HomeMy WebLinkAbout0026 HELMSMAN DRIVE - Health E26 HELMSMAN DR., CENTERVILLE
A= 194 063
UPC 12534 0 ��
No.2 153LOR
HASTINGS. INN
No. O/HE COMIWONWEALTH OF MASSACHUSETTS FEE
n! �, BOARD OF H LTjH
OF
AP LIGATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - [:]Complete System ❑Individual Components
W4_16<A-4,d) )MIJ
atio r Owner's Name
ap arce Address
` /'s Name eGsHI)i s NLf,Oj
�.4nstallerT,yay Address
Addrey
Telephone# Telephone#
Type of Building: CBS Lot Size Sq.feet
Dwelling—No.of Bedrooms Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow m' .r quired) gpd Calculated design flow gpd Design flow providec�O- gpd
Plan: Date <' IV Number of sheets ! Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator l,Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS jU// i i� %/79 ' d n,r)
/ iS7la A6At
The undersigned±ages tVinstol e above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and fu aot system in operation until a Certificate of Compliance has be n issued by the Board of Health.
Signed Date
Inspections
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
r
TOWN OF BARNSTABLE
LOCATION6 ttP�M51`t 4yV '7)�Q, SEWAGE# t,01Y, 227
VILLAGF�f'! e,CViI _ASSESSOR'S MAP&PARCEL/9(/ 3�' (
INSTALLER'S NAME&PHONE NOC l'ImA4W elni,"
SEPTIC TANK CAPACITY /DVO g4111,w
LEACHING FACILITY:(type)Z b'� ?jV C kyle q 7'6'eS (size) r/U yZ
NO. OF BEDROOMS
OWNE pC
PERMIT DATE: > COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet
Private Water Supply Well and Leaching Facility(if any wells exist
on site or within 200 feet;of leaching facility) feet
Edge of Wetland and Llaching Facility(if any wetlands exist
within 300 feet of leaching:facility). feet
FURNISHED BY
�- g
3
N��---�7
.. 3
NO. r"' THE COMMONWEALTH OF M,ASSACHUSETTS FEE
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) ❑Complete System
The unde's ned hereby certif that the Sewage Disposal System;Constructed Re aired ,�U Upgraded Abandoned
g Y Y g P Y �k< P ��1, Pg ), )
by. D/�sTQc,cy%G/V
at -4
has been installed in accordance t the )rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. P '"� dated s. Approved Design Flow (gpd)
Installe>/� �/ WO
0 f
Desi ner:� �%® Inspector __ �/ JiD ate
The issuance of this certificate shall not be construed as a guar guarantee that th syst�m will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No.
OM�THE COMMONWEALTH OF MASSACHUSETTS FEEy
BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT !`
Permission is hereby ranted t Construct Repair,( Upgrade ( ) Abandon ( ) an individual sewage
disposal system at ` /t. i _ , 'A as described
in the application for Disposal System Construction Permit No. ,dated
Provided:` onitructiA shall be completed within three years of the date of this permit.l 11 lUro�cal/�lconditio s1must be met.
Date / Board of Health r �/1
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON.
p►
�.'
OM�Vi_ pO`fW LTH OF MASS,ACHUSETTS FEE
.. BO'ARD :OF H A'LTH
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( } Abandon ( ) - ❑Complete System ❑Individual Components
y _
t17� G/ Ali) deP,Si�.t l,setl
t,p " g Owner's Name
a /Parcel# � Address
Lot# Fl phone#
nstaller's Name Desig er's Na e
Add)� Address
pp Telephone# Telephone#
Type of Building: !C e S Lot Size Sq.feet
Dwelling—No.of Bedrooms Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria (. )
Other fixtures a
�D sign Flow n. equired)5?)D gpd Calculated design flow� gpd Desigrfflow provide F%Z gpd
Plan: Date Number of sheets Revision Date
Title
� t t �. N.Desertpfion of Sotl(s)
Soil Ev�uator Form No. Name of,Soil Evaluator NZ Date of Evaluation
,,.. DESCRIPTION OF REPAIRS OR ALTERATIONS:1.✓!,�J 4// i( i 04k W, 1
("+ The"undersigned ag ees to instal thel above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 andd4urthe afire Is not top a the system in operation until a Certificate of Compliance has been issued
by the Board of Health.
Signed Date
Inspections t
�Y1�[
FORM ll - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 •F"'
' Town ®f Barnstable
0tTHF TQ Regulatory Services
Richard V. Scali, Interim Director
RARNSTABLE.
�. g Public Health Division
i639'°JFo,39 ' 'Thomas McKean, Director
c
200 Main Street,Hyannis, TNLA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: Z1� Sewage Permit-4 ltl— '2-S? Assessor's Ma.pTarcel
Designer: ' Installer: CA-epu� 4'
Address: �V��� {� l�t� � Address:
On
4�5 was issued a permit to install a
(d e) (instalher) ��, �y�'
septic system at 7�� IAJ y�— based on a design drawn by
{� ,nn (address)
*uO�7, 1' l V6C)L-J dated
(designer)
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.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed in com Hance with the terms of
th \A approval letters (if applicable)
�Y Sin
a DArlI
tAS�I !§
stalle, ignature)
INN 1066
+STS yap
(Designer's Signature) (Affix Desib p Here)
PLEASE RETURN TO BAIUNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
4
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS F0RM AND AS-
BUILT CARD ARE RECEIVED BY THE BARiNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
QASeptic\Designer Ceiiification Form Rev 8-14-13.doc
r
Commonwealth of Massachusetts
Executive Office of Energy E,Environmental Affairs
Department of Environmental Protection
One Winter Street Boston, MA 02108.617-292-5500
DEVAL L.PATRICK RICHARD K.SULLIVAN JR.
Governor Secretary
DAVID W.CASH
Commissioner
APPROVAL FOR GENERAL USE
Pursuant to Title 5, 310 CMR 15.000
Name and Address of Applicant:
Infiltrator Systems,Inc.
P.O.Box 768
6 Business Park Road
Old Saybrook,CT 06475
Trade name of technology and model: High Capacity chamber, Quick4 High Capacity chamber, Quick4
High Capacity HD chamber, Quick4 Plus High Capacity chamber (8-inch invert), Quick4 Plus High
Capacity chamber (13-inch invert), Standard chamber, Quick4 Standard chamber, Quick4 Standard HD
chamber, Quick4 Plus Standard chamber (5.3-inch invert), Quick4 Plus Standard chamber (8.0-inch
invert), Quick4 Plus Standard LP (Low Profile) chamber (3.3-inch invert), Quick4 Plus Standard LP
(Low Profile) chamber (8-inch invert), Infiltrator 3050 (Storm Tech SC-740) chamber, Equalizer 24
chamber, Quick4 Equalizer 24 chamber, Equalizer 36 chamber, Quick4 Equalizer 36 chamber, Quick4
Equalizer 24 LP (Low Profile) chamber (6 inch invert), and Quick4 Equalizer 24 LP (Low Profile)
chamber (2 inch invert) (hereinafter the "System"). Schematic drawings of the System and a design and
installation manual are a part of this Certification. This approval allows the installation of the above
identified chambers without aggregate.
Transmittal Number: X259183
Date of Revision: May 22,2014
Authority for Issuance
Pursuant to Title 5 of the State Environmental Code, 310 CMR 15.000,the Department of Environmental
Protection hereby issues this Certification to: Infiltrator Systems, Inc., P.O. Box 768, 6 Business Park
Road, Old Saybrook, CT 06475 (hereinafter "the Company"), for General Use of the System described
herein. The sale, design, installation, and use of the System are conditioned on compliance by the
Company, the Designer, the Installer and the System Owner with the terms and conditions set
forth below. Any noncompliance with the terms or conditions of this Approval constitutes a
violation of 310 CMR 15.000.
