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HomeMy WebLinkAbout0003 JOHNNY CAKE ROAD - Health 3 Johnny Cake Road Centerville A = 210. 045 Ow ord, NO. 1521/3 ORA ;:;. 10% /L1 Commonwealth of Massachusetts d Title 5 Official Inspection Form �` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3 JohnnyC ake Road, Centerville Property Address Joseph Kennel Owner Owner's Name information is Centerville MA 02632 April 1, 2010 required for every p page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your �:J U cursor-do not Troy Williams use the return Name of Inspector key. Troy Williams Septic Inspections Company Name 19 Hummel Drive Company Address � South Dennis MA 02660 City/Town State Zip Code (508) 385-1300 S1682 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that.,the information reported below is true, accurate and complete as of the time of the inspection. Thg inspection was performed based on my training and experience in the proper function andsmaintenance„Qf onAte sewage disposal systems. I am a DEP approved system inspector pursuant d Section 11.340,qf Title 5 (310 CMR 16.000). The system: j, ® Passes ❑ Conditionally Passes ❑ Fails `'" ❑ Needs Further Evaluation by the Local Approving Authority � r --,.-- ,� ate' April 1,2010 Inspector'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 c at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. ly/A3 Johnn Cake Road Centerville•03/08 y Title 5 Official Inspection Form:Subsurface age Disposal S •Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �(0 3 Johnny Cake Road, Centerville Property Address Joseph Kennel Owner Owner's Name information is Centerville MA 02632 Aril 1, 2010 required for every __— p page. Cityfrown 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: System meets minimum standards set by Mass DEP at the time of inspection only. This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes or components. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is ( structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: N/A ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 3 Johnny Cake Road,Centerville•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3 Johnny Cake Road, Centerville _ Property Address Joseph Kenney Owner Owner's Name information is Centerville MA 02632 Aril 1 2010 required for every — P page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: N/A ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: N/A C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 3 Johnny Cake Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 3 of 15 c Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3 Johnny Cake Road, Centerville — Property Address Joseph Kenney_— -- -- ----- - Owner Owner's Name information is MA 02632 Centerville April 1, 2010 required for every _ — _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'". Method used to determine distance: N/A This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Q� 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. 3 Johnny Cake Road,Centerville•03108 - _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 3 Johnny Cake Road, Centerville Property Address Joseph Kenney Owner Owner's Name information is Centerville MA 02632 Aril 1, 2010 required for every — _ P page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of.a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) . Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes' or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of,a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes' to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 3 Johnny Cake Road,Centerville•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 3 Johnny Cake Road, Centerville Property Address Joseph Kenney Owner Owner's Name information is Centerville MA 02632 Aril 1, 2010 required for every — — — p 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)] 3 Johnny Cake Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3 Johnny Cake Road, Centerville_ _ Property Address Joseph Kennel Owner Owner's Name information is required for every Centerville MA 02632 April 1, 2010 - page. Cityfrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 09=143,000gals g ( y g (gpd)): 