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HomeMy WebLinkAbout0102 LAKESIDE DRIVE EAST - Health 102 LAKES E D ., CENTERVILLE A=252.106 �- 3_ Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IT' l0"t .-a AIrc s c% .0r1vy- Cb S. Property Address ,To a Ails- -e i o .. Owner Owner's Name « information is required for every Ce ��p f e oa 6 za , b h -"�v �j G A4 r page. City/Town State Zip Code Date of I spection 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, use only the tab 1. Inspector: key to move your a✓T �4-�/ cursor-do not (/ use the return Name of Inspector L_ J key. Z�V O TG G Company Name �o QooC /a.(2 Y Company Address `f'L ,( 0D b oC City(rown �qo ��Q� /O State�O�� Zip Code 6Telephone Number % License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title;(310 C 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs.Further Evaluation by the Local Approving Authority !U 4A-. Inspector'I 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 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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Iy?VIS Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewagfe�Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name /' ,�f information is / eo4erv,Ile /i� oa 6 3.Z required for every v page. City/Town State Zip Code Date offinsperction B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System sses: 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /off -m lns�cl� Dr- �Gs}- M _ Property Address Owner Owner's Name Ce /�information is 444&y ///I �/required for every � -- page. City/Town State Zip Code Date of finspedon 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 Title 5 Official Inspection Form Subsurface Sewag���e Disposal System Form -Not for Voluntary Assessments {)/�1/� 1 Property Address Owner Owner's Name /� information is Ce#146111144 /-4 0"A., s ///�' -grequired for every page. City/Town State Zip Code Date of Itfspecti6n 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 ❑ Tll� 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 ❑ Y'."— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El Liquid depth in cesspool is less than 6" below invert or available volume is less th /2an' day flow t5ins.doc•rev.6/16 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 keS1 LEG'S 7L Property Address A/ 4142 t✓/ Owner Owner's Name /� / J� information is / pN�14_ A /Y1 r �1 17111 required for every v �C page. City/Town State Zip Code Date of nspe Ion 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. E] 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.] ❑ e 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System/ Form -Not for Voluntary Assessments l0 2 Lm kv—S I J.e- r[/r 46E�,S Property Address ///'(/n/s4e !0Owner Owner's Name �! Q information is Cew4o•v,l�� �,4 Oa.6 3.z 511211 " required for every page. City/Town State Zip Code Date offinspec4on C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes o ;'--�-V lumping information was provided by the owner, occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? ❑ as the system received normal flows in the previous two week period? ElHave 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? e--�o 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 ra Residential Flow Conditions: Lf Number of bedrooms (design): — — Number of bedrooms (actual): — �6a DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): AS � CO;le t5ins.doc•rev.6116 �� Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' M loj- Z a k-e-s i el.e- '0" L s 7L Property Address �1 Owner Owners information is required for every 6e0 page. City/Town State Zip Code Date o�Infp�ect?i D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes Eff No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes 59-1 o Seasonal use? Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): — Detail: Sump pump? ❑ YYes No /. Last date of occupancy: Date u 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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I Commonwealth of Massachusetts u r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /O� Zakrsiek Property Address Owner Owner's Name information is C,. // 1�54 Od!3i orequired for everyt '� {! page. City/Town State Zip Code Date c/Inspeftion D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: r-�- Source of information: J S— 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 Sys 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 N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /0 a knes i / V Property Address h I Owner Owner's Name information is �� �6 3� Wspe�required for every N —page. City(Town State Zip Code Da D. System Information (cont.) IF Approximate age of all components, date installed (if known)and source of information: 8oS Qa Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): /C;)—// Depth below grade: feet Material of constructi;040 ❑ oe cast iron PVC ❑ other(explain): �o r Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): C f/ Depth below grade: feet Materi 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: Sludge depth: ! t5in5.