May 22,2014
David Ferris, Director Date
Wastewater Management Program
Bureau of Resource Protection
This information is available in alternate format.Call Michelle Waters-Ekanem,Diversity Director,at 617.292-5751.TDD#1-866-539-7622 or 1.617-574-6868
MassDEP Website:www.mass.gov/dep
Printed on Recycled Paper
Infiltrator Chamber,Infiltrator Inc. Page 2 of 6
Approval for General Use—May 22,2014
I. Design Standards
1. The models listed in Table 1 are covered under this Certification.
Table 1: Chamber Dimensions
Dimensions Invert
Model W x L x H Height
Inches Inches
Equalizer 24 15 x 100 x 11 6
Quick4 Equalizer 24 16 x 48 x 11 6
Quick4 Equalizer 24 LP 6-inch invert 16 x 48 x 8 6
Quick4 Equalizer 24 LP (2-inch invert) 16 x 48 x 8 2
Equalizer 36 22 x 100 x 13.5 6
Quick4 Equalizer 36 22 x 48 x 12 6
Standard Chamber 34 x 75 x 12 6.5
Quick4 Standard 34 x 48 x 12 8
Quick4 Standard HD 34 x 48 x 12 8
Quick4 Plus Standard 5.3-inch invert) 34 x 48 x 12 5.3
Quick4 Plus Standard 8-inch invert) 34 x 48 x 12 8
Quick4 Plus Standard LP 3.3-inch invert 34 x 48 x 8 3.3
Quick4 Plus Standard LP 8-inch invert) 34 x 48 x 8 8
Infiltrator 3050 or StormTech SC-740 51 x 85.4 x 30 22.25
High Capacity Chamber 34 x 75 x 16 11
Quick4 High Capacity 34 x 48 x 16 11.5
Quick4 High Capacity HD 34 x 48 x 16 11.5
Quick4 Plus High Capacity 8-inch invert 34 x 48 x 14 8
Quick4 Plus High Capacity (13-inch invert) 34 x 48 x 14 13
I Includes Infiltrator MultiportTm invert adapter attached to the side of the end cap.
2 Includes Quick4 Plus Periscope adapter attached to the top of the Quick4 Plus All-in-
One 8 Endcap.
3 Only systems installed with this invert height shall be allowed to use the effective
leaching area associated with this model in Table 2
4Includes Quick4 Plus Periscope adapter attached to the top of the Quick4 Plus All-in-
One 12 Endcap.
2. The System is an open-bottom leaching unit molded from polyolefin resin. It can
be installed without aggregate or distribution pipe as an absorption trench or as a
bed or field. If the System is installed with stone aggregate then the "Effective
Leaching Area" in Tables 2 and 3 is not applicable, and must be designed in
accordance with the provisions of 310 CMR 15.000.
3. The total effective leaching area for any Chamber Model shall be calculated by
multiplying the Effective Leaching Area per square foot of chamber times the
total length of chamber from end cap to end cap including end caps.
k
Infiltrator Chamber,Infiltrator Inc. Page 3 of 6
Approval for General Use-May 22,2014
4. For new construction or upgrades, the applicant can size the System in a trench
configuration,using the effective leaching areas presented in Table 2.
Table 2: Effective Leaching Area in Trench Configuration for New
Construction and Remedial Sites5
Effective Effective
Model .Leaching Leaching?
Area Area
SF/LF SF/LF
Equalizer 24 3.76 N/A
Quick4 Equalizer 24 3.90 N/A
Quick4 Equalizer 24 LP (6-inch invert) 3.90 N/A
Quick4 Equalizer 24 LP 2-inch invert 2.78 N/A
Equalizer 36 4.73 N/A
Quick4 Equalizer 36 4.73 N/A
Standard Chamber 6.53 N/A
Quick4 Standard 6.96 N/A
Quick4 Standard HD 6.96 N/A
Quick4 Plus Standard 5.3-inch invert 6.20 N/A
Quick4 Plus Standard 8-inch invert 6.96 N/A
Quick4 Plus Standard LP 3.3-inch invert 5.65 N/A
Quick4 Plus Standard LP 8-inch invert 6.96 N/A
Infiltrator 3050 or StormTech SC-740 N/A 6.71
High Capacity Chamber 7.79 N/A
Quick4 High Capacity 7.93 N/A
u1ck4 High Capacity HD 7.93 N/A
Quick4 Plus High Capacity (8-inch invert) 6.96 N/A
Quick4 Plus High Capacity(13-inch invert) 7.93 N/A
5. Effective April 21,2006,310 CMR 15.251(1)(b)maximum trench width is 3 feet.
6 Effective leaching area is equal to 1.67 (bottom width+(2x invert height)) for Systems
3 feet or less in width.
'. Effective leaching area is equal to 1.0 (3 +(2x invert Height)) for Systems with a width
greater than 3 feet.
8. The maximum trench width allowed to calculate effective leaching area is 3 feet.
5. Systems installed on remedial sites shall be allowed to utilize the effective
leaching areas presented in Tables 2 or 3, or additional reductions in soil
absorption system may be allowed. In no instance shall the reduction in the soil
absorption system required in 310 CMR 15.242 exceed the maximum reduction
allowed for alternative systems approved in accordance with 310 CMR 15.284.
6. For new construction or an upgrade, the applicant can size the System in bed or
field configuration, using the effective leaching areas presented in Table 3.
Infiltrator Chamber,Infiltrator Inc. Page 4 of 6
Approval for General Use—May 22,2014
Table 3: Effective Leaching Area for Bed or Field Configuration New
Construction and Remedial Sites
Effective
Model Leaching9
Area
SF/LF
Equalizer 24 2.09
Quick4 Equalizer 24 2.23
Quick4 Equalizer 24 LP 6-inch invert 2.23
Quick4 Equalizer 24 LP (2-inch invert) 2.23
Equalizer 36 3.06
Quick4 Equalizer 36 3.06
Standard Chamber 4.73
Quick4 Standard 4.73
Quick4 Standard HD 4.73
Quick4 Plus Standard(5.3-inch invert) 4.73
Quick4 Plus Standard 8-inch invert 4.73
Quick4 Plus Standard LP 3.3-inch invert) 4.73
Quick4 Plus Standard LP 8-inch invert 4.73
Infiltrator 3050 or StormTech SC-740 7.10
High Capacity Chamber 4.73
Quick4 High Capacity 4.73
Quick4 High Capacity HD 4.73
Quick4 Plus High Capacity 8-inch invert 4.73
Quick4 Plus High Capacity 13-inch invert 4.73
I
9.Effective Leaching area is equal to 1.67 times bottom width only.
7. When the System is used with a secondary treatment unit approved in accordance
with 310 CMR 15.284 or 15.288, additional reductions in soil absorption system
may be allowed. In these situations the reduction in the SAS cannot exceed the
maximum allowed under the secondary treatment units approval. In no instance
shall the reduction in the soil absorption system area required in 310 CMR 15.242
exceed the maximum reduction allowed for alternative systems approved in
accordance with 310 CMR 15.284.
II. Special Conditions
1. The System is an approved Alternative Chamber for use as an Alternative Soil
Absorption System. In addition to the Special Conditions contained in this
Approval, the System shall comply with the"Standard Conditions for Alternative
SAS with General Use Certification and/or Approved for Remedial Use" (the
'Standard Conditions'), except where stated otherwise in these Special
Conditions.
2. New Construction This Certification is for the installation of a System to serve
new construction or an existing facility with a proposed increase in flow, for
Infiltrator Chamber,Infiltrator Inc. Page 5 of 6
Approval for General Use—May 22,2014
which a site evaluation in compliance with 310 CMR 15.000 has been approved
by the Approving Authority and the site meets the siting requirements for new
construction, as provided in Paragraph 6 in section II Design and Installation
Requirements of the Standard Conditions.
3. Remedial Site This General Use Certification also applies to the installation of a
System for the upgrade or replacement of an existing failed or nonconforming
system,provided that the facility meets the siting requirements for upgrades, as
provided in Paragraph 7 in section II Design and Installation Requirements of the
Standard Conditions
4. The System shall be exempt from the minimum inlet spacing requirements of 310
CMR15.253.
5. The System shall have a minimum of one inspection port through the top of one
of the chambers. The inspection port shall be capped with a screw type cap and
accessible to within three inches of finish grade.
6. When the System is installed in trench configuration, then the system shall
comply with these requirements:
a) Length(each trench) 100 feet maximum(310 CMR 15.251(1)(a));
b) Width(each trench) 2 feet minimum to 3 feet maximum(310 CMR
15.251(1)(b)). - Chambers greater than 3 feet wide, when specifically
approved, are subject to other Special Conditions and limitations;
c) The minimum separation distance between any two trenches shall be two
times the effective width or depth of each trench, whichever is greater, or
where the area between trenches is designated as reserve area, three times the
effective width or depth of each trench, whichever is greater(310 CMR
15.251(1)(d));
d) The effective leaching area shall be calculated using the bottom area and a
maximum of two feet(per side) of side wall area for each trench(310 CMR
15.251(1)(e));
e) Trenches shall be situated, where possible, with their long dimension
perpendicular to the slope of the natural soil. Where possible they shall follow
the contour lines (310 CMR 15.251(2));
f) Trenches constructed at different elevations shall be designed to prevent
effluent from the higher trench(es) flowing into the lower trench(es) (310
CMR 15.251(3));
g) The area between trenches may be designated as system reserve area only
where the separation distance between the excavation sidewalls of the primary
trenches is at least three times the effective width or depth of each trench,
whichever is greater(310 CMR 15.251(4)) - Chambers greater than 3 feet
wide, when specifically approved, shall be separated by three times the actual
width and are subject to other Special Conditions and limitations; and
Infiltrator Chamber,Infiltrator Inc. Page 6 of 6
Approval for General Use—May 22,2014
h) Effluent distribution lines exceeding 50 feet in length shall be connected and
venting provided in accordance with 310 CMR 15.241 (3 10 CMR
15.251(11)).
