The URL can be used to link to this page

Home My WebLink About0309 LAKE ELIZABETH DRIVE - Health 309 Lake Elizabeth Drive Centerville A=227 - 144 Salmi UPC 12534 - No.2-15_3LOR �► YAiTlN�.YY T L �� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 309 Lake Elizabeth Property Address Phil ClDonnell µ Owner Owner's Name information is required for every Centerville MA 02632 11/10/2016 , page. City/Town State Zip Code Date of Inspection )V i•+ W 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 314 l a 6 on the computer, use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. Same Company Name 4 Glacier Path Company Address East Sandwihc MA 02537 City/Town State Zip Code 508-833-2177 S1287 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority November 16, 2016 Inspector's Signature r 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 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. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-/Page 1 of 17 y/ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ac°M •''V 309 Lake Elizabeth Property Address Phil ODonnell Owner Owner's Name information is required for every Centerville MA 02632 11/10/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The observations noted in this inspection report represent the condition of the septic system on November 10, 2016 at Noon only and does not represent the condition of the system into the future nor does it represent the proper operation of the system from the inspetion date forwarded 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 309 Lake Elizabeth Property Address Phil ODonnell Owner Owner's Name information is required for every Centerville MA 02632 11/10/2016 page. City/Town 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 309 Lake Elizabeth M Property Address Phil ODonnell Owner Owner's Name information is required for every Centerville MA 02632 11/10/2016 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 Y2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 309 Lake Elizabeth Property Address Phil ODonnell Owner Owner's Name information is required for every Centerville MA 02632 11/10/2016 page. CitylTown 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.doc•rev.6/16 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 309 Lake Elizabeth Property Address Phil ODonnell Owner Owner's Name information is required for every Centerville MA 02632 11/10/2016 page. CitylTown 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? E ❑ 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 309 Lake Elizabeth Property Address Phil ODonnell Owner Owner's Name information is required for every Centerville MA 02632 11/10/2016 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gp ))� Detail: 2014; 34,000 gallons. 2015; 229,000 gallons, 2016; 5000 gallons as of June 2016. Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 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 wM 309 Lake Elizabeth Property Address Phil ODonnell Owner Owner's Name information is required for every Centerville MA 02632 11/10/2016 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 309 Lake Elizabeth Property Address Phil ODonnell Owner Owner's Name information is required for every Centerville MA 02632 11/10/2016 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance issued 6/29/2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: NA feet Comments (on condition of joints, venting, evidence of leakage, etc.): No observations with components below grade. Septic Tank(locate on site plan): Depth below grade: .5 fe et 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: Typical 1000 Gal Sludge depth: 2" t5ins.doc•rev.6/16 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 w 309 Lake Elizabeth Property Address Phil CIDonnell Owner Owner's Name information is required for every Centerville MA 02632 11/10/2016 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 32 Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent level with outlet invert. PVC tees in place. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 309 Lake Elizabeth Property Address Phil ODonnell Owner Owner's Name information is required for every Centerville MA 02632 11/10/2016 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.): 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): Dimensio ns: 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 309 Lake Elizabeth Property Address Phil ODonnell Owner Owner's Name information is required for every Centerville MA 02632 11/10/2016 page. City/Town 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 Effluent level with outlet invert 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.): Top of distribution box is at grade. 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.doc•rev.6/16 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 309 Lake Elizabeth Property Address Phil ODonnell Owner Owner's Name information is Centerville MA 02632 11/10/2016 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1-16'x38' ❑ 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.): Probed system with no indication of standing effluent. No inspection port in field because such was not required at that time. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 309 Lake Elizabeth Property Address Phil ODonnell Owner Owner's Name information is required for every Centerville MA 02632 11/10/2016 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 309 Lake Elizabeth Property Address Phil ODonnell Owner Owner's Name information is required for every Centerville MA 02632 11/10/2016 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 309 Lake Elizabeth Property Address Phil ODonnell Owner Owner's Name information is required for every Centerville MA 02632 11/10/2016 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: 6 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: Permit date 6/13/2006 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Perc Tests on file ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Perc test for this property is on file with the BOH and Design plan approved by BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 309 Lake Elizabeth Property Address Phil ODonnell Owner Owner's Name information is required for every Centerville MA 02632 11/10/2016 page. City/Town 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWI•l.O.F.,BARN STABLE ' LOCATION �s � f1 �G-` f�� ' � SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO.' 01 i40* SEPTIC TANK CAPACITY LEACHING FACILITY:(type)f;,1W'4 6 (size) /e X 3a'Jcd NO.OF BEDROOMS OWNER PERMIT DATE: O `��`® COMPLIANCE DATE: �� 9�� Separation Distance Between the: 1 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 k 'ii* i kz t y . ' 4 TOWN OF BARNSTABLE ffTION -309 ��/°�� SEWAGE# �®��dX?6' V;[LLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. �'� Lc�.Po�`G'�" /'��" ®?0.7 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) -?aoF''> NO.OF BEDROOMS OWNER PERMIT DATE: f� `�'� 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 1.within 300 feet of leaching facility) / Feet FURNISHED BY G�� r �J �(J No. ' Fee__�C/! THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pphration for �Mpogaf �§pgtem Cow5truction Permit Application for a Permit to Construct( ) Repair(19,00 Upgrade(A< Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No._3®% Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. /tea Lc�Y -"�� - 07 of i�j ,� ,/'a,/� /¢', 31 z!'a Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building � • No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) —?.:Pep gpd Design flow provided gpd Plan Date � ��d�—®� Number of sheets Revision Date Title Size of Septic Tank ��✓�'T�^.s' to c�`9�i I Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this r of Health. / Signe � b Date t ' Application Approved by vm*uDate Application Disapproved by: Date forahe.following reasons on q on A Permit No. !!" Date Issued G% / ;/ 1 f No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABL�E, MASSACHUSETTS Zipprication for Migpogal Ae' pgtem Cottgtruction Permit Application for a Permit to Construct( ) Repair(Al"Upgrade(1-le Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. �/' "14 e 11�/4_1161fTi� Owner's Name,Address,and Tel.No. ci?�'coi�tE' �C�7oT Assessor'sMap/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 3� ;1177 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building ��-� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3�G gpd Design flow provided gpd Plan Date y /d'— O 6- Number of sheets Revision Date Title Size of Septic Tank `G�XiJ'T�^�s /c+cc�,Q 1. Type of S.A.S. cs'-L-e-e ;Olvwf !KA, r Description of Soil i Nature of Repairs or Alterations(Answer when applicable) f, t Date last inspected: t Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bajard of Health. / ' Signedl7a, 11 , 4 Date 6 Application Approved by o, / � �/�� Date - Application Disapproved by: Date .'.,for the following reasons U `.Permit No. Date Is'sued —— — v— tr a s9 —————— —=———————————— i ✓ THE COMMONWEALTH OF MASSACHUSETTS ` BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO`'CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( !l< Upgraded (P11)" .Abandoned( at -T a'1c' ..C��" ��iL/Q�7?y /(�,�j , has been constructed in accordance —}� with the provisions of Title 5 and the for Disposal System Construction Permit No. (p 4 6 dated Installer Designer !ir o wi OP. X - #bedrooms _ Approved design flow ,� gpd The issuance of this permit sh 11 not be construed as a guarantee that the systemwiI-functi�signed. Date Inspector _ --=—=ft— ---_ ----------- =---No. ————_ Fee V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS ig AgaY pgtelTY_�or�gtruction Permit Permission is hereby granted to Construct ( ) Repair (!/f 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 S and the following local provisions or special conditions. Provided: Constructtion ust be/completed within three years of the date of this ermit. Date / � Approved by Town of Barnstable Regulatory Services Thomas F.Geiler,Director tNS1ABTuE, + a Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: Designer: OID MA1 �lj Installer: �� Address: . —1A! 'i Address: 02537 was issued a permit to install a (date) (installer) septic system at: �� E based on a design drawn by (address) I + dated 4�` 9_.p (de 'goer) -certify that the septic system referenced above was installed substantially according to the design, which may include minor ppproved changes such as lateral relocation of the distribution box and/or septic tank. L4cpcD �pue � ecvynt� Glw W%? OT f 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. OF T o AVID (Installer s.Signature) B. con g MASON rn o -+ No:1fl66 SgAll TAR�P� , (Designer's Signature) ( e igner's Stamp Here)fi ' PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF CONIIPLIANCE WILL NOT BE ISSL'EID UNTII, BOTH THIS FORM AND AS- BUILT CAItID AI2E RECET +',ID BY 7l'HE�B '?NSTA$LE PUBLIC HEALTR DIVJSJ6N. YOIT�. - _. w _ . Q:Heait}.,'. L esner Ge ;catio:Acrm y l } ( CATION Imo'" ` SEWAIGE PERMIT NO. Li` VJ_LLAGE INSTA LLER'S NAME i ADDRESS 17 "t L4X _,PCe U I L D E R OR OWNER L�r DATE PERMIT IStU E D _ 7 DATE COMPLIANCE ISSUED f� . r `,.a--� �� rG V `J \\\\ � ,\` J-� �"� -- �,r ---- c� --------- Z. _r� �-- ` Of�t.•-a. 0jq :4 SUBJECT To f- / BARNSTABL No.........(/.... :. E Ct�N �.. ............... THE COMMONWEAf-THCPPVA�SSAPCNHUSETTS i BOARD OF HEALTH �9-11. ;�c�J.. ...........OF...../.E!.!oi(.�-�5 ............................................... ppliration for Uispoii al nrkii C�nnitrnrtinn ami# Application is hereby made for a Permit to Co struct ( ) or Repair ( �). an Individual Sewage Disposal �lG .................... . �� ocatio ddress -.--or.Lo �yy Owner Address W . ' ...................................................................... ........ � Installer Address `� .. feet aDwelling—No. of Bedrooms.................. --------------------Expansion ttic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons.......... ........... Showers ( ) — Cafeteria ( ) Q' Other fixtures .........-•-•----•--•--•------ -- •-- W Design Flow..................J,?oO............gallons per person pe day. Total dailv�iow.._......_._ 4 ..__.._....._.. �ns. W Septic Tank—Liquid capacity/ --gallons Length------ Width...I.._..___ 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 Dosin a / �-�L /'•. CK Date Percolation Test Results Performed by �.__E�._.. ........ Test Pit No. 1...... .minutes per inch Depth of TiPit.t,� .................... Depth to ground water____.. ..__. (s, Test Pit No. 2......�...minutes per inch Depth of Test Pit.................... Depth to ground water----�_5�...... a O Description of Soil....W, ..... - ----•-•---- ----------------------_-----__- x U ------- •---------------••._.-•-.. ------------- •---------------- -............. .._............. ----.---•--------------------------------------------------------------- W ••••--••--------------------•---------•-••••-------•----••.....-----••--•---•------••••----•--••--•--------••--•--- -WO----------------------------------------------------------------------- - UNature of Repairs or Alterations—Answer when applicable_____________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT11 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued.by the board of health. Signed--------. e1`----------------------------------------------------------------------- -------------------------------- Date Application Approved By......... �.- _----••--•-••--•--- .../1�-----f."._7�...._ Date Application Disapproved for the following reasons:-------•--------------•-----------------------------------------------------------------------------....-------- ...........-•--•••-••-••----•••-•••---••--•-••--•-----•-•-------•••-••••••...•.............•---••--•••-•-••••------......-•-----•----------------••-----------•---••---••-----••----•••••-•••-----•----. Date PermitNo.......................................................... Issued-....................................................... Date Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ...................................... 0/Zk'. Owner Address Installer Address Type of Building Size Lot..../K��:esq. feet .-Expansiormttic Garbage Grinder 1:4 Septic Tank—Liquid capacit -gallons �ength...... Width, - Disposal Trench—No....../........... Width....?V......... Total Length.... 3b /1110 Z Other Distribution box ( v) - ' +" Percolation Test Ilexolta� - ----.-_ �' Performed Test �� - - ---'�� D�� of T�� ' D�� to �om� water ' ^� �'��'�= �� TestPit No. 3_-_ �-'o�ootesper ioo6 Depth of Test Pit.................... Depth to ground water........................ �. Pd -.-'--__-----'-_'_'--_______________________________._________ `' of - 11 Description ��L�{��--'7�7��pJ-�m�r��T----------'---------'-'------------------------- � __-'-----'_--------------- _--'-------------------- ------------------------------------ ---------------------------------------------------- --------------- -------- ---'--_ � --'-------'---------'''--'----------------'--------------------'''------'---- �u1or� c6 �ln�utkm� Answer| �� ux��azr» «r -- applicuide--.---- ________________.__________ ---'--------'�------------''--'-------------------------''-----,p-'----------'_...--.--------'--'---_ ugrcemcot: The undersigned agrees to install the oforedeazibed Individual Sewage Disposal System iu accordance with the provisionsof TZIU14 5of the State Sanitary Code—The undersigned further agrees not to place the system in operation until u Certificate of C of health. . ^�� +«� __'_____'��---�'-��-��'-- �_ e o=* Application Approved By.............................................. --'-----_----..----- o"m 7 Application Disapproved for the following reasons:.......................................................... ' .......... '.............'...'....'...........' � Date Permit ' � No Date | THE COMMONWEALTH ussrrs ' | � BOARD � --'.-------�''-��F�---______________�_______.� , � | by.. or has been installed in accordance with the provisions of I o T,�e State Sanitary Co THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. THE COMMONWEALTH oF NtASSACHUSETTS BOARD HE CQ � ��F 2�u---_��,��° --------------' --'^----------`---�---------' �m — ' -^--'---'-'--'---- � ' To Int nfit ,- Permission ishereby granted........ ......... --- .... ...... .. ..or ~- Street as shown on the application for Disposal'�'Vorks Construction Permit4o-__ Wated.......F__!�............................. � . .. � . t ' _ a"=a � a°a� < �~ - ' q�s 1 a „ _ L t t I Crnl l�' er i 44-1 lf. r ,.1 �z 3 ! t i x J yA E f I s Ti t ,s p �• t e r. �:=•� _ r_'.t [ ;i. tyT ► ;, ?3sNt"'., _`+ ui u^ I Aklv -0 TA 12 ` j —I J 7 f" a�At � � r 1 �, ,c'F,c. �': •` � -.P ,.. �yE.;!'r,, ,��a':tLt`�7�a�f?+.ry �"'s7a��'� M�+'�:-its ,l�.d,;lvtf } a�4'1: U�\+L. r Flc:>U/ -i3 •t i l ra = 'r,= , 1: r',.:•L� C,..t�,,' �.. ,! Kul j �,' ; i ✓� Ao ko y i r i lAl t E!R �. .....,.. __,......._,.._....-.•--....-......-......�...« ....-..._...+a..•..�.......,,..u.,...+.„-...w,..r..-.._v........_+....._.�...�.�.�..+..«_..-.�.,L•...�-A.-.-.......v.-...-..-......-....vc.....__....-w,�,...�-.....s...a.-r.....,..•.�«..+r,,..r.+r.. . ..w...-+..w.....+.._ ..... ._. �, ASSESSORS MAP: ZZ TEST HOLE LOGS NOTES: { c� PARCEL: _( /`/7� + I ` / FLOOD ZONE: Wo/ SO 1 L EVALUATOR: ,I IW L 1 The installation shall WITNESS: Ikt, ) al comply with Title V and Town of Barnstable Board of REFERENCE: c'��7't�t�D t' 67- �_•.,� (l- l nU Health Regulations. 2� _ _.;~... �t�o DATE3 a4c TF0 , a,k-77 ® PERCOLATION2) The installer shall verify the location of utilities, sewer inverts and septic ^ _ RATE: .C. 2. t t,.1, t components prior to installation and setting base elevations. 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/81, foot. The- ii peg' -first TH- I TH-2 two feet out of the dbox to the leaching. Pressure piping to be 2 inch schedule 40 PVC with pressure fittings. Y. ti 4) This plan is not to be utilized for property line determination nor any other 3 4 purpose other than the proposed system installation. lA 1 1 G7- 5) All septic components must meet Title V specifications. to 6) Parking shall not be constructed over H10 se tic components. - _ LOCAT ION MAPCtiI?;S) :� taw - p P . t0 y q '7) The property is bounded by property corners and property lines. g° t` 8) The property owner shall review design considerations to approve of total IlW - design flRw.and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan s (i p hall be deemed approval of the design flow by the owner. � .� 9} The existing septic leaching components shall be pumped and removed per °( Title V abandonment procedures. Those within the proposed SAS shall 1)e �' GG removed along with contaminated soil and replaced with clean washed sand \ y��•t.{�,_ .Z) t 7.QJ per Title V specs. pp 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 6 inch SCH 40 PVC with ends grouted. If 3Z- �c�o�70 i SEPT I . S YES T EM DES 1 GN water line is cannot be 10 feet from SAS,the water line's to be relocated per service provider specifications. FLOW TEST I MATE 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. BEDROOMS AT f 0 GAL/DAY/BEDROOM -T GAL/DAY 12)A 5 foot removal around the SAS and below is required to a depth of approx. jZ 'A L---TANK i j j�� C-V1�O�j 56 inches or until medium sand is encountered. A 40 mil poly liner is to be SEPTIC A Imo; '"'- placed around the exterior of the removal area as indicated in bold. 3�6AL/DAY x 2 DAYS • la6O GAL b USE GALLON SEPTIC TANK / 611W&�l - _ 0 01 L ABSO PT.1 OPT; SAS _-J? A u fry y\ _ »p 51{t. �r-tt .lt� I .. 't'v p o� ! _ .. _.._ �33 �� 11 SIDE AREA: 01 �G{;P�PUIG tQ.. r . y t �*' 11 --� �C? BOTTOM:AREA: 16'x 9, . SC D�`��' 1Z�f Fl6C,iG 11+4L�(£. t ` CJ ' 40 .o- tje1L�2t'�!-_! .. -. ►�?f�15v!a-s,� «� SEr� E c�er�x i SEPT [C SYST -_ - -..� EM of EL,::.c - D ,�.. 5 �1G = 6`>►�ht, I-l1 , qy �..e�c�.. Z u� 6F 3/8 27�'3 . _la7q. J / a 13,E UOa GAL ! IM I v SFPTIC T AuKyr 16�X � DAVID TW MASON m T S I TE AND SEWAGE PLAN LOCATION : 4 3Q104 a PREPARED FbR : o a W SCALE: / �=Z� - z DAV I D B . MASONI S DATE: /S DG s DBC ENVIRONMENTAL DESIGNS W EAST SANDWICH . MA - :-DATE HEALTH AGENT (508) 833-2177