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments_ ' M _ Property Address / S7Le r Owner Owner's Name ` /� / /� p Q information is C��'�"�of Ile A4 ��b.7� �� u required for every page. City/Town State Zip Code Date of In ection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness At —Sc u Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? -- Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): (A V"42 IF y 77—t%N W Q^n cl- 4eax v9 o C.o�df-��o✓! 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Property Address l Owner Owner's Name ` �y Q information is required for every �e N_' Ic i _ / � _Q_a ?d 6✓ - I o VV �. page. City/Town State Zip Code Date of nspec on 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form i= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name Ce /fifinformation is ,44v 6 3� s �-/Arequired for every — e �% 4—� � — 1,#7 page. City/Town State Zip Code Date of Insp ction D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert �1-'-e C-1 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.): 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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /off -Za4-e-stf4 Dr- oe!�:Gs-� Property Address Owner Owners Name information is4 e 6 3� required for every O page. Cityrrown State Zip Code Date of I specti n D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ eaching trenches number, length: leaching fields l number, dimensions: � � 61 ❑ 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.): S-40-e— Cfege, gwJ Z410 �� ✓tS ae:r- 4 eira w l c IF ltv4lele" 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 Officiai inspection form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments// L� /0 d- 4,e-s i c4 Property Address Owner Owner's Name information is CQN,,,�✓V� AA required for every page. City/Town State Zip Code Date of In ection 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 4 4-e51 4�0- JE:;4 f 7L Property Address Owner Owner's Name Ile- page. ,�/f� information is CeoJew /% �, t'�required for every — City/Town State Zip Code Date of I pecti D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two emanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where p c water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately / -G �( Q , 1 -- /So o G.1 elo,1 - _. U - 31 t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form s� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for eve ✓1 i — page. City/Town State Zip Code Date o Inspection D. System Information (con t.) Or- Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar mod) 02 t3 ❑ 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) 21-1�Checked with local Board of Health -explain: -- /"4,/.7s ---- Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how l ou established the high ground water elevation: W C% X a n C w vy oT .Ze 7'C-1 10 t01/ ':;,r4.de Ct/ V-t7 c2.-? c-44 �+ J4 w o n Q vt A 90 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's NameAII information is � w Ac �,¢ required for every '�'w ' 1 Ce� page. City/Town State Zip Code Date of nspe ion E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed em Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file O t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 G� O � ,. Fee No. / / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS t 0[ppfication for Zigaaf *p-5tem Congtruction Permit Application for a Permit to Construct( )Repair(t/)Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address Tel.No. Assessor's Map/Parcel Ce e- 5T Installer's Name,Address,and Tel.No / Designer's Name,Address and Tel.No. xarp4W� C®� B1-142-rj I-D��il Type of Building: Dwelling No.of Bedrooms Of Lot Size sq.ft. Garbage Grinder( � Other Type of Building G No. of Persons Showers( ) Cafeteria( ) Other Fixtures / Design Flow lld gallons per day. Calculated daily flow yb Z_ gallons. Plan Date le—30-7$ Number of sheets l Revision Date Title v��—`�� L`' r��J ®s4'l S 5 /OZ Ca E5/.fie /7i'i�i� Q'S% Size of Septic Tank lg­e a 9A' Type of S.A.S. ✓`7�©�� 1Ci� 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 Certifi- cate of Compliance has been issu=thid Health. /Z/lea l/�r Signed Date f Application Approved by Date Application Disapproved for the following reasons Permit No. ) Y� S Date Issued 9,�" Q ;yw.sc^w^-,,,.. w-.- -.- L�,•-.+al,r.., s .�.,�e.+..:� .-v�ul..it`rt..,-:.,,rf-•.)