7. When installed in trench configuration, approved Alternative Chambers greater
than 3 feet wide:
a) shall be installed with a minimum separation distance between any two
trenches of two times the actual width of the chamber, or where the area
between trenches is designated as reserve area, three times the actual width of
the chamber; and
b) shall only be entitled to a maximum effective width of 3 feet for the purposes
of calculating total effective leaching area.
8. When installed in a bed or field configuration,the System may be installed
without distribution piping,but must comply with the following requirements in
310 CMR 15.252:
a) the use of leaching beds or fields is restricted to systems with a calculated
design flow of less than 5,000 gpd per leaching bed or field(3 10 CMR
15.252(1));
b) the maximum length of chambers in series shall be 100 feet(3 10 CMR
15.252(2)(b));
c) separation distance between adjacent beds/fields shall be ten feet(3 10 CMR
15.252(2)(f)); and
d) the effective leaching area shall include only the bottom area,not the
sidewalls (3 10 CMR 15.252(2)(i)).
9. For Systems constructed in fill and installed, the System shall be installed as
specified in 310 CMR 15.255- Construction in Fill, except the minimum 15 foot
horizontal separation distance to be provided between the soil absorption area and
the adjacent side slope shall be measured horizontally from the top of the
chamber.
10. The System is exempt from 310 CMR 15.287, specifically items: (5) requiring
written notification of alternative system prior to property transfer, (6) need for a
certified operator, (9)need for an operation and maintenance contract with an
operator and(10) deed notice requirement.
'Town of Barnstable
Regulatory Services
ti
Richard V. Scali, Interim Director
+ BARNSTABLE, : Public Health Division
9 MASS.
1639.�a`0 Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
3
Office: 508-862-4644 ,, Fax: 508-790-6304
Homeowner Certification Form for Alternative Systems
Property Address: A -�&
Assessor's Map\Parcel:
Property Owners Name:
In accordance with Massachusetts DEP alternative system approval letters, the following certification
information is required by the Owner of record. The Owner of record must place an "x" in the
applicable box next to each line certifying the information.
r1A
I have been provided a copy of the Title 5 I/A technology Approval letters.
5 page Standard Conditions letter and the specific technology letter)
❑ ave been provided with the Owner's Manual
❑ I ave been provided with the Operation and Maintenance Manual
❑ For Systems installed under a Remedial Use Approval, I agree to fulfill my
responsibilities to provide a Deed Notice as required by 310 CMR 15.287(l0)
and the Approval
❑ For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to
provide written notification of the Approval to any new Owner, as required by
310 CMR 15.287(5)
zo
If the design does not provide for the use of garbage grinders, the restriction is understood
and accepted
Whether or not covered by a warranty, I understand the requirement to repair, replace, modify
or take any other action as required by the Department or the LAA, if the Department or the
LAA determines the System to be failing to protect public health and safety and the
environment, as defined in 310 CMR 15.303
AIA � �S� agree to comply with all terms and conditions above.
ty O ners printed name
7 /0
erty Owners Signature Date
Note: This form must be submitted along with the septic system disposal works 'permit
application for all I\A systems including new construction, repairs\upgrades, with and
without aggregate (stone) and with conventional design criteria or credited design
criteria.
Q:\Septic\IA homeowner certitication.doc c
i
i
TRANS. NO.:
CITY/TOWN:
APPLICANT:
ADDRESS: "_
DESIGN FLOW: gpd
REVIEWED BY: DATE:
N/A OK NO
GENERAL
Legal boundaries denoted [310 CMR 15.220(4)(a)]
Street, Lot, tax parcel number and lot number noted on plan [310
CMR 15.220(4)(u)] _
Locus Provided [310 CMR 15.2204(t)
Plan proper scale?(1"=40' for plot plans, 1"=20' or fewer for
components) [310 CMR 15.220(4)]
Easements shown [310 CMR 15.220(4)(b)]
System located totally on lot served [310 CMR 15.405(1)(a) for
upgrades]- if not, a variance is required [310 CMR 15.412(4)]
Location of impervious surfaces (driveways,parking areas etc.)
[310 CMR 15.220(4)(d)]
Location all buildings existing and proposed 310 CMR
15.220(4)(c)]
Location and dimensions of system components and reserve
areas. [310 CMR 15.220(4)(e)]
System Calculations [310 CMR 15.220(4)(f)]
daily flow
septic tank capacity(required andprovided)
soil absorption system(required and provided)
whether system designed for garbage grindei
North arrow 310 CMR 15.220(4)(g)]
Existing and pro osed contours [310 CMR 15.220(4)(g)]
Location and log of deep observation holes (existing grade el. on
each test) 310 CMR 15.220(4)(h)]
Names of soil evaluator and BOH representative [310 CMR
15.220(4)(h) and(i)]
Location and date of percolation tests (performed at proper
elevation?) 310 CMR 15.220(4)(i)]
Percolation test results match loading rate? 310 CMR 15.242]
Certification statement by Soil Evaluator[310 CMR 15.220(4)0)]
Observed and Adjusted groundwater(method for adjustment
given or indicated) [310 CMR 15.103(3) and 310 CMR
15.220(4)(n)]
Address Sheet 1 of 7
N/A OK NO
Location of eve water supply,public and private, 31 CMR
�' ppY,p p , [ 0
15.220(4) k
within 400 feet of the proposed system location in the case
of surface water supplies and gravel packed public water supply
within 250 feet of the proposed system location in the case
within 150 feet of the proposed system location in the case
of private water supply wells
Location of all surface waters and wetlands located up to 100 ft.
beyond setbacks listed in 310 CMR 15.211 and any catch basins
located within 50 ft. [310 CMR 15.220(4)(1)]
Water lines and other subsurface utilities located [310 CMR
15.220(4)(m)] if water line cross see 310 CMR 15.211(1)[1 )
Profile of system showing invert elevations of all system P
components and the bottom of the SAS [310 CMR15.220(4)(o)]
Stamp of designer[310 CMR 15.220(1) and 310 CMR 15.220(2)]
Stamp of Registered Land Surveyor(required if construction
activities within 5 ft. of lot line) [310 CMR 15.220(3)]
Test Holes adequate(two in each of the primary and reserve
unless trenches as permitted in 310 CMR 15.102(2) or as
approved for an upgrade under LUA at 310 CMR 15.405(1)(k)]
Test hole adequate to demonstrate four feet of suitable material?
[310 CMR 15.103(4)] 01
Test Holes adequate to confirm adequate groundwater separation?
310 CMR 15.103(3)
Benchmark within 50-75' of system [310 CMR 15.220(4)(q)]
Materials specifications noted? [various sections of 310 CMR
15.000]
System components not> 36" deep (unless Local Upgrade
1,A2proval or LUA requested) [310 CMR 15.405(1 b)]
Address Sheet 2 of 7
N/A OK NO
SEPTIC TANK
Size OK? [310 CMR 15.223(1)
Inlet tee located ten inches below flow line 310 CMR 15.227(6)]
Outlet tee 14" or 14" + 5"per foot for increase ft depth[310 CMR
15.227(6)]
Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)] i
Note regarding installation on stable compacted base [310 CMR
15.228(l)]
Separation between inlet and outlet tees(no less than liquid
depth) [310 CMR 15.227(2)]
Inlet/Outlet elevations at least 12" above high groundwater /
(except as described 310 CMR 15.227(5)) or permitted for /
upgrades under LUA [310 CMR 15.405(1)(k)]
Minimum cover 9" (Tanks buried more than 9" must have risers
on all openings and on the d-box) [310 CMR 15.2228(1) and 310 Q
CMR 15.232(3)(f)]
Three access covers (inlet and outlet must be 20" or greater) -
middle access at least 8" (by 7/07) [310 CMR 15.228(2)]
Access to within 6 " of grade - one port for systems<I000gpd,
two for systems>1000 g
pd 310 CMR 15.228(2)]
All at-grade covers secured to unauthorized access? [310 CMR r
15.228(2)]
> 10 ft from building foundation[310 CMR 15.211 1 ]
Buoyancy calculation Required/Done [310 CMR 15.221(8)] 1
H-20 Where appropriate? [310 CMR 15.226(3)]
Setbacks from resources [310 CMR 15.211]
Multi-Compartment Tanks
Required when other than single-family dwelling or flow>1000
d[310 CMR 15.223(1)(b)]
First compartment 200% daily flow; Second compartment 100%
daily flow [310 CMR 15.224(2) and(3)
"U" pipe through or over baffle, outlet of each compartment with
gas baffle or approved filter [310 CMR 15.224(4)]
Address Sheet 3 of 7
i t
N/A OK NO
BUILDING SEWER AND OTHER PIPING
Located at least ten feet from any water line? [310 CMR
15.222(2)
Disposal piping at least 18" below water line (when water and
sewer cross, see 310 CMR 15.211(1)[1])
Cleanouts required/provided? 310 CMR 15.222(8)]
Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)
Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable
[310 CMR 15.222(6)]
Proper pitch on all runs? (.005 within gravity-distributed trenches
and beds) 310 CMR 15.251(9) and 310 CMR 15.252(2)(c)]
Siphonproblem/(leachfield below pump chamber)
Endca s or vent manifold specified?
Size and orientation of discharge holes specified? (not smaller
than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310
CMR 15.252(2) h
Materials specified (310 CMR 15.251(5) specifies various pipe 1
types allowed)
DISTRIBUTION BOX
Stable compacted base [310 CMR 15.221(2) and 310 CMR /
15.232(2)(a)] '
Splash plate or baffle tee required on inlet/provided? (when
pressure sewer to d-box or steep pitch of gravity sewer) [310
CMR 15.323(3)(a)]
Riser if deeper than 9" [310 CMR 15.232(3)(0] c
Inside minimum dimension 12" 310 CMR 15.232(2)(b)]
Minimum sum 6" 310 CMR15.232(3)(e)
Watertight cover if<2000gpd); waterproof manhole if>2000gpd
[310 CMR 15.232(3)(d)]
PUMP CHAMBERS
Capacity(emergency storage above working=design flow)? [310
CMR 231(2)]
Proper setbacks 310 CMR 15.211 (same as septic tanks)]
Watertight 20-in minium access manhole at least 20" MUST BE
TO GRADE [310 CMR 15.231(5)]
Service components accessible (not too deep with piping,
disconnects accessible)
Alarm floats- alarm on circuit separate from pumps specified?
Exceeds two units must have two pumps operating in lead-lag
mode. [310 CMR 15.231(6) and(8)]
Stable Co m acted Base [310 CMR 15.221(2)]
IBuoyancy calculations needed?Provided? 310 CMR 15.221(8)
Address Sheet 4 of 7
i
N/A OK NO
SOIL ABSORPTION SYSTEMS (SAS) GENERAL
Calculations correct?
4 feet of naturally occurring material demonstrated? [310 CMR
15.240(l)]
Required separation to groundwater? [310 CMR 15.212)]
Aggregatespecified as double washed[310 CMR 15.247(2)] r
System Venting required/provided? (system under driveway or
>36" deep) [310 CMR 15.2411
Inspection ports specified and within 3"final grade? [310 CMR
15.240 13
Breakout requirements met?(No violation of breakout elevation
within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and
Guidance Document]
GALLERIES,PITS,CHAMBERS 310 CMR 15.253
Chambers and Gal. in trench configuration supplied with inlet
every 20 ft. [310 CMR 15.253(6)]
Each structure with one inspection manhole(if>2000 gpd must
be to grade) [310 CMR 15.253(2)]
Aggregate 1' minimum-4'maximum. [310 CMR 15.253(1)(b)]
2' sidewall credit maximum [310 CMR 15.253(1)(a)]
In bed configuration, inlet every 40 s . ft. [310 CMR 15.253(6)]
TRENCHES 310 CMR 15.251
Width 2' minimum 3' maximum 310 CMR 15.251(1)(b)
100 feet-maximum length[310 CMR 15.251 1)(a)]
Minimum separation 2x effective depth or width whichever
greater(3x if reserve between trenches) [310 CMR 251(1)(d)]
Situated along contours 310 CMR 15.251(2)]
Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document]
BED SAS (Maximum size of bed or field 5000 gpd)
minimum 2 distribution lines [310 CMR 15.252(2)(a)]
Maximum separation between lines 6' 310 CM R15.252(2)(d)]
Maximum separation between lines and outside of bed 4' [310
CMR 15.252(2)(e)]
Aggregate depth below discharge pipes 6" minimum, 12"
maximum. 310 CMR 15.252(2)(g)]
Separation between beds 10'minimum. [310 CMR 15.252(2)(f)]
Bottom area used in calculations only [310 CMR 15.252(2)(i)]
Address Sheet 5 of 7
I
N/A OK NO
DID THE PLAN INVOLVE
Pressure Dosed System ? Provided pump and piping
calculations as required 310 CMR 15.220(4)(r)]
Pressure dosing required on all systems>2000gpd or alternative
systems under remedial approval [310 CMR 15.254(2) and I/A
Remedial Use Approvals]
If used in gravelless system-make sure jet is directed as not to
scour soil interface [Guidance Document]
Inspections once per year(systems< 2000 gpd) or quarterly
(>2000 d) good to note on plan[310 CMR 15.254(2)(d)]
Construction in fill -Did the plan specify that the fill shall meet
the specification of 310 CMR 15.255(3)?
Impervious barrier and/or retaining wall? [Guidance Document] ti
Impervious barrier installation must be supervised by
designer 310 CMR 15.255(2)(b)]
Retaining wall must be designed by Registered Professional
Engineer [310 CMR 15.255(2)(a)]
Side slope not exceed 3:1 ? [310 CMR 15.255(2)]
Breakout requirements met? [310 CMR 15.252(2) and
Guidance Document
At least 5 ft. from impervious barrier to edge of SAS (10 ft.
recommended) [310 CMR 15.255 (2)(e)]
Gravelless System[UA Approval Letters]
Check DEP Approval letters for credits and design conditions
If used with pressure dosing do not allow pressure discharge
to scour soil interface
Alternative Septic System[I/A Approval Letters]
Was DEP Approval Letter provided and/or have you
reviewed the letter for conditions?
Is the technology being properly applied and does it meet all
DEP Approval Conditions?
Is there a note on the plan regarding the requirement for
perpetual maintenance agreement?
Any alarms involved on separate circuits
Did the applicant submit an operation and maintenance
manual?
Has applicant submitted a copy of a maintenance
Variances
Are the variances listed on the plan? [310 CMR 15.220
(4)(
RLS Stamp necessary on plan if a component is within five
feet of property line [310 CMR 15.412(4)]
New construction or increased flow proposed- [Refer to 310
CMR 15.414
Address Sheet 6 of 7
N/A OK NO
Nitrogen Sensitive Areas
Is the system in a Designated Nitrogen Sensitive Area(Zone II for
a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and
310 CMR 15.216 - also refer to Policy regarding upgrades of such
existing systems]
Is the system proposed on the same lot as served by private well ?
310 CMR 15.2142)
Are the nitrogen loads proposed in compliance? [310 CMR
15.216(1)]
Miscellaneous
Pumping to septic tank? [ 310 CMR 15.229
Shared System [310 CMR 15.290]
Address l/� � � �►°'► �j Sheet 7 of 7
Town of Barnstable P#
�� � V,
Department of Regulatory Services
BAnlv9'rASM Public Health Division Date
.6 q.6 2 Main Street,Hyannr'`s MA 02601 J
IAOtt I! ?'
Date Scheduled Time Fee Pd.
i
lisuitabili,ty Assessment or Sew a s s l f
Performed By: Witnessed By: —
LOCATION&GENERAL INFORMATION
Location Address ,►S,q�,q{' Owner's Name ],��,('�e
/� ` Address
y`�1'�G�^l
Assessor's Map/Parcel: �t;��/� Engineer's Name ,
NEW CONSTRUCTION REPAIR Telephone# -3.6 1 -
Land Use Slopes(%) Surface Stones
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft
Drainage Way ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locati9lns of test holes&perc tests,locate wetlands in proximity to holes)
V.)
6--•p y A�
E'T ,_-C
r.
%,n
Parent material(geologic)�A Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level
PERCOLATION TEST Date Time
��'yy
Observation XI I
Hole# Time at 9"
Depth of Perc Time at 6"
Start Pre-soak Time @ l Time(9"-6")
End Pre-soak 1/ ,,I
Rate MinAnch j 9 A,
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:\SEPTIC\PERCFORM.DOC
I
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
b
LL L )
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)
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)
11
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsefl) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
Flood Insurance Rate Mao: /
Above 500 year flood boundary No/Yes
Within 500 year boundary No /Yes
Within 100 year flood boundary No_/% Yes
Death of Naturally Occurring Pervious Material
Does at least four feet of naturally occurrmg pervious material exist in all areas observed throughout the
area proposed for the soil abso lion system?