08=120,000gals Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date CommerciaUlndustrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A Last date of occupancy/use: N/A Date Other(describe): N/A _ 3 Johnny Cake Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 3 Johnny Cake Road, Centerville Property Address Joseph Kenney_ Owner Owner's Name information is Centerville MA 02632 April 1 2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Last pumped in 2008 per owner. Was system pumped as part of the inspection? ❑ Yes ® No N/A If yes, volume pumped: gallons How was quantity pumped determined? N/A N/A Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Tank,d-box& leaching were installed on 8/28/02 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No 3 Johnny Cake Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts f Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments „ 3 Johnny Cake Road, Centerville Property Address Joseph Kenney________ _ Owner Owner's Name information is required for every Centerville MA 02632 April 1, 2010 - - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18"+ feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Flushed lines and found clear at the time of inspection.— Septic Tank(locate on site plan): 18"with riser to 9" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 6'X 10.5'X 6' 1500 gallon Sludge depth: 4 Distance from top of sludge to bottom of outlet tee or baffle 2 8 — Scum thickness 4 Distance from top of scum to top of outlet tee or baffle 6 — Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Probe!Measured 3 Johnny Cake Road,Centerville•03108 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 3 Johnny Cake Road, Centerville Property Address Joseph Kennel _ Owner Owner's Name information is Centerville MA 02632 Aril 1 2010 required for every -_ _- _1 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pvc inlet and outlet tee's were present. No evidence of leakage or damage was found. Pumping is recommended at this time. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/A 3 Johnny Cake Road,Centerville•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M yt 3 Johnny Cake Road, Centerville Property Address Joseph Kennel Owner Owner's Name information is Centerville MA 02632 Aril 1 2010 required for every ------ -------_— �— _ — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: N/A Capacity: N/A gallons N/A Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A_— -- Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A . Date Comments (condition of alarm and float switches, etc.): N/A Attach co of current pumping contract(required). Is co attached? Yes. No PY P P 9 PY ❑ ❑ Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level with Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was found level and in working order. No evidence of solid carryover or backup in the past was found present at the time of inspection_ _ Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 3 Johnny Cake Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3 Johnny Cake Road, Centerville Property Address Joseph Kenney Owner Owner's Name information is Centerville MA 02632 Aril 1, 2010 required for every P page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: N/A Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gallon w/4 stone ❑ leaching galleries number: 25'X 13'X 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.): Soil was sandy. Water level was low at the time of inspection. Checked stone and found dry and clean with no evidence of hydraulic failure or problems in the past found at the time of inspection. 3 Johnny Cake Road,Centerville-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM ti 3 Johnny Cake Road, Centerville Property Address Joseph Kenney Owner Owner's Name information is Centerville MA 02632 Aril 1 2010 required for every P , page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A ,a Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A 3 Johnny Cake Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w„ 3 Johnny Cake Road, Centerville Property Address Joseph Kenney _ Owner Owner's Name information is Centerville MA 02632 Aril 1, 2010 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. G 3 r cr r G 3 � 3of i i � 3 0 o . Y 3 ' � o - I 5. Z 3 Johnny Cake Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 3 Johnny Cake Road, Centerville _ Property Address Joseph Kenney Owner Owner's Name information is Centerville MA 02632 Aril 1 2010 required for every P 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: 12.0 + 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: 6/3/02 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: AIW 247 Zone C 21.9' 1.6' adjustment You must describe how you established the high ground water elevation: Soil was sandy. Test hole recorded on plan showed no water found at 12.1'. Groundwater adjustment in area at the time of inspection was 1.6'. Bottom of leaching at 5.3'was found not to be located in the high groundwater elevation at the time of inspection. 3 Johnny Cake Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 • a No. C —�laJ Fee 1-��i�� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for &9;ponl *pgtem Construction Permit Repair rade Abandon Com lete System ❑Individual Components Application for a Permit to Construct( ) ep (� ( ) ( ) � p y po Location Address or Lot No. ��yt� CR Owner's Name,Address and d Tel.No. Assessor's Map/Parcel C����"�v f 1v r y 0 k14 -Z/Q ,— Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. (` JaS C/�ti D cf3�w'a� G, t_k,V'r b rws {avt f ,S s Type of Building: Dwelling No.of Bedrooms Lot Size iC,-T 0,-0 sq.ft. Garbage Grinder(-_ep Other Type of Building J .l j No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Q gallons per day. Calculated daily flow 3 5_3 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 2—"19!2 C,ka4-,6 4,r_1 Description of Soil — Nature of Repairs or Alterations(Answer when applicable) 1P-eC Gt,� ' �/ 8✓ 7' /,��"P/ �'1 �iG a 06`LTO r_ a4, Z f>(—/t7 SV-0� C ktlt,4,2 bJ 0,)- `c'7 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 Bo d of Health. Signed Date Application Approved by Date L[all ay Application Disapproved for the following reasons Permit No. — - Date Issued119 1 Of Fee 1�?oi L„J 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: je/l Yes OPUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Miopaar *proem Con6truction Permit Application for a Permit to Construct( )Repair(,.,Ydpgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No. 3 J��tiro�✓ � Owner's Name,Address Tel.No. t 'O e r (!y . ®tVt 1 Assessor's Map/Parcel z iv s— Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. (` Jw�e�4 D-�O'j�r%'a S 6. 14,r r LL� {i�� T Type,of-Building: ai Dwelling No.of Bedrooms 3 Lot Size�O� �dJ sq.ft. Garbage Grinder(I Other Type of Building No.-of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow O gallons per day. Calculated daily flow a S-3 gallons. Plan Date / OZ— Number of sheets Revision ate M Title Size of Septic Tank J�� Typed of S.A.S. Z— 9 ti-1 e-rJ zt, Description of Soil eq/a-w1 1 f i ture of Repairs or Alterations(Answer when ap licable) �' t,4 14 C( L�SJpFt/ IV ) #1 1S��gl ///D 'A No. -ra l 14 , h-B'oX a Z H-�b SVV a/ CA 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 systenI in operation until a Certifi- cate of Compliance has been's.d by this7Bod of Health. Date Signed " Application Approved by 4 " «.. i- Da eta'r Application Disapproved for the following reasons Permit No.�C '35 Date Issued--------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS 2' v /p y BARNSTABLE, MASSACHUSETTS. ` Certificate Of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired )Upgraded( ) Abandoned( )by at O N h U I has been constructed in accgrd nce with the provisions of Title 5 and the for Disposal System Construction Permit No ''dated l l g l�r Installer Designer The issuance othiys shalll not be construed as a guarantee that t e syste wil fuctio. as de igned. Date 4 leprat c" � t Inspector c� No / - _ - Fee THE COMMONWEALTH OF MASSACHUSETTS -� ���46___ PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS / " MiOpogal *pgtem Conotruction Permit Permission is hereby granted to Construct( )Repair( Upgrade(/�) /Ab'andon( ) System located at 3 So h h Y ti kQ � C. 44 7 , Vi/lam 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 m p st be completed within three years of the date of this permit. r� Date: Approved by Town of Barnstable p# Department of Health,Safety,and Environmental Services �T►+a'r Public Health Division Date 6 oz Sl, 367 Main Street,Iiyannis MA 02601 eeaxarear$ NAM rEotuutt► Date Scheduled Time Fee Pd. Soil Suitability Assessin`ent for Sewage Disposal Performed By: Witnessed By: Location Address �� _I � Owner's Name � ,r G� Address Assessor's Map/Parcel: Engineer's Name f; ��%v�t�nAL a° r NEW CONSTRUCTION REPAIR Telephone# J—b • I Land Use Slopes(0/9) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft i SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) //. ISC- i y ^ I ' I i i Parent material(geologic) ` Depth to Bedrock y(46 Depth to Groundwater: Standing Water in Hole: /� Weeping from Pit Face Estimated Seasonal High Groundwater >i�I :::»:::>DETETr1VHNATIQl�1:. ':( T2:S + :«:;:<:....:... :.;:;:................................ ASONA ,< 1G..:..>'UVATTr. 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 ft. .tndex Well N Reading Date: __ Index Well level _ Adj.factor Adj.Groundwater Level > €PERC( L T'IC1. ..: A . .. .N.TEST<>`':'<€ <::<::<:::<'��� >>'< ''`'' Observation Hole# Time at 9" i Depth of Perc Time at 6" Start Pre-soak Time® Time(9"-6") End Pre-soak Rate Min./inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back j Copy: Applicant . ......... Depth from Soil Horizon Soil Texture Soil Color Soil Other 01 pl Z Surface(in.) (USDA) (Munsell) Molding (Structure,Stones,Boulderes. % 2- ?, �� s �V 0--/ 2y -s G s°k,`d z.s y 614 Ste' /�`lo- a (,,e,. so".4.d DEEP..OB TI HO► .:. N.. .....E..L. :Is>::><::>: >::;<:>:>Hol ::.:.:::.:::.::.:<:::><;::>;:<:.. .. ... ..: Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % i • •I i i i I i ................. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,u B��RVATION::.HC1LR<L�:G.: :::>::>:<:>::<:::<:::»;:H Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. o e j Flood Insurance Rate Man: j Above 500 year flood boundary No— Yes Within 500 year boundary No— Yes Within 100 year flood boundary No_ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? j If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. I Signature ° ` Date 5/25/01 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM {�avvi!3�v�Ori�,hereby certify that the engineered plan signed by me dated l3 0'Z concerning the property located at BOG, Ca(a- meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: ,.✓ A) Top of Ground Surface Elevation(using GIS information) �1 B) G.W.Elevation +adjustment for high G.W. _ W""e?,,,,�.� mod'. DIFFERENCE BETWEEN A and B d `J' SIGNED DATE: Q NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:percezmp Y // TOWN OF BARNSTABLE LOCATION .3 cJo kz �Z� SEWAGE # ZBO�L— VILLAGE ASSESSOR'S MAP & LO' T?!D— Oi'X— INSTALLER'S NAME&PHONE NO. �0�Y20- 973B Jot r K4 //-e SEPTIC TANK CAPACITY 1-tVv LEACHING FACILITY: (type) 2-S190 6/a/Dr•y (size) X X 2( PS NO. OF BEDROOMS 3 BUILDER OR OWNER A.W(, PERMITDATE: 3-1 JO'Z COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet urnished by - 4 e £ 0 >> Q h P TOWN OF BARNSTABLE LOCATION .3 �o�id r�u l-�ak/, k4el SEWAGE # ?002— 358 VILLAGE_ r.6Wl"2Q V-1111 ASSESSOR'S MAP & LOT 2/D— INSTALLER'S NAME& PHONE NO.,roE- 22a— 9713 1.//01 SEPTIC TANK CAPACITY /_fVV LEACHING FACILITY: (type) 1,-S0o 6141 Dry W151l (size) X X X PS NO. OF BEDROOMS BUILDER OR OWNER 1*-Ve(4 ee Le-ll PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ` a / •b ,o h�' 10 S TOWN OF BARNSTABLE LOCATION ����'�- C /Z SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 10 INSTALLER'S NAME PHONE NO. SEPTIC TANK CAPACITY AOO LEACHING FACILITY:(type) (size) NO. OF BEDROOMS Z PRIVATE WELL OR PUBLIC WATER'Al/-iIc BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No '4JR a►I&1) D m�c� ol3u +4� t h� �'t - \ "'k 99,40' O/ / /�/� Design CGlculatlons Number of Bedrooms: 3 T 98,9a5' Garbs, Grinder: No Leaching Capacity Required: 330 Gal./Da o g y �6 2,0 S3 Of poi Leachin-g Area Required: 330 Gal./(0.74 Gal./Sq.Ft.)=446 Sq.Ft. a �0 S e o, o 0 �6 9 ,,, e /�/� Proposed Leaching Structure: 1-25'L X 13'W X 2'D Leaching Trench o WEQUAQUET LAKE a v Leaching Area Provided: 477 Sq.Et. 1173 3C.97.37' �O X' 95,36' Proposed Leaching Capacity: 353 gpd > 330 gpd. req'd. B . B . 4' 5' 4, o 3 2" OF 1/8" TO 1/4' -Joh n c S� G� PEASTONE (WASHED) Cak I T E g�a0 C� 100,04' �� L Thread Needle Ln. ® ® = o Littie 1 o \I' S e }7 © I= O 24" MIN. ors o �e 7 (IV NO 2 H-10 500 gal. chambers rent Ma P pie 3 X 9 ,20' Ve 3/4" TO 1 1/2" WASHED CRUSHED STONE Road Marsh C 9 0 FF ��� ead utilities 0 E /�/ TRENCH CROSS—SECTION iX 98,98 f 4-, ,07 C X 96.a —� No SCALE LOCUS T 54 cell' 0 .3s, NO SCALE AREA — 1 0+ SO. FT. / X 01' pac C5 0 0 Q U 00 _( Q SC, 1 ,3 ' B GENERAL DOTES p c SP 5 110I 36' ` J 1. ADDRESS: #3 JOHNNY CAKE ROAD D— BOX 0� 2. ASSESSORS NUMBER: MAP 210 PARCEL 045 98 �aCk O 3. DEVELOPER'S LOT: 54 Ln 4. TOPOGRAPHIC INFORMATION WAS COMPLIED FORM AN ON THE GROUND INSTRUMENT SURVEY. 7� 0 N 5. MUNICIPAL WATER IS PROVIDED TO SITE AND OF� 0 SURROUNDING PROPERTIES. �' C 70 ��> p/, %/C� T, #1 6. REFERENCE PLAN: PLAN BOOK 126 PAGE 103 op .,_-")6g 7. NO WETLANDS ARE LOCATED WITHIN 100 FEET OF SAS. Arax., 9 ,92' 8. NO POTABLE WELLS ARE LOCATED WITHIN 150 FEET OF SAS. ��(/ �� 9. THIS DESIGN PLAN IS TO BE USED FOR SEPTIC INSTALLATION ONLY. Ja 98 /66 ° fe 98.73' 1 — 25 'L X 13 'W X 2, 07 D r 991eachIng trench using CONSTRUCTION NOTES X 9`38 2 H _ 10 500 gal . Chambers with 1. Contractor is responsible for Digsafe notification o f Stone o n sides ends. and protection of oil underground utilities and pipes. 2. The septic tank and distribution box shall be set level on 6" of 3/4"-11/2" stone. 3. Backfill should be clean sand or gravel with no stones over 3" in size. 1-20"SIAMI ACCESS MANHOLE 4. This system is subject to inspection during installation by Glen E. Harrington, R.S. SOIL EVALUATION -8_;. 5. The contractor shall install this system in accordance Dote of Soil Evai.: June 3, 2002 '„_.__-�._'�_,_--:_,-._`�.... '_ ' 5' with Title V of the Massachusetts Environmental Code Test Performed By: GLEN E. HARRINGTON, R.S., CSE I j'': and the Regulations of the Town of Barnstable. Excavator: Joey's Septic Service L' 6. Provide a Acme Precast 1,500 gal. septic tank, 5-hole H-10 D-box USE PERK RATE < 2 MPI FOR DESIGN PURPOSES I ,1 r;' ``• with 2-500 gal. H-10 leaching chambers or equal. 7, No vehicle or heavymachines shall drive over the 24„ 34" septic system unles noted as H-20 septic components. Test Hole 0 0 No. 1 i..._..-._.._.,:..._,-___-----..-- _._.__._....__r, _ 8. install gas baffle or equal on septic tank outlet tee end. 9. All existing inverts an site conditions shall be verified by contractor. F12 solLs ELEV. STEEL REINFORCED PREcasT coNCRETE 2 H-10 500 gat. chambers 10. Existing cesspool to be pumped and backfilled. 97.92' PLAN VIEW END-SECTION 11. Existing irrigation well to be discontinued & removed, loamy and GYR3/1 96,92' H-10 500 GALLON CHAMBER taw — . 24" o,Rs s 5.92' NOT TO SCALE anld USE ACME PRECAST OR EQUAL .35-40%grovel SITE PLAN gravel 52' 2,5Y6/4 93.59' a 2 SCALE: 1 "=20' f-m sand t0% m-c BENCH MARKON TOP CORNER ygk�k � OFMq 9 PROPOSED SEPTIC SYSTEM UPGRADE gravel 146" 2.5Y6/3 85.75' OF STOOP ELEV.=100.00' (ASSUMED) �yd, LEN PREPARED FOR NO GROUNDWATER ENCOUNTERED LEGEND MARY V. OWEN 8 R1 AT l EXISTING PUMPED &EBACKFOILLED L TO BE Q 3 JOHNNY CAKE ROAD *NOTE: ALL PIPES ARE TOFLEEOR EOUAL SCHEDULE SEPTI40 P.VOOUTLET TEE. o o PROPOSED 1,500 GAL, qAt/T/,JR\ BARNSTABLE (CENTERVILLE), MA 10, min. from H-10 SEPTIC TANK house to septic tank Septic tank covers must be Finished grade over system=2% slope away .. ,. DENOTES Exlsnvc PREPARED BY: Existing House within 6" of finished grade 5 HOLE X 104.46 SPOT GRADE N, DIST. BOX First FL Elev.=101,35' EXIsTI GLEN E N'ACE Existing Grade Ela-99't R.S ,,,. 95 EXISTING CONTOUR 02' miax.n. 9 B D A ROSE LANE S=.01 Level for 2' Min. 2"-1/8"-1/2 36 m o' =3/41"-11/2" s=.o1 washed stone Top Peastone Elev.=96.37' DEEP TEST HOLE M A R S TO B MILLS, M A 02648 037 O 14' Invert Elev.=95.87` � °� o o ® o o ® z4"MIN. ------------ -- - --- APPROX. LOCATION AFFLE o Bottom of Leah �nf fir✓---- TEL: 508-428-3862 ORUAL a vl. q - 25' Trench Elev.= 93.87' EXISTING WATER SERVICE w v —4 — > LEACH TRENCH FAX: 508 28 3862 a = STONE d --.-----------------(-- --____ APPROX., LOCATION _ _ EXISTING GAS SERVICE y Bottom of T.H. #1 Elev.=85.75' SCALE: 1 "=20' DRAWN BY: GEH AUG. 13, 2002 w SYSTEM PROFILE 6" OF 3/4"-11 J2" STONE IRRIGATION WELL (TO BE Not to Scale REMOVED) ET M: ASSUMED FILE: OWENS.DWG SHEET 1 OF 1 I_ _