...,:^...w.'v':`..r-^✓."vy'..''v'f+*y+••�..i.�'•;t+.-+fir .,,.-�.�-..ir'.;L•ya w3R«s..,.�^* -,.-..-iae•.. No. / �� is +rrT�uG._ Fee S i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:{ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE.,AASSACHUSETTS � Yes ZIppfication for Migpozar 6potem Conotrudion Vermit k Application for a Permit to Construct( )Repair(V)Upgrade( ),Abandon( ) Complete System ❑Individual Components j � a Location Address or Lot No. Owner's Name,Address arld,T61.No. Assessor'sMap/Parcel Ce�1 fCrvJ//,e. Installer's Name,Address,and Tel.No Designer's Name,Address and Tel.No. �Dr7LeLOI�i C®Iu�7` �` Type of Building: t 1 Dwelling .No.of Bedrooms Lot Size .'4' sq.ft. Garbage Grinder( d Other Type of Building �5/ ��lG�No.of Persons l r,%, Showers( ) Cafeteria( ) Other Fixtures V Design Flow gallons per day. Calculated daily flow % 7 V/Z- gallons.` Plan Date /a-30-¢'S Number of sheets Revision Date Title ,j e!. L� Size of Septic Tank, 3 /S— ®9' Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �-11, LIzf Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system _tn 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 issuedjbZP y thi B AHealth.. CSigned '1 �/ Date Application Approved by Date e Application Disapproved,f44the following reasons Permit No. / Date Issued THE COMMONWEALTROF MASSACHUSETTS -,,k BARNSTABLE, MASSAC�HUSETTS (Certificate of (Compliance THIS IS TO CE THY,that the On-site Sewage Disposal System Constructed( )Repaired ( k4upgraded( ) Abandoned( )byG' at /D Z C 4'C6 S•/ & �, ,ST 6 e#1_er&1/Ilehas been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. `iF- -5 dated Installer Designer The issuance of this ermit shall not bef jon true s imarantee that the s s th fu cti•n as d $fi ad. Date p r�.J _ 7 Inspector y _ J z No. ��--------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Xigoga1 *p5tem Construction permit Permission is hereby granted to Construct( )Repair( V<pgrade( )Abandon( ) System located at h2 Z- G¢,�P ✓�/,fie 11 7— 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 p t F`/ . Date: Z — Approved by / , /��- TOWN OF BARNSTABLE LOCATION /O2 G?,e 5 f Q7 ,4,y, �SjSEWAGE # g©S VILLAGE ff/'�/j ASSESSOR'S MAP& LOT C--�' INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY / C0 Gc LEACHING FACILITY: (type) (size) `/ :�(c �C/ NO.OF BEDROOMS y / BUILDER OR OWNER PERMTTDATE: /z `Z r-QS' COMPLIANCE DATE: i -Separation Distance Between the: I Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 7 Feet Private Water Supply Well and.Leachin ' g 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 I %�PX-7-T 4,40 - - - - - - - - - TOWN OF BARNSTABLE �tCATION /0`Z GQ,��- S ®� 0*, P—,9 SEWAGE # VILLAGE 60eAr/// ASSESSOR'S MAP& LOT " O INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 3 dr? LEACHING FACILITY: (type) FIrZ,01 (size) NO.OF BEDROOMS BUILDER OR OWNER Z144?141 PERMTTDATE: Jz 'Z Qg COMPLIANCE DATE: Separation Distance Between the: ' Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility J74 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 16 Y O• 3 �a A*6„ Iq-3 . - DEEP OBSERVATION HOLE LOG_ SYSTEM DESIGN CALCULATIONS GENERAL NOTES LEGEND . Test Hole Depth From Soil Horizon Soil Texture Soil Color Soil Mottling ether i� Number Surface(iRe+ ) (USDA) (munsell) A) Neither driveway nor parking areas are allowed r- (Structure, I.) Basis of Design ----- -- 32 Existing Contour �F Stones,Consis over septic system unless H 20 components are used. 3 2 Number of Bedrooms: ,`- Proposed Contour tency,%Gravel Other: B)The designer will not be responsible for the system 24x5 El(lsting Spot Grade ��- - as designed unless constructed as shown.Any changes . , . o = v GlAir . ....._ Proposed Spot Grade ade�. _ j 2.)Dasign Daily Sewage FIow '�4 shall be approved In writsg•G P D 43 , 73 C LOAMY 'ae'up 10 y ,Z 41f o — w— Water Service t r ► e t e h Overhead —o u— Utility n � �--� '^'�Roors 3.)Septic Tank Capacity Required. SRO Gal C)Cont Contractor be responsible or verifying the ' 'ty Line(s) e(s) �Sto� •I` .�.... .... ..0.Z;..j. '. . .. .._.g_ ... .. .W'`MY _S4ND „•., •-• • ••, o • . ` /yo t gs PrOVlded= ....r�� ..--.. Gal. location of all underground and overhead utilities — u -- Underground Utility Lines) �yT prior o commencement of work. -- g — Gas Line v �• � 1 � - �,o ' c Sf�r 4aa � �, +i �s •'• ••"• )Boll Absorption System pat NTH � a 4,. , . 1 M /�; w/►�.tg Smug m Required, �.a G.P.D. Test Hole and/or Boring Location r S s � _ o t sly. . Provided: G�Z_ ?A. � � 4 ref/ E Sr MEc. ; G.PD. S.T. Septic Tank `PNTr—,VVILL.IF1 MA. � A Z4 X 7(,, X 1 LC*_4 %,F H D.B. Distribution Box - -- -- -- T14 �?1lFt) F'y fit./'C.tf? Art/" -- 1�........