r�(oe'S 'Tu%S PL&I\I 15 KJO*T [3nSr=ram o►d AN osTFriZVILLfr • MASS• IN5•T•Q-uM6WT SUeV1<Y ( -TNE r)I:r5F-7 5 6WOU A�pT f',F- V5EOT0 OE'TER.'^I►�� l �-r I• IN PPLIcAINJ FINISH GRADE OVER D-BOX-110.7�± ' - PROP. VENT WITH CHARCOAL FILTER TO ABOVE GRADE GENERAL NOTES FINISH GRADE OVER CHAMBERS = 11 O.O 112.5 P SLOPE @ 2% MIN. OVER SYSTEM 3/4" TO 1-1/2" DOUBLE WASHED PROVIDE EXTENSION RISER REMOVABLE WATER-TIGHT COVER OVER STONE TO CROWN OF PIPE 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION WITH COVER OVER INLET& RISER TO WITHIN 6"OF FINISHED GRADE 4" SCHEDULE 40 PVC INSPECTION PORT WITH ACCESS METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL FINISH GRADE OUTLET TO WITHIN 6"OF F.G. MIN SLOPE 1% BOX TO F.G. (SEE NOTE 21) 2" OF 1/8"TO 1/2" DOUBLE WASHED CODE AND ANY APPLICABLE LOCAL RULES. ' F.G. OVER TANK EL. = 109.5'♦ r5" DIA OUTLET(S) @ FND. EL.= 109.5 ± - -- I STONE OR GEOTEXTILE FILTER FABRIC t 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE li PLACE RISERS ON ALL DESIGN ENGINEER. „ PROPOSED 4" 4.3' MAX. TOP OF SAS = 107.00� CHAMBERS WITH EXISTING 4 5.5 MAX. 3. 4" SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL SCH. 40 PVC SEE NOTE 23 106.00' SEE NOTE 23 INLET PIPES TO 6" OF SEWER PIPE �� BREAKOUT EL= 106.50 SYSTEM UNLESS OTHERWISE NOTED. SEWER PIPE � FINISHED GRADE 6„ 3„ 3' DROP MAX _ MIN.SLOPE @ 1% 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN 2" DROP MIN 3„ 9 -781± PROVIDE WATERTIGHT ELEVATION = 106.50' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A - o 0 13" 74" PVC IN FROM JOINTS (TYP.) 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S. AND THE TOP OF *1 / C TANK 4" PVC OUT TO 0 0 0 0 0 0 0 0 0 0 0 o o THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. 14 0 0 CONTRACTOR TO PROVIDE O LEACHING FACILITY o0 0 0 0 0 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. SPECIFIED DROP BETWEEN I oo INLET AND OUTLET CONTRACTOR CONTRACTORS HALL �! OUTLET TEE 106.37' M N. 6 106.20' 2 00 00 00- 0 o 0 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. SHALL VERIFY SIZE 48 VERIFY CONDITION OF \ o0 00 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK AND CONDITION OF EXISTING TEES GAS BAFFLE 6" CRUSHED STONE 0 0 0 0 = = oo FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS EXISTING SEPTIC AND REPLACE AS OVER MECHANICALLY o00 00 _ o NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH TANK NECESSARY COMPACTED BASE 4.0 AND DESIGN ENGINEER. 8.5' (TYP) - 4.0 4.0' 4.0' 5 OUTLET DISTRIBUTION BOX 4Y83 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM. BENCHMARK ELEVATION OF 110.00, TO BE INSTALLED ON A LEVEL STABLE LL I25.0' (NP') ESTABLISHED ON A NAIL SET IN A UTILITY POLE AS SHOWN ON PLAN. BASE. FIRST TWO FEET OF OUTLET 10400' GROUND WATER ELEV= < 98.50 12 83' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION . PIPES TO BE LAID LEVEL. THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT EXISTING 1 ,000 GALLON CONCRETE SEPTIC TANK 2 - 500 GALLON H-20 CHAMBERS 5' MIN. CHAIVIbLK LNU ViLVV 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES CROSS SECTION VIEW *CONTRACTOR TO VERIFY EXISTING SEPTIC TANK PROFILE H-20 DISTRIB�► I ITV TYPICAL CHAMBER PROFILE BOX DETAIL CHAMBER DETAILS TO THE DESIGN ENGINEER. 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT. NOTIFY ENGINEER IF DIFFERENT, NOT TO SCALE NOT TO SCALE NOT TO SCALE �_... -..T_.... _ -. __.._-___ -_ .. ---- ----- 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED TF ST PIT DATA REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM NOTES: ..0, � : ' �� � O PERC NO. I tl�� ! ���M R� b APPROPRIATE AUTHORITY. 15922 p/'- "��� TO)� � 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS LOCATED 1. MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF EACH •/ r �r�` c; r/ r , , �?/ice i i INSPECTOR: Donald Desmarais, RS UNDER MORE THAN 3 FEET OF COVER OR LOCATED UNDER PAVEMENT, DRIVES, OR �~ �. .t ' _ EVALUATOR: Michael Pimentel, EIT, CSE SEPTIC SYSTEM COMPONENT. �11 T�70 Y. TRAVELED WAYS IN WHICH CASE THEY SHALL WITHSTAND H-20 LOADING. J�yt -� .. �- <<a ,✓' Oct. 27, 1999 2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF THE ' �, �� --� -�-; �1 F'.,;5., C.S.E. APPROVAL DATE: p ,� �`�s ..-- _ .r' T r-, -r- 113. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY WITH TEST PIT DATA ,i� r' - �J ® r� March 22, 2019 i SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL BOARD OF HEALTH IF (' r °� C- � � 5. w 9' n PIT 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE 4 . ® E #: MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. 112� 0 ELEV TOP= 110.50 REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, " FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). 3. A PORTION OF THE PROPERTY IS LOCATED WITHIN A DEP APPROVED ZONE 2. = ' ) ELEV WATER = t 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN 4.) SWING TIES SHOWN ON THIS PLAN ARE PROVIDED ONLY AS A COURTESY W j' I PERC RATE _ < 2 min./inch SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. FOR THE INSTALLER. INSTALLER SHALL VERIFY SWING TIE MEASUREMENTS IN r�7. _> ` "'� fi -✓ e �. THE FIELD PRIOR TO INSTALLING THE SYSTEM. CONTRACTOR SHALL NOTIFY � � t= � `��- �`��--..._ , �,J.-� �,..�'�'' t � f- DEPTH OF PERC= 24 -42 16. PROPOSED PROJECT IS LOCATED WITHIN: ENGINEER IF MEASUREMENTS APPEAR TO BE INCORRECT. .> r�C� ' � O �"; , 'i � ��' 'E?� TEXTURAL CLASS: 1 ASSESSOR'S MAP 194 LOT 78 O >" ai z Q M LOCUS ' F ON S050 02'48"W i r Q -' . / s OWNER OF RECORD: WILLIAM H. DOHERTY 26.3T w a P ADDRESS: 11 HELMSMAN DRIVE / , f �- -- ; p 110.50' CENTERVILLE, MA 02632 0`9`� o\ a ;(_, _�'' I Fill \ ( 0 W // , `� Q. j UbI1C 2 110.33 FEMA FLOOD ZONE X Landing COMMUNITY PANEL# 25001C0561J V _ Y 8 o ......... I Loam Sand 17. DEED REFERENCE: BOOK 14822, PAGE 182 uJ - r _ B 10Yr 5/6 wv ` 18. PLAN REFERENCE: PLAN BOOK 379, PAGE 69 \ U.P. #1574/U C_; b, ; t ....�.__,._, `) ` \• 24" 108.50' (fl . �.107- ��: � t` _. sr '• �1• Perc 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. 4 ol�` + lY t ' 42" 107.00' 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY �� , . s . FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY 5� ti�,�� , • ,'•oil. . a -+ , FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. MAP 194 p f� �� MAP 194 i 21. A 4" PERFORATED SCH. 40 PVC PIPE SHALL BE PLACED IN A VERTICAL POSITION TO A LOT 77 ya LOT 76 ,' ,�O/, �` f �,� �' s C Fine Sand DEPTH OF THE BOTTOM OF THE SAS AND EXTEND TO WITHIN 3" OF FINISH GRADE. A ol�'I� . ,� 2.5Y 7/4 REMOVABLE THREADED CAP SHALL BE PLACED ON THE TOP TO ALLOW FOR INSPECTIONS. enchmark PROPOSED 876°0�� /^ /113 j l i Nail in U.P. #574/2 v+ 22. OWNER/APPLICANT/ CONTRACTOR SHALL BE RESPONSIBLE TO OBTAIN ANY AND ALL 40, NI REQUIRED PERMITS AND APPROVALS FOR THIS PROJECT. INSPECTION PORT----,,, I 109 �8, E / .'�'�2 ,/ / / Elevation = 110.00' ,� ► �� LOCUS PLAN � // / Approx. M.S.L. - _ `L Opp 23. IN ACCORDANCE WITH 310 CMR 15.401 - 15.405, THE FOLLOWING LOCAL UPGRADE PROPOSED 4" PVC VENT PIPE- ( ( I 17p - 'o, �' '�� SCALE 1"= 1000' APPROVALS ARE REQUESTED FROM 310 CMR 15.221 (7): : EXACT LOCATION PER OWNER ✓ I i / (� `� GllY WIRE . \ 144" gg 50 1 (1.) A 2.5' WAIVER (3.0' - 5.5') FOR THE MAXIMUM COVER OVER THE LEACHING FACILITY. (2.) A 1.3'WAIVER (3.0' -4.3') FOR THE MAXIMUM COVER OVER THE DISTRIBUTION BOX. I � No Mottling, g p� PROPOSED 2-500 GALLON H-20 I - - - - �-', � _,._-_ Weeping Observed APPROXIMATE � g, Standing or ee i LEACHING CHAMBERS W/ o/ LOCATION o �°8 TE DESIGN DATA LE i to i t-'I I U �/ I � �� -- � , SURROUNDING AGGREGATE-- _ i � PERC NO. 15922 LEGEND PROPOSED H-20 I I o)� BIT. / ' .a INSPECTOR: Donald Desmarais, RS 50x0' EXISTING SPOT GRADE W DISTRIBUTION BOX TP 1 TP 2 DRIVEWAY ;` NUMBER OF BEDROOMS 2 (EXISTING) EVALUATOR: Michael Pimentel, EIT, CSE - -- - 50 - -- -- EXISTING CONTOUR ,■ � , J.P. NUMBER OF BEDROOMS 3 (PER ORIGINAL PERMIT#84-850) 110x5' 110x5' 1574/2 C.S.E. APPROVAL DATE: kcov C.? / / J -, � \ � // I; � Oct. 27, 1999 � PROPOSED CONTOUR MAP 194 A / / J �` DESIGN FLOW 110 GAUDAY/BEDROOM I DATE: March 22, 2019 LOT 33 2 / ( f20 2� / / .00 MAP 194 TOTAL DESIGN FLOW 330 GAUDAY 50 PROPOSED SPOT GRADE 12" OA \ / TEST PIT#: w �C , <.20 GP/ I J LOT 79 DESIGN FLOW x 200 % = 660 GAUDAY GARAGE ELEV TOP= 110.50' EXISTING GAS LINE / \ SLAB = 111.1'+ o USE EXISTING 1,000 GALLON SEPTIC TANK ELEV WATER = < 98.50' O 18"� / O/H/W EXISTING OVERHEAD UTILITIES OAK / PATIO / / I N SWING-TIES SCALE: 1"=20' PERC RATE - / W W - EXISTING WATER LINE #11 I r' DESCRIPTION HC-1 HC-2 DEPTH OF PERC - I MAP 194 INSTALL 2 - 500 GAL. H-20 CHAMBERS w/ AGGREGATE TEST PIT LOCATION MAP 194 �/ �'`ti EXISTING, CORNER OF STONE (1) 22.2' 26.1' 1 TEXTURAL CLASS: 1 LOT 78 LOT 34 x / ^ 2DWELRLIING 55,924± S.F. CORNER OF STONE (2) 46.0' 35.T SIDEWALL CAPACITY EXISTING 1,000 GALLON SEPTIC TANK / (LENGTH -WIDTH) (2 SIDES) (2 HIGH) (0.74 GPD/S.F.) GAL/DAY 10:��c CORNER OF STONE (3) 50.3' 45.9' (25.0' + 12.83') ( 2 ) (2' ) ( 0.74 GPD/S.F.) =112.0 GAUDAY 011 _ 110.50' PROPOSED 4" SOLID SCHEDULE 40 PVC PIPE i \ / / ,109 CORNER OF STONE (4) 30.1' 39.0' 2 Fill 110.33' f� 108 BOTTOM CAPACITY 0 PROPOSED H-20 DISTRIBUTION BOX / LP ` MAP 194 (LENGTH x WIDTH) (0.74 GPD/S.F.) = GAUDAY Loamy Sand �p PROPOSED 500 GALLON H-20 LEACHING CHAMBER S76* LOT 76 (25.0' x 12.83') (0.74 GPD/S.F.) = 237.4 GAUDAY B 10Yr 5/6 EXISTING 1,000 GALLON I\ 10 07 40"E EXISTING LEACHING PIT TO BE SEPTIC TANK TO BE g�8' 24" 108.50' PUMPED, FILLED WITH CLEAN UTILIZED IN THIS DESIGN TOTALS: (3 I REV. DATE BY APP D. DESCRIPTION COARSE SAND, AND ABANDONED TOTAL NUMBER OF CHAMBERS 2 • 2S.0, o TOTAL LEACHING AREA 472.2 SQ.FT. EXISTING DISTRIBUTION MAP 194 PROPOSED SEPTIC SYSTEM UPGRADE TOTAL LEACHING CAPACITY 349.4 GAL./DAY BOX TO BE ABANDONED LOT 33 CV O PREPARED FOR: ° 4) Fine Sand CAPEWIDE ENTERPRISES 2) C 2.5Y 7/4 _W (1 LOCATED AT _ o MAP 894 0 C 1 11 HELMSMAN DRIVE Cl) Cn 55,924± S.F. CENTERVILLE, MA 02632 z H C- 144" 98.50' SCALE: 1 INCH = 20 FT. DATE: APRIL 1, 2019 2 ' GARAGE �tN OF u1 0 10 20 40 80 FEET SLAB = 111.1'j No Mottling, Standing or Weeping Observed / - JOHN L. ��,� PREPARED BY: CHURCC JR. / a / RESERVED FOR BOARD OF HEALTH USE CIVIL con JC ENGINEERING, INC. NO. 41807 2854 CRANBERRY HIGHWAY #11 EAST WAREHAM, MA 02538 EXISTING SITE PLAN 2-BEDROOM 508.273.037_7 SCALE: 1"-20' DWELLING Drawn By: SJI Designed By:SJI Checked By: MCP JOB No.4592