If not,what is the depth f na fly occurring pery ous material.
Certification `1� G
I certify that on W 4 (date)I have passed the soil evaluator examination approved by the
Department of Envtro enta Protecti and that the above analysis was perfio�mej by me consistent with
the require J ' ,expe i an xp n e described in 310 CMR 15.0r1n7. q
Signature Date `�
Q:\SEPTIC\PERCFORM.DOC
!�r
TOWN OF BARNSTABLE I
17/
a
LOCATION PC �elM�/� 4& SEWAGE# Z.01 y -ZZ 9
VILLAGEv"ez,7e-4,Vi'f&--, ASSESSOR'S MAP&PARCEL/9 L/ 63
INSTALLER'S NAME&PHONE NO6426t�, Mo eleai A t 6452� 4t--
SEPTIC TANK CAPACITY I&WO 9411 Ae
LEACHING FACILITY:(type) b', 1�1���y�'47'6 S (size) YV K v
NO. OF BEDROOMS 3
OWNE �e
PERMIT DATE: > q COMPLIANCE DATE: e-
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
31
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I
Town of Barnstable Health Inspector
Office Hours.
Regulatory Services 8:00-9:30
BAMSTABLE, ' 1:00-2:00
• Thomas F.Geiler,Director onlyKma
o► � Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644. Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT QUESTIONNAIRE
1. General Information:
Address: ddMS-r110117 Gf f't lye : C.e krvj1I2 Map_L2y Parcel 063
Name: —Kc`r e m Phone:V. 3 k -5-0-7 0
2. How many bedrooms exist on your property now?
2a. Please include a copy of your floor plans. L,--
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 INSID or OUTSIDE a Zone of Contribution to public
supply wells?
5. Is the dwelling connected to an ONSITE WELL or to =WATER?
6. Is a disposal works construction permit on file? 0 or NO
6a.If yes,how many bedrooms were approved according to this permit? 3 Bedrooms.
7. Were any building permits obtained for construction of additional bedrooms? YES r NO
8. Is there an-engineered septic Sys em plan on file at the Health Division? 0 or NO
y By �r
9. Has the septic system been inspected by a DEP certified inspector within the last two years?
ES' .or NO Nab. Alme ��e , Ahd nehr�F�til N� JAcreASP--------------------------------------------------------------------------------
Ct (JVMQ OWWiQ.!
FOR OFFICE USE ONLY
TO BE SIGNED BY A HEALTH INSPECTOR/AGENT ONLY
The Public Health Division has no objection to—3--Lgedrooms at this property.
Signed: 4t��
WV
Inspector(Print): w.
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I certify that this o �'c '
located in Flood Hazard ZonepCr(Out$side the 500'year flood) as identified
by the Department of Housing and Urban
Development (HUD) .
)ate Dec. CERTIFIED PLOT PLAN
15 o r• f,-
LOCATION
SCALE �� DATE
Reg. nd��$ e PLAN REFERENCE
'�rsa (CrrTE� .379
`-.�,�L LA'S,;;. �" �G' ,� . . . . .. .. . .. .. . .•. . . . . . . .. . . .
I certify to Cape Cod Bank &Trust and its title ins.co. .
that there are no visible encroachments THE LOCATION OF THE ORIGINAL DWELLING
)r easements except as shown and that this SHOWN HEREON,EITHER WAS IN COMPLIANCE
WITH THE LOCAL APPLICABLE ZONING BYLAWS
)Ian was prepared under my immediate IN EFFECT WHEN CONSTRUCTED (WITH
upervision. RESPECT TO HORIZONTAL DIMENSIONAL
REQUIREMENTS ONLY),OR EXEMPT FROM
VIOLATION ENFORCEMENT ACTION UNDER M.O.L.
el,Y, &-A R4-77 TITLE VI I ,CHAPTER 40A,•SECTION ?,UNLESS
OTHERWISE NOTED OR SHOWN HEREON.
' Fee.3�
No.
Entered in computer:
THE COMMONWEALTH OF MASSACHUSETTS Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIPPrication for Oiopogal 6potem con0ruction permit
Application for a Permit to Construct(repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. G ��S�9�hS /', Owner's Name,Address and Tel.No.
�7-r vi//E ��gp� f> '1���
�T
Assessor's Map/Parcel la 4F 0Of
Installer's Name,Address,and Tel.No. q7 7--d 5?9 Designer's Name,Address and Tel.No.
i�lir�s
Type of Building:
Grinder
( )
Dwelling No.of Bedrooms�_ Lot Size —sq. Garbage
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow
gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil S,qn
Nature of Repairs or Alterations(Answer whyn applicable) rO
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
ental Code and not to place the system in operation until a Certifi-
in accordance with the provisions of Title 5 of the Environm
cate of Compliance has been issued by this oard o Heap. Date
Signed 2�
Date
Application Approved by
Application Disapproved for the following reasons .
Permit No._._�g' q� Date Issued
THE POMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of COMPIiance
THIS IS TO C11 TIFY,that the On-site Sewage Disposal System'Constructed( ep ed( )Upgraded( )
Abandoned( )by I .0 ��i".,. has been constructed in accordance
at r dated
with the provisions of Title 5 and the for Disposal.System Construction Permit No.
Installer �-� /-��+�rd _____-Design
The issuance of this permit shal not be construed as a guarantee that the system will unction as designed.
Date 7•• 9 ��
Inspector
J - -------------------------- �.,�
�
No. v
IN No.
COMMONWEALTH OF.MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,MASSACHUSETTS
i$tl *p aem Conotrurtion Permit
Permission is hereby granted to Construct(4.*Repair( )Upgrade Abandon( )
System located at
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:Constructio must be completed within three years of the date of this permit.
Date: ` Approved by
Barnstable Assessing Search Results Page 1 of 2
' xY,�s}Art- ZK6
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Home: Departments:Assessors Division:Property Assessment Search Results
<<back to search 26 HELMSMAN DRIVE
Owner: Property Sketch Legend
ADLER, KAREN A
_..._....................
Map/Parcel/Parcel Extension
194 /063/
Mailing Address
ADLER, KAREN A
26 HELMSMAN DR
CENTERVILLE, MA. 02632
Assessed Values: r
Appraised Value Assessed Value
Building Value: $ 116,100 $116,100 .....-:: ..............
Extra Features: $9,500 $9,500
Outbuildings: $0 $0
Land Value: $48,700 $48,700 Interactive Property Map: Map re wires Plug in:
Totals:$ 174,300 $174,300 1 have visited the maps before
Show Me The Man
Sales History:
Owner: Sale Date Book/Page: Sale Price:
OKEEFE,MICHAEL P&MARY V 3/15/1985 4453/247 $75,500
SMITH,JAMES K TRS 9/15/1984 4252/228 $0
Tax information: Tax Rates: (per$1,000 of valuation)
Town Tax $ 1,614.02 Town Fire District Rates Other Rates
9.26 Barnstable 2.61 Land Bank 3%of Town Tax
C.O.M.M.FD Tax $240.53 C.O.M.M. 1.38
Cotuit 1.69
Land Bank Tax $ 1,902.97 Hyannis 2.54
West Barnstable 1.54
Total: $ 1,902.97 Due to rounding differences these values may vary
i
http://www.town.bamstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing/... 11/6/2002
'Barnstable Assessing Search Results Page 2 of 2
Land and Building Information
Land Building
Lot Size(Acres) 0.65 Year Built 1985
Appraised Value $48,700 Living Area 1591
Assessed Value $48,700 Replacement Cost$128,954
Depreciation 10
Building Value 116,100
Construction Details
Style Cape Cod Interior Floors Hardwood
Model Residential Interior Walls Drywall
Grade Average Grade Heat Fuel Gas
Stories 1 1/2 Stories Heat Type Hot Air
Exterior Walls Wood Shingle AC Type None
Roof Structure Gable/Hip Bedrooms 3 Bedrooms
Roof Cover Asph/F GIs/Crop Bathrooms 3 Bathrooms
Total Rooms 6 Rooms
Extra Building Features
Code Description Units/SQ ft Appraised Value Assessed Value
BFA Bsmt Fin-Aver 500 $6,800 $6,800
FPL2 Fireplace 1 $2,700 $2,700
Property Sketch Legend
BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished)
BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished)
CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area(Unfinished)
FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story(Unfinished)
FCP Carport GRN Greenhouse UUA Unfinished Utility Attic
FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished)
FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck
FOP Open or Screened in Porch TQS Three,Quarters Story(Finished)
http://www.town.bamstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing/... 11/6/2002
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE �fer7T%vdll ASSESSOR'S MAP & LOT.'
INSTALl.l RsS.N ,&PHON> NO.
SEPTIC TANK CAPACITY /UJO Gam/
LEACHING FACILITY: (type) 9-00 6*1, (size) rX /
NO.OF BEDROOMS
BUILDER OR OWNER
PERM&DATE: / I- S- 9 COMPLIANCE DATE: 19-
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 fa�cilii Feet
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Town of Barnstable Health Inspector
"' optNE t� Office Hours
H tio� Regulatory Services Of8:0 —9:ur
• Thomas F.Geiler,Director 1:00—2:00
anuvsTABM i
'"ASS. Public Health Division Only
1639• `0�
prFD MAC
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644
Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT QUESTIONNAIRE
1. General Information:
Address: )6 Map Lqj&3 Parcel a(o
Name: _�C! . t/ /��L-� .
Phone:
2. How many bedrooms exist on your property now?
2a. Please include a copy of your floor plans for the entire propertyz,-
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 r OUTSIDE a Zone of Contribution to public
supply wells?
S. Is the dwelling connected to an ONSITE WELL or to �UB=WATER?
6. Is a disposal works construction permit on file? YES or
6a.If yes, how many bedrooms were approved accor Ing to this permit? 3
Bedrooms.
7. Were any building permits obtained for construction of additional bedrooms?0
or NO
8. Is there an engineered septic system plan on file at the Health Division? OYESor NO
9. Has the septic syste> been ins pected by a DEP certified inspector
YES I or NO within the last two years?
---------------------------------------------------- _ _____
FOR OFFICE USE ONLY `�
TO BE SIGNED BY A HEALTH INSPECTOR/AGENT ONLY
U, V���
The Public Health Division has no objection to bedrooms at this property.
g Date: M
�4-
Signed: M
M u
Val
Inspector(Print):
viM
Q;/health/wpfiles/amnestyapp ,�
THE Town of Barnstable Barnstable
�pP rpm
Regulatory Services Department j�"a o
+ BARNEWABLE,
3 Public Health Division
�p i6gq. ��
a 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL # 7012 1010 0000 2851 3665
June 20, 2014
Karen A. Adler
26 Helmsman Dr
Centerville, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 26 Helmsman Drive, Centerville,MA, was last inspected
on 5/12/2014, by Fred Swain, a certified septic inspector for the State of Massachusetts.
The inspection of the septic system showed that the system" Fails"under the guidelines
of the 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool.
• Static liquid level in the distribution box above outlet invert due to an
overloaded or clogged SAS or cesspool.
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S. CHO
Agent of the Board of Health
1
Q:ISEPTIC\Letters Septic Inspection Failures or Future Evl\26 Helmsman Dr Cent Jun 2014.doc
Parcel Detail http://issgl2/intranet/propdata/Parce]Detail.aspx?ID=14098
Y c
Logged In As: Parcel Detail Wednesday, June 2014
Parcel Lookup
Parcel Info
Parcel,_. ._.._._ __.__ _. .._ _ _._ Developer._.__.._ _._.- ._ . ._._ .
ID 194-063 Lot LOT 26
Pri
Location;26 HELMSMAN DRIVE Frontage
Sec; __ _I Sec
Road' Frontage
___... Fire -
Village CENTERVILLE I District C O-MM
Town sewer exists at this Road -20-_..
addressNo Index
Interactive '�
Map
Owner Info
Owner ADLER, KAREN A Owner
Streetl 26 HELMSMAN DR Street2
City CENTERVILLE _..__----- State MA Zip 02632 country'
Land Info
Acres10.65 J Use;Single Fam MDL-01 Zoning,RC Nghbd 0105 J
Topography Level Road'Paved
__. ..___..._..__.......___w.. _ ...._.__ ____... ...,..
Utilities IPublic Water,Gas,Septic Location;
Construction Info
Building 1 of 1
Year? Roof Ext
Built 1985 Struct`Gable/Hip Wall Wood Shingle
Living _- _. Roof�-._._ __ _.- ......_ AC- _ _....
1602 'Asph/F G' Ern'p None
Area Cover Type' K
Int;__ Beds _.._.__.. ._.._
Style Cape Cod jDrywall 3 Bedrooms
Wall Rooms' en €
Model;Residential I Int Hardwood I Bath 13 Full
Floor Rooms' x 4r
Heat ________ Total:_._ ..___.
Grade;Average T e Mot Air Rooms'`6 Rooms e -
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Stories 1 1/2 Stories Fuel IGas _ J ation'Poured Conc.
Gross
httD:Hissal2/intranet/DrODdata/ParcelDetaii.aspx?ID=14098 6/18/2014
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Helmsman Dr
Property Address
Bob Barsansky
Owner Owner's Name
information is Centerville MA 02632 May 12, 2014
required for every y
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, n
use only the tab 1. Inspector:
key to move your
cursor-do not Fred Swain
use the return Name of Inspector
key.
Wind River Environmental
Company Name
1958 R Broadway
Company Address
Raynham MA 02767
City/Town State Zip Code
(508)822-2003 651
Telephone Number License Number
B. Certification
-.
I certify that I have personally inspected the sewage disposal system at this address and that.tbe
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 sffe
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15_'.340 of4"
Title 5(310 CMR 15.000). The system: a
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
May 12, 2014
Inspec or'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. n
I U ly
1
t5ins-3/13 Title 5 Official Inspection Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 26 Helmsman Dr
Property Address
Bob Barsansky
Owner Owner's Name
information is required for every Centerville MA 02632 May 12, 2014
page. Cityrrown 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:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 26 Helmsman Dr
Property Address
Bob Barsansky
Owner Owner's Name
information is Centerville MA 02632 May 12, 2014
required for every Y
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 26 Helmsman Dr
Property Address
Bob Barsansky
Owner Owners Name
information is Centerville MA 02632 May 12, 2014
required for every y
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
'*This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
® ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/z day flow
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Helmsman Dr
Property Address
Bob Barsansky
Owner Owner's Name
information is Centerville MA 02632 May 12, 2014
required for every Y
page. Citylfown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 26 Helmsman Dr
Property Address
Bob Barsansky
Owner Owner's Name
information is Centerville MA 02632 May 12, 2014
required for every y
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Helmsman Dr
Property Address
Bob Barsansky
Owner Owner's Name
information is Centerville MA 02632 May 12, 2014
required for every y
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Unavailable
Sump pump? ❑ Yes ® No
Last date of occupancy: currentDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Helmsman Dr
Property Address
Bob Barsansky
Owner Owner's Name
information is required for every Centerville MA 02632 May 12, 2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Wind River Environmental
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1,000 gallons
gallons
How was quantity pumped determined? Tank size
Reason for pumping: To check the structural integrity of the septic tank.
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Helmsman Dr
Property Address
Bob Barsansky
Owner Owner's Name
information is Centerville MA 02632 May 12, 2014
required for every Y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Dec 1999 per plans
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2 1/2
feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 20'
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipes in walls and under floor. No evidance of leaking.
Septic Tank(locate on site plan):
Depth below grade: 2'
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:
10ftx5ftx5ft.
Sludge depth:
6 inches
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 26 Helmsman Dr
Property Address
Bob Barsansky
Owner Owner's Name
information is Centerville MA 02632 May 12, 2014
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 27 inches
Scum thickness 2 inches
Distance from top of scum to top of outlet tee or baffle 1 inches
Distance from bottom of scum to bottom of outlet tee or baffle 24 inches
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
System has a filter but it was partially clogged causing a high level in tank. I cleaned the filter and
the tank level dropped to proper level.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 26 Helmsman Dr
Property Address
Bob Barsansky
Owner Owner's Name
information is required for every Centerville MA 02632 May 12, 2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°�„ ,•°'r 26 Helmsman Dr
Property Address
Bob Barsansky
Owner Owner's Name
information is Centerville MA 02632 May 12, 2014
required for every y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 1/4"
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.):
The distribution box is 16"x 16"and is 3' bg. The box cover was deteriorated and replaced at this
time.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
26 Helmsman Dr
Property Address
Bob Barsansky
Owner Owner's Name
information is Centerville MA 02632 May 12, 2014
required for every y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number:
2
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching galleries are over full as system was not working properly.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Helmsman Dr
Property Address
Bob Barsansky
Owner Owner's Name
information is required for every Centerville MA 02632 May 12, 2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Helmsman Dr
Property Address
Bob Barsansky
Owner Owner's Name
information is Centerville MA 02632 May 12, 2014
required for every y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
I -
oy: SIFHUS; 508 362 5030; Ap;-27-01 5:UiPM, Fag@ 1/1
.d.'`'.':.ic:.:�:'n!:^ a.y o-�r+�._✓.- "L�s�--',:-'.',`-„a,_'••` _��- _ _ - -..per�.+�.yn �- -•�.:w ._... _ ...
It:;j� `.isG.• .�1.'a. :.;7•'' ';y.;C•,. .�_
di
j . TOWN OF BARNSTABLE ,G
i LOCATION SEWAGE#' LP-,;
f-t;_
VII:LAGE .-erT>=�V�./F_ ASSESSt}R S MAP&LOT/
dNSTALLBR'S NAME do PHONE NO. =%_" ;-:' y
SEMC TA* CAPACITY IOt;;�J /. -
LEACKnO FACHXrY: (type) -�✓J fit. ilis� :c„•:.1� (sire)_�S`;. /_? _
NO.OF BEDROOMS
BUILDER OP.OWNER
FM-iMIi'DATE: COMPL:IANCE DATE:_. _� ?- � � .• .
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility.(If any welds exist
on site or within 200 feet of kaehing facility) Fed
Edge of Wetland and Leacltsng Facility(If any wetdands exist.
within 300 feet of leaching fats ) F
Furnished by
r•
4 .
...
• i
a
. J•
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Helmsman Dr
Property Address
Bob Barsansky
Owner Owner's Name
information is required for every Centerville MA 02632 May 12, 2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Property drops off approximately 20' at power lines. High ground water elevation to be determined at
time of new system.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i
Commonwealth of Massachusetts
ffi Inspection Form ial Title 5 Official
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Helmsman Dr
Property Address
Bob Barsansky
Owner Owner's Name
information is
required for every Centerville MA 02632 May 12, 2014
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
TOWN OF BARNS
TABLE , G
LOCATION SEWAGE # f 9-,3 t?/
VILLAGE 'fenTrFrV,,///� ASSESSOR'S MAP &LOTS
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1, JO
LEACHING FACILITY: (type) I-0' 76, :yLLILI (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: / - ; ' 9
COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 fa�cilili Feet
Fugnished by
a
i
V
;mod
t i
j
w>
No. Prl
I :, Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipplication for Migaal bpgtem Con5truction 3permit
Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. H_ 0,,, Owner's Name,Address and Tel.No.
Assessor's Map/ParcelL G17/_r V/Ile
Installer's Name,Address,and Tel.No. C�/��_ 3 C�/9 Designer's Name,Address and Tel.No.
JDs�d�/`j V e, 1-34 Oe ✓&5G%-lI Z2L/3s�l�G^G s
Type of Building:
Dwelling No.of Bedrooms -3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
s
Title '
Size of Septic Tank Type of S.A.S.
Description of Soil �S/q," ,�
Nature of Repairs or Alterations(Answer wh n applicable) —1-. 5rZzl�
Date last inspected:
Agreement:
. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this oard o He
Signed Date
Application Approved by Date / Z '
Application Disapproved for the following reasons
Permit No.�_�� Date Issued
' ( y i
ETA
No. I — .1r 1 , Fee_�
w.
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
— Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
Application for Migaal *pgtem Con!5truction Permit
Application for a Permit to Construct(&Ilepair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. G He/&MIf es 4-1 Owner's Name,Address and Tel.No.
�,an1r'rV/&C CST /W 10
Assessor's Map/Pazcel
Installer's Name,Address,and Tel.No. �/7 7_O 3�'9 Designer's Name,Address and Tel.No.
\1o.Scf�4 ve- /3a�^,-a5 ✓o.s,_/04 lei�oa,,n—i S
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
'Title
Size of,Septic Tank Type of S.A.S.
Description of Soil ..S,4"d
Nature,of Repairs or Alterations(Answer wh n applicable) io.5&,g ll 57,00 j2-w 4Qz_;./'A c
Date last inspected:
Agreement: `
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with,the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board gf Hea th.
e
Signed .e r Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(tertificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( <-).Repaired( )Upgraded( )
Abandoned( )by
at a G L2e f lam' as been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer �c;��.e dA2YvW Designer Joseo4 /,
The issuance of this permit shal not be construed as a guarantee that the system will unction as designed.
Date 1 - Inspector
---------------------------------------
No. 0G� - Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Migpogar *pMem Construction Permit
Permission is hereby granted to Construct(Repair( )Upgrade( ,)Abandon( )
System located at 2G r/�/c l �4rlS (,?r t LI'
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 permit.
Date: Approved by
^ A
1/6/99
NOTICE: 'This Form Is To Be Used For the Repair Of Failed
,Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, J s e4 & lf*,,e os , hereby certify that the application for disposal works
construction pe:rrait signed by me dated /2- 2 8- concerning the
property located at 16 111,11/s"sH- I-qns U/,t vx�' meets all of the
following criteria:
• e failed:y:;tem is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
c
A�'The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
ere are no wetlands within 100 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
ere is no-increase in flow and/or change in use proposed
A�ere are no 1ranances requested or needed
• The bottom of the proposed leaching facility will not be located less than five feet above the
maximum a.dJuged groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable]
• If the S.A.S. sell be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facil;:ry will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation Zo—+the'VAX. High G.W. Adjustment
DD ERErICE B
�'WE G S—
EN A and B
SIGNED
(Sketch proposPc'plan of DATE'
a:'+wu t�o,d,� system on back].
.:/n jcl� S4��u��f�,��
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,;
�.
� ( S�
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6 ��`
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a �
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O
,,:
' TOWN OF BARNSTABLE , G
LOCATION -° h'F��SIs'I/3/� D/, SEWAGE #
VIl.LAG ASSESSOR'S MAP & LOT - D63
INSTALLER'S NAME&PHONE NO. e-/7 7-0 3 9%
SEPTIC TANK CAPACITY /GOO G6a
LEACHING FACILITY: (type) I 0ru Gyi 11 (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: / °J— 2 _COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 facili ) Feet
Furnished by L✓�
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1 I°: M/apt T(LE�►�
'I1�! OA'I, f�,bu,Hsrt6k SMC&
'I0CATibN SEWAG PER , IT No.
• VILLAGE - / 1
INSTALLER'S NAME It ADDRESS '
12
BUILDER OR OWNER '.
T¢
s
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED i3 ,
sf Pao
�cn
Board of Health
Town of Barnstable
No.. P.O. Box 534 .........
iA4-;t TH EF"Mjji6Wa98ZJ*10eft!QM1 U SETTS
[BOARD qF HEALTH
.. ... .......... ....................OF....
.......... .. ....................
Appliration for Dhipaiial Works Tonarurtion Frrutit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
system,at:
.......................................
. ..........
ocation ddress . ...N
........................ ...........
Wa
0 Add�ss
........OL
........................ ... ... ... . ...................................
Installer Address
Type of Building Size Lot df,21.9_��...Sq. feet
U 3............................. (V4) Garbage Grinder P40 Dwelling—No. of Bedrooms____.._.. Expansion Attic
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
04 Other fixtures ......................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity............gallons Length................ Width.______..._..... Diameter._-_____-___---- Depth......_.........
Disposal Trench—No..................... Width....._....._._._._.. Total Length............_....... Total leaching area....................sq. f t.
Seepage Pit No--------------------- Diameter............._...... Depth below inlet_...._.............. Total leaching area..................sq. ft.
Z Other Distribution box Dosinonk i. . .....
Percolation Test Results Performed by. .. . ... . .........................
-- Date/..........9V�..........
Test Pit No. I---_-_-------minutes per inch Depth of Test Depth--e pt h----t-o ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.__.............__.. Depth to ground water..__.___............_...
P4 --------------- ......---------------------*.......*'*'*--------------
•
0 Description of Soil.--_ _,�........ .........................................................
U ......................................al.:1.tl....... .........................................................
W
�4 .......................................................... .........................................................
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
.......................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLITIL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
op r iountil Ce tificate of Compliance has been issued by the board of
. �_0ea_lth.
ASi�ned......4 .... ... ........ . .
..................... ..-.-.. ....
Date
Application Approved By...... ...... .. .. ............................................... .......
..............
Date
Application Disapproved for e following reasons:.................................................... ...........................................................
.........................................................................................................................................................................................................
Date
Permit No......V:q ........................ IssuedL......... -.RS...............
Date
----------------------
No......................... Fms..............................
� . THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
, ppliratioi fur Disposal Works Cfonstrurtion rnmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
/1 Location,--'Address- _ or Lot No.
....................... .........:..... ✓c/F ° .s ' .....................................
Owner Address
Installer Address / ` j'`w-�..
Type of Building Size Lot,,_._' .=2........Sq. feet
g— ..............Expansion Attic Garbage Grinder X,10)
Dwelling No. of Bedrooms____.___s. __________________
aOther
—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures .----•------------------------------------------•-•-------••••-•----------•-•-•-- ••----•--•-•-•-•---•------------------•----•--•---•---•-----------.
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing, nk ( ) -1 ,+
Percolation Test Results Performed ---------------- Date/ _"_!{/_... �f
aTest Pit No. 1................minutes per inch Depth of Test Pit____ ......_._...._ Depth to ground water........................
rZ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ..................... .....................-=.............................................................................................................
D Description of Soil-_6....='------..t.7
j,
r
UW ---•---•••••---------••--------••-••--------------••----•--•-----•----••....... -----•--•---------------•-•--•-••--••---------••-••------------------------•-•-•••-••-------•--------
Nature of Repairs or Alterations—Answer when applicable_-•---•__-_•____________________•-_•______---_----•-___-_____----____--__-------_-•__-_.__-___.
--------------------------------------------•----------•---•-------------------•-----------------....---••-----_--••-•---•------•-------..._•--••---------.---•••--•--•--•••-•--•--•---•-••••--••-----_..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the rovisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
p at' n ' a ertihcate of Compliance has been issued by the board of health.
f 1 v
Signed-------:-_Y'!/T L"_> -K-'-- ` `'•' ter' ' ------••-•--•--- -'• - '`•5---
r r Date
j' Application Approved BY-----. 4)....... . -------------------•------•-•-•-----------------
1 i Date
Application Disapproved for a following reasons-------------------------------------------------------••----------------------------------------------•--....._
..............................•------------••--•.....•-•------•-•--•-•.....--------....••---•--•--........_.....---••-•-----------------------•--••-------------------•••-••----•--•••---••••----------_..
Date
Permit No...... ' '"" } ............................ Issued.--•--_ x ----------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......OF... c" ' % ? ........................
Trtifirab of Tontplianrr
T IS I TO CERTIFY That the Individual Sewage Disposal System constructed ( or Repaired ( )
by.......(..... ..............................Installer ----._...._..__......._............. .._..._..___.........._....................._
at_ _ ram'fp Q ��//�-c1.!Y, :/...:fin.✓----X. '----•-----'
s ✓ /
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated---.._-__-._--._____---..._.....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A GUARANTEE THAT THE
SYSTEM WILL F NCzzTI NGSATISFACTORY.
DATE............ ... J-;3 A-•s.......-•---------------------•---- Inspector...---- ---•-. ----
THE COMMONWEALTH 'OF MASSACHUSETTS
BOARD OF HEALTH
FEE.---• ......
.....No...... ....-� ----
fitDisposalPerm n inn r�ernti
---------------- ••------•........••••.------•-
to Construct
or Repair granted __._._•-_livid!uail
................... Disposal System
Yg -
(� p ( , ) an In Sewage,
at No..•=- 'i�-Girn_-� , .....�'`f it-.----------------- yrt �t ........... /.�.
...... -'J----------------------•--......
Street
as shown on the application for D* osal Works Construction Permit No.._.______
J � :
- ------------
Board of Health
DATE................................................................................
FORM 1255 A. M. SULKIN. INC., BOSTON
pEsi��v oa•rLa �` � �3,.�y��.� � ` to
Y 3 t
A10 GAoeBAGE G.e/.voEA- a rN P,r �etti .
OA/LY FLOW - mo X 3 = 330 G.P.
I SEPl/O T.Q.V/l = .��OX/SO o =5�9�G.P ,:� .<♦.�Tp-;'�� ����'' ��� S
-
I
l_b ll 2 60
X Z.f 2& 295 S-F.
' TOTAL_ I>.d/L}�FLord= .330G•P.v, \62. j-' �
I .
'; QEs/G.tr/ PE.2GOL4T/oN.P�4T�•' /"/.t/2�/N. GaE�LE.� ��\�/ - _..
i
i F .
r V [
� ) LI .
. I
rt
-396 3
=� =lol FG• _ �o/
2 /,aoo /.v✓. GAL. 97-& � �,
6a�. /.y✓ BoX q7, .SEor�G
f: Pir 9-7
W-/
/2�r7 i.! r /it/✓. /"V✓
wA hti fr47 :� 97.Z 97¢ G E.2T/F/EO SLOT P"✓
.• .Sr1si+`rE
LvT 2�
f/E.t'Ea�/ GGt�1PLY•.f k//T�/THE S/OEL,/NE B.4X7F,e���t/ll�E /•vG.
.4�vv.fET1�.4G,e ,eEQV/eEMENTS of Tf✓E .2Ewsr��.�-moo.SI�,L✓Eyd�S
L oo.QrE� W/Th'/N T.�/E �L�oP[..4/� �g,goL icawr' -yam -� / ;�,�• � /
/s Ala7- l��Ev Oiv alit/ /iXS1�Z-
.Shb K/�/yE,P�4�✓.5,�/o!/L O it/OT G� USED
Ta E.ST�L/Sy Lor- L./N�S
I
j
ASSESSORS HAP : !� I
TEST 1-10 t.L L 0 G S
`J�2Yf PARCEL:— ?j 1) The installation shall conj Willi Title V and Town 01-fiAL*I1oard oh
FLOOD zONE : tiI�
SOIL EVALUATOR:,` YI C (lealth Itegulations.
REFERENCE: ( '~~ .__._~� - WITNESS : _ 0;A 1MId��I t , t2SP 2) The installer shall verily (lie location ol'utilitics,sewer inverts and septic
�� ���� �.� � _ _ DATE: ! ! components prior to installation and setting base elevations.
C .''�) 1 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first
.. _ _ � PERCOLATION R/TE: . .4 t � I
--�•� �� two leet out of the d-box to the leaching shall be level.
4) This plan is not to be utilized for property line determination nor any other
T11- I TII-2
purpose other than the proposed system
stem installaton.
5) '
All septic components must meet Title V specifications.
tVu 6) Parking shall not be constructed over If 10 septic components.
bounded b property corners and property lines.
7) The property is bout Y P p Y P p Y
8) The property owner shall review design considerations to approve of total
LOCATION MAP 4/ �Yu ID 1 design flow and number of bedrooms to be considered for design. Receipt
"b r y�D of payment for the plan and installation based on the plan shall be deemed
approval of the design flow by the owner.
9) The existing leaching or cesspools shall be pumped and fille'd�with material
\ �► vl� � GI per Title V abandonment procedures. Those within the proposed SAS shall
0 10 t"l' be removed along with contaminated soil and replaced with clean sand per
Title V specs.
8Y 'l1 3�1 10)System components to be 10 feet from water line. Sewer lines crossing the
�--•1�� 1 -- water line shall be sleeved with 4 inch SCI 140 PVC with ends grouted if
applicable. The proposed SAS ►s being installed below the water service
1 61
line. The line is to be sleeved as aforementioned and maintained in place.
G
\ v SEPT 10 SYSTEM I D E S I G N 11) if a garbagegrinder exists it is to be removed and is the responsibility of the ;
owner to ensure such.
12)The installer is to take caution in excavation around the gas line if such
\ FLOW 6T I MATE 1 exists.
13),ne installer shall verify the location, quantity and elevation of the sewer
BEDROOMS AT AID GAL/DAY/B DROOM -3,R)GAL/DAY '
lines exiting the dwelling' rior to the installation.
/e Trequirements.
m can it on a property meeting This plan is representative
Y that a s ste
c Title
GAL/DAY x 2 DA �S • ��U GAL
_ e1c , / \ USE ID GALLON SEPTIC TANK �T _
O tB oC-1 RPTIN SYSTEM
j
_ \ \ ` rUl�h I } ►>al�il,l H INN C, C.'}} G� 1 F?qa
ih
a
MASON
•�,� —_ SIDE AREA:
BOTTOM AREA: ! - a No.1066Q
�oD r� _ �C - 2r X `C7 s
c� C 3�s /
SEPTIC, SYSTEM SECTION
_- 1 Ov�j��r'l _ ��,� [] ���7i z o '"� s f I"�,, X`
GAL � � - � ��,Z � ---
----
CZl3_�0�1 _ D-q 0
SEPTIC TANK
-7
0 04 DE
b/D
I T E AND SEWAGE PLAN
- Z _ -- -a ''� �_ --__ -- - LOCAT I ON : A-z� 11
;: y7 -
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DQC ENVIRONMENTAL DESIGNS
W I EAST SANDW I CI-I . MA
I DATE I HEALTH AGENT ( 508 ) 833— 2177
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