- ......... .... ry 4C. _ S.A.S. Soil Absorption System • - � ... - Abaor t __�. . ..... _. ... System Z¢X ? x < < `tto (�D FKEY MAP no scale �. Rea Reserved forS s 5FWP M�41'JL i 0- Utllit 5.)A Garbage Disposal is N07-permitted w/this design. y Pole _....... .. . . . . ... ._ ...... ..... .. . . . 9 P g 4 TDP ar• CEL iBasinPlan Book ...... P ... . .. . � . . ... ... ® Catch / �� age Z L, SO,7Z. �' Fire Hydrant Deed Book -`�_ _. .. _ . . .. . . . . C� � D P 9 WsII Assessors MapZ' -,Porce)•I Date of Test ? .q�`� .-. . Use Solt G Ia ss w 1 tt1 a "(, ZDZ39� Sint f� Percolation Rate 1:ZM)AJ, +f•1, /!L�' pert. rate of less than .`�--_ _._..j - re'Z ` 7�-1-- I Min./in for a loading rate of i gt - 4t r .GPD /s f Witnessed by J. . EVAA),r, e, - TN- / c rZ ('JL,-lZz�. FLOW PROFILE ' ; o- X •a - -- —, _ Top of Foundation !// t?FSEt�e % t Elevation= .. (,.7. >, � !/ ARpq + t ' ' f Finish Grade = d'.-! t Fmish Grade= : / t � � y. 48,E�-- 136"max. 4 —r, 'r. �i►st t.>:,+lct�l i ` i g _--' 11"M IIV s�y�+ ��1 Pf / / ? we0 I 3b" max. ;T— � LE• flow line E)!t5T long CAI? r D ISO _! .� r E0 min ;4" �" �- __ __ t- '�C ruff r►c I /\ h/ T / i f 1 gas baffle f _. - 44,�� i �. , t w/ - ei 1-0 Gal. Septic Tank Distribution Box (•w�M Or iz"eA►- / / I LONIf ST k'UR to 3 LGn I y��^ (f'j l f LEACAING� �iEL .! t CONSTRUCTION NOTES 10.) Base aggregate for leaching facility U All construction shall conform to the State shall / Environmental Code, Title 5, and the requirements of consist of 3/4" to 1-1/2" double washed stone free the local Board of Health. of iron, fines and dust and shall be installed from 2.) Septic Conk(s),grease crop(s),dosing chomber(s), below the crown of the distribution line to the bottom I / / ^hu and distribution box(es) shall be set on a level stable of the soil absorption system. Base aggregate shall boss which has been mechanically compacted, or on a be covered with a 2"loye r of 1/8" to 1/2"double l�j 3.) Septic tank(s) shall meet ASTM standard C system when distribution 6Inch crushed stone base. washed stone free of iron, fines and dust. _ 11.) Vent soil absorption h 1127-93 and shall have at least three 20"diameter lines exceed 50 feet, when located either in whole Ti t iS 4 ZEti: manholes. The minimum depth from the bottom of or in part under driveways, parking, turning areas, 7CWA) '/V4T-r-tL, septic tank to the flow line shall be 48' / ( f Or other impervious material, or when dosed. - u maer I 4.) Schedule 40 PVC inlet and outlet tees shall 12.)Soil absorption system shall be covered with o hq ? extend a minimum of 6"above the flow line of the minimum of 9"of clean medium sand (excluding -1- septic took and shall be installed on the centerline topsoil ) / 9 41 .• c�^"� , j of the tank directly under the cleanouf manholes. 13.) Finish rode shall be a maximum of IG E ISVN[ teAGI! .IT g 36 over the i � � � (� ?"� 5.)Rai" covers of the septic tank and distribution top of oU system components, including the septic tank, PUMPFC, FIt..t.ED AFA U!)OjJF. distribution box,dosing chamber and soil absorption r7rC, IZEutG\VE-�), box with pre-cast concrete water tight risers over � . • • L.,-/-i Inlet and outlet tees to within 6"of finish grade. system. Septic tanks sholl hove a minimum cover - of 9 6.) Piping shall consist of 4"schedule 40 PVC or PROJECT equivalent. Pipe shall be bid on a minimum 14.) From the dote of installation of the soil LdU� , c� )-j�1`r t^ continuous grade of not less than I °/°, aborption system until receipt of o Certificate of 1Jt�TT-1 kQ� p I P F L) i Mid' Compliance, the perimeter of the soil absorption 7.) Distribution lines for soil obsor tion system TITLE SEWAGE P y system shall be stoked and flutes to prevent the DISPOSAL SYSTEM (as req'd) shall be 4"diameter schedule 40 PVC use of such area for all activities which might a laid of 0.005 ft./ft. Line shall be capped at damage the system. _ iDl �QKF F D1?1VF =q�;. �1-A ITT s end or ds noted. (���""G''��1��( �- - � �T 15.) The Bootd of Health shall require inspection of 51{011ptr1 �•1��a1,1 lh �S lea Outlet pipes from D-box shall remain level for at all construction by an agent of the Board of Health L-r- ge �, +� BENNETT A O'REILLY Inc. a least 2 feet before pitching to soil absorption system. (or the designer if this system requires o variance) and Water test pboz to assure even distribution. �� s�. ^ Engineering & Environmental Services 0 may require such person to certify in writing that all w N OF �UHN Y d ALMON l yi O'REIt Ly It 9.) D-box shall hove a minimum sump of 6 measured work has been completed in accordance with the terms �P CIY(L Irri rf 1573 Main Street RoRoute6A 0 rb o below the outlet Invert. of the permit and approved plans. 48 hours advance t4a rr P.O. Box 1667 notice requested. HAP,T,1IL s S 508.896.6630 Office Brewster, MA 02631 508 896-db87 Fax W R� `('#YAL t'1 DATE: SCALE: BY: CHECK: JOB NUMBER: