Loading...
HomeMy WebLinkAbout0024 LARCH LANE - Health 24 LARCH LANE Centerville A= 189 -006 -015 I - 1 i f SMEAD i�� No.2-153LOR upC 12534 r smead.com • Mado in USA �J 1 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 24 Larch Ln. Centerville, MA 02632 Property Address Asa Kenneth Luechauer 572 Rt. 149 Owner Owner's Name information is required for every Marstons Mills MA 02648 4/5/2018 page. City/Town State Zip Code Date of Inspection all 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 �oZ 9 55 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return Name of Inspector key. Cape Cod Septic Services r� Company Name 350 Main St Company Address W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 S15016 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. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 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 l� 4/13/2018 Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of.17 Commonwealth of Massachusetts a Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Larch Ln. Centerville, MA 02632 Property Address Kenneth Luechauer 572 Rt. 149 Owner Owner's Name information is required for every Marstons Mills MA 02648 4/5/2018 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: System is in working condition. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 17 Commonwealth of Massachusetts w — w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Larch Ln. Centerville, MA 02632 Property Address Kenneth Luechauer 572 Rt. 149 Owner Owner's Name information is required for every Marstons Mills MA 02648 4/5/2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Larch Ln. Centerville, MA 02632 Property Address Kenneth Luechauer 572 Rt. 149 Owner Owner's Name information is required for every Marstons Mills MA 02648 4/5/2018 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.%day flow t5ins•3/13 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 24 Larch Ln. Centerville, MA 02632 Property Address Kenneth Luechauer 572 Rt. 149 Owner Owner's Name information is required for every Marstons Mills MA 02648 4/5/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C M 24 Larch Ln. Centerville, MA 02632 Property Address Kenneth Luechauer 572 Rt. 149 Owner Owner's Name information is required for every Marstons Mills MA 02648 4/5/2018 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 110x3= 330gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 6 of 17 Commonwealth of Massachusetts u - W Title 5 Official Inspection Form j Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w by0'a 24 Larch Ln. Centerville, MA 02632 Property Address Kenneth Luechauer 572 Rt. 149 Owner Owner's Name information is required for every Marstons Mills MA 02648 4/5/2018 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 0 Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available usage last 2 year 2016=118gpd ( Y g (9pd))' 2017=123gpd Detail: 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Larch Ln. Centerville, MA 02632 Property Address Kenneth Luechauer 572 Rt. 149 Owner Owner's Name information is required for every Marstons Mills MA 02648 4/5/2018 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: No Records 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•3/13 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 wM 24 Larch Ln. Centerville, MA 02632 Property Address Kenneth Luechauer 572 Rt. 149 Owner Owner's Name information is required for every Marstons Mills MA 02648 4/5/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1986 Per BOH records. Were sewage odors detected when arriving at the site? ❑ Yes ® No 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: +10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line was checked with sewer camera and found to be clean, properly pitched with no sign of root intrusion. i Septic Tank(locate on site plan): 1. 8-1 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000Gal Sludge depth: 6-8 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Larch Ln. Centerville, MA 02632 Property Address Kenneth Luechauer 572 Rt. 149 Owner Owner's Name information is required for every Marstons Mills MA 02648 4/5/2018 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 Scum thickness 2-3 11 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? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000gal tank in good structural condition. PVC tees in place. Tank at normal operating level. Covers 8" below grade. Recommend service of tank. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 110 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal a g p System Form Not for Voluntary Assessments 24 Larch Ln. Centerville, MA 02632 Property Address Kenneth Luechauer 572 Rt. 149 Owner Owner's Name information is required for every Marstons Mills MA 02648 4/5/2018 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts - m Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Larch Ln. Centerville, MA 02632 Property Address Kenneth Luechauer 572 Rt. 149 Owner Owner's Name information is required for every Marstons Mills MA 02648 4/5/2018 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 oti 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.): H-10 DB-3 with 1 line in and 1 line out in fair condition. Box is showing signs of wear but walls are intact. Some solids carryover. No sign of overloading or hyrdaulic failure. Cover 24" below 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Larch Ln. Centerville, MA 02632 Property Address Kenneth Luechauer 572 Rt. 149 Owner Owner's Name information is required for every Marstons Mills MA 02648 4/5/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-Flowdiffusors ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 3-Flowdiffusors with stone. T'of effluent in chambers during inspection. No sign of overloading or hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts u w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 24 Larch Ln. Centerville, MA 02632 Property Address Kenneth Luechauer 572 Rt. 149 Owner Owner's Name information is required for every Marstons Mills MA 02648 4/5/2018 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•3/13 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 24 Larch Ln. Centerville, MA 02632 Property Address Kenneth Luechauer 572 Rt. 149 Owner Owner's Name information is required for every Marstons Mills MA 02648 4/5/2018 page. Cityfrown 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 l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `[ 24 Larch Ln. Centerville, MA 02632 Property Address Kenneth Luechauer 572 Rt. 149 Owner Owner's Name information is required for every Marstons Mills MA 02648 4/5/2018 page. Cityrrown 7§tate Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells +8' Estimated depth to high ground water: _ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Hand auger did not encounter water at 8'. Max bottom of leaching is 4' Before filing this Inspection Report, please see Report Completeness Checklist on next page. Lt'5,,,s /13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Larch Ln. Centerville, MA 02632 Property Address Kenneth Luechauer 572 Rt. 149 Owner Owner's Name information is required for every Marstons Mills MA 02648 4/5/2018 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 3N3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ---------a - �._. rage 1 of2 ASSESSOR'S B-fi . PARCEL_ �j t0CATI ��� SEWACE PERMIT N0: VILLAGE 'INSTALLER`S,. NAME A ADDRESS r �J UILDERY OWNER DATE PERMIT ISSYE0 DATE COMPLIANCE ISSUED l t-oar-4 N d� do L .. l U\li r http://www.townofbarnstable.us/Assessing/H.Mdisplay.asp?mappar=189006015&seq=1 3/28/2018 i ASSESSOR'S M K- PARCEL L,O CAT 110 ,��� � SEWAGE PERMIT NO. L s L��GA VILLAGE ALL ER'S NAME i ADDRESS 1�, \ r e U I.L D E. R OR OWNER 1. c:>wrs, DATE PERMIT ISSUED Lot �� DAT E COMPLIANCE ISSUED S \ 1 >i � �l I. - FEB....No...........- - �®........... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH rZ37 �^ 7^ . .....`.�........ .....:1�. ,z ram.--�--'-�.� e.,� Apphration for Uiopoottl Workii Tomitrurtion Frrutit Application is hereby made for a Permit to Construct ( 1,Tor Repair ( ) an Individual Sewage Disposal System at Location-Address or Lot No. !� ��s �L����....avt�S i3� .. �17 7ZT�l3 Nc`s' - .... --........- ...- -�......_..�1� •-••----- Owner Address Installer Address �� 49 ..^IR Q Type of Building Size Lot... ,e........`........Sq. feet U Dwelling—No. of Bedrooms._.___...___ ........................Expansion Attic_-f Garbage Grinder-(- j" �. 114 Other—Type of Building ... :................... No. of persons.._____ _____:____._..__ Showers f�'— Cafeteria-(��- QOther fixtures . ..... W Design Flow................ ............................gallons per person per day. Total daily flow............................................gallons. f� Septic Tank—Liquid capacityl�®.gallons Lgngth..�.'6". Width.`�.�.�®e` Diameter................ Depth...."...... Disposal Trench—No......!............. Width...!.0......... Total Length....,3.'�'.....Total leaching area_.4 ...sq. ft. Seepage Pit No..................... Diameter............ _.... Depth below.inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( V� • Dosing tank (ir aPercolation Test Results Performed by.. .r.. -�_.. 3!- _.��N ._--__ Date..._...I_.2)-Z-/ Test Pit No. 1...............minutes i er inch Depth of Test Pit.... Depth to ground water.__-9 _19J cd57', 44 Test Pit No. 2...=........minutes per inch Depth of Test Pit..... ...... Depth to ground water.._........................ x ...................................,............................ --------------------------------=------------------------------------- O Description of Soil....../?'i E :v" --•••f---Fin✓ '-----'��--`-�-------------------------------•---•----•--------------------•--------•----- V •--------•---------•..................•-----••• � 5..,.. .tr' - _7"ii -------------------- J 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 TI:LL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance lies beenUedbboard of health.SignedateApplication Approved BY ---- .--•-------=--•-••------•••... ------J 1-� ja�,�------- ate Application Disapproved for the llowing reasons:.................................................................................... .................. P ..........................................................................................•........................---......._•._....._........_.•........_._.............•----........_......_.....--... Date PermitNo.......................................................... , Issued....................................................... Date No......................... FBB.............................. THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD OF HEALTH T 7..... .......OF......� .. :.'.:: ...` (- f L E - ----------------•....-----......---- Appliration for Disposal Worko Tonotrn.rtion Frrutit Application is hereby made for a Permit to Construct ( v% or Repair ( ) an Individual Sewage Disposal System at: ...................................... .. ........----.....-------_.......------ ..........;..................................................... / ...q w i=�✓Tc 2 �//y L i Location-Address or Lot . No rjL G M./1. 5 C L ? iC'7-4 f _�.................r_G ...._...._ ._.... - ...................................................................y��r✓i1/.!•�5 .........._... W Owner Address J a -••--•---------------••-...._...--------......------..........._---•--......................... ---------------.....---....-••--------.......------.........,......------•••................... Installer Address Type of Building Size Lot..._ - .--8•--------Sq. feet Dwelling—No. of Bedrooms_..__'_ .........................Expansion Attic'"-' Garbage Grinder-�^"')"� aOther—Type of Building ---9 r_ _! No. of persons.......(.................. Showers ( --) — Cafeteria Other fixtures :_'"'";`6-------------------------•--------------- ------- W Design Flow........................... ?_.`a.......gallons per person per day. Total daily flow............:`_� .................gallons. WSeptic Tank—Liquid capacity/C}O 2.gallons Length_ . -.._ Width.4._.�`.' Diameter---------------- Depth.. .....__. x Disposal Trench—No. .....1............. Width... ....... Total Length.....:._:....._ Total leaching area. 2:;?K...sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing tank ( f ' Percolation Test Results Performed by..L_:...TL,:-.._=_t+''.�! ._ _.....f_ '...... Date....... Test Pit No. L.. .. ? minutes per inch Depth of Test Pit...f._ ..` __._ Depth to ground water----- Test Pit No. 2._.. . .__._m'inutes-per inch Depth of Test Pit----I...:I°'_.-_. Depth to ground water--- .`> I..........` ----------------------------------------------------�......----•---••----•--------••-----••-----•--------•----•...---•----••---••-•------•--•-----_...-- oac Descriptionof Soil -•..............•-••-•---------......,................................---......................................................................................... V .....----••. - ; -/ ............................................................... U Nature of Repairs or Alterations—Answer when applicable...................................................•..............._.____..........._......._.. ........................................... --------•-•-----••-••••------- Agreement: aLJ ed , The undersignagrees to install the aforedescribed Individual Sewage Disposal System in accordance with i the provisions of TIT1E 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. ySigned. ....------••----------•---------•-•----•.................................••---•• ..............0........... ApplicationApproved By................•..................................................=............................. ....-•-•-------•----Dace---•--..-_.... Date Application Disapproved for the following reasons:........................:...........................•----.-_____._.--.---____._.._______. ---.__--..--- ,. ......... .......•-...-•-•----------•----••--•------............•--•--............•--Date f, PermitNo......................................................... Issued.......................................................Date ,s THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -........................................1-::.......................... Tnrtifiratr of Tomphanrr :i THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ({/T�or ,Repaired ( ) ' ... by------------------------------------------------------------------------------------------- nstaller...----••-------•-•---.� -:...---- ••--....._.�./...... _ nsta I has been installed in accordance with the provisions of TIS of—T4i`e State Sanitary Code as�d cribed in the �-� ,1 application for Disposal Works Construction Permit o......................................... dated-----_J. �., THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR�IED AS A GUARANTEE THAT THE SYSTEM WILL T� SATISFACTORY. ISSFACTORY. DATE...........................--•••• .. ...................................... In Spector.................................................................................... x 1' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH { 1...... ?.v!� ✓..oF....... •:?...`'�-5.:%-�---- --. :�.......... :c No.....`� > �� FEE........................ RoVasa1 orkii Tonsfr ion rrmit f) - Permission is hereby granted.......... .. :.'---J--- _--.--f_--l.�'..��._<'._ to Construct (� or Repair ( ) an Individual Sewage Disposal System at No �a -, Street r ashown on the application for Disposal V�orks Construction Permit No `_ .______ Dated....... _) . .........................� �- ..... .... ..............." ' ''-'.��:.7_'12 _......................-- t - /DATE ..- �� { {� ............................... Board of Health FORM 1255k,HOBBS & WARREN, INC.. PUBLISHERS �` r rcnmi 1 Numbcr:- ---081c: _ l' O�6. 6 Completed by C (Z , N 0I-LT- HIGH GROUND-WATER LEVEL COMPUTATION Site Location: lr>AWS CFni7-e1Z. Lot No. Owner: /5oz.1_ GwS Address: / 3 / Ot,D /2T',E /,,3 S Contractor: Address: ii Notes: STEP 1 Measure depth to water table ` to nearest 1/10 ft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Z 0/6's, date STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: i w 23 0 A) Appropriate index well . . . . . . . . . . . . B) Water-level range zone . . . . . on. . . f, STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to 244 water level for index .well i2/e, mo yr STEP 4 Using Table of Water-level Adjustments for index well STEP 2A , current A pth. to water level for index well (STEP 3) , and water-level zone (STEP 2B) determine water-level adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . STEP 5 Estinate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water `7r9 level at site (STEP 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-vp @ c L. 7. q / w AT�g2 2 2.Z . . SO i L LOG .5` 2 37 E !, DATE_ ` WITNESSED BY T�}M ES Can/ L4N Li ©, y , I `y e r 1 J EL 271 � 1N Ea) (!" N E EL 22. 2 S�Na WATF}L 7ilA)CH .5 r 7'I c.,j f T E- r r2 rJ GN 9 M �i J /✓ 1 ti MANHOLES AND COVER TO BE BUILT WITHIN ELEV. TOP OF FOUNDATION � ,---;•'" 12" OF FINISHED GRADE . ` • r . �'" z, 6 �;$E<Pr/ ��\ �t ::°' � .. FINISHED 6RADE � ' -' MIN 2� SLOPE p �opc�s r K�• TANK v4 5�1� 0 4 CAST I RO 4.. P V r J F".�Ml4yEM4v� L o:� 4;- •,. ,.. VC SC 40 IST tAJi. - 2� `.% o , A.i G Jt_Qurli7 _/2Fr�, G `; PVC SCH. 40 _ - y✓ PITCH I�,a" FT. � 2'LEVFI 10� MIN. 2'► LAYER '\ j>W,•L_L/nl Y C G '.h.n1 v C T 1/8 - 112 PEA S TO N E t�' ��' ►\ Nv i r-> > �L 29,D I I` FT Ll IVII-1. .i 2e.S� 28.2 �~f .O Q Op°� 14 s TN �3 INVERT R•ti: 29. 75 oao INVE T DIST. • "..cl - IG � :;e GALLON RR iNYE1tT .,- ;•; ►, rr INVERT 26.40 BOX eO 3 4 1 1/2 D IA . ► r SE TANK n< < n 4:: 4 O 32 LC-AG1-t 5 . INVERT 27, o Ct /,[i = p4 WASHED STONE to •' ALL AROUND . :� U ..� .--- -- _ r E D•• R� es 1 V Z�i�/ M1 ARBAGE -•� = ELEV. BOTTOM N GGRIN0ER d -�' f PIT 2 0 2 ,nr • O . - r ELE V A'Al' 22 .2• PROFILE OF GROUND WATER TABLE SANITARY DISPOSAL SYSTEM ►3 3z NOT TO SCALE -DESIGN DATA y • .�_ BEDROOMS CONST. R UCTION OF SANITARY DISPOSAL DESIGN FLOW 33© GAL.1DAY . . SYSTEM SHALL CONFORM TO MASS. E .c ENVIRONMENTAL CODE TITLE 'V (REVISED 7- I - 77) LEACH RAT MIN./INCH k AND THE TOWN OF f3 �tz.vsr' 13L1=' LEACH CAPACITY IN PROPOSED � { ' 8 � on32►� O i $ rJ 8 3 �� • HEALTH REGULATIONS. r • SEPTIC TANKS DISTRIBUTION BOX AND LEACHING r PITTO BE OF REINFORCED CONCRETE . 441 GAL/DAY N� Tom' T4p4 . P Fe hZ.� ay A ,:4A7-EM y�' /VYF ///G, MIN. CONCRETE STRENGTH 3000 PSI R ,E-G+/ STE'lt 'Ca LAMA SV/Zv Yo1ZS, ,G'SrFT�� LG tr9. MIN. STEEL STRENGTH 2O,00OPSI �ATD H 10 DESIGN LOADING • DRIVEWAYS NOTTO BE LOCATED OVER SYSTEM UNLESS H - 20 DESIGN LOADING IS USED. • ALL PI PES AND FITT I NGS TO BE WATERTIGHT AND TO BE OF CAST I R ON OR SCH E D 40 P.V. C. SITE PLAN SHOWING PROPOSED CONSTRUCTION SH.�-OF .SHS LEGEND L b C AT I O N: FOR L- L3,�,G.. -- S o L.- vt/'S ,f� •YE',L . C 1 At P. APPROVED 19 SCALE: J ..� 3Q, u, � BOARD OF HEALTH D A T E � --- ,� _� t. BUILDING SETBACK REGULATIONS PER EXISTING CONTOUR - --16--- PEFERENCE: L. 07- 1,S` � s sf,� gw�/ � �✓ BUILDING INSPECTOR OR BUILDP,NG 7"G.��/ ,t3 4o4 PG, a COMM15S1'ONER . Zonis' RC PRO -POSED CONTOUR 16 DATE AGENT fv! IN. FRONT ` SETBACK 2© EXISTING SPOT ELEVATION 17. 6 ` ! PROPOSED WATER SERVICE yy �a�\jHUFMA MIN. SI DE SETBACK /O o� CR ' A/ftN, REAR SETBACK* �� TEST HOLE LOCATION o s s IL . 27483 ..r R . SHORT INC * �� C/STER�� S101VA1 PROFESSIONAL LAND SURVEYORS L ENGINEERS i 1586 MAIN STREET (RTE. 6A) EAST DENNIS, MASS. 02641 , -J N. J , - SOI L LOG DATE= 12 / 2®,fes WITNESSED BY: T z caL0 / L3 en, H C 9rci / Gn re. 5 H Q /Z 7- ,G?E, o Tf 1 E� 30. / a T�/ �� r[, 29.4 8 F L__ 2 4, •� �r r SAND \� 3 L. X'I L L A7 L 271 Q . M .ED I u h1l F N --''" ' • 3 • s�A/Z] E L 2 2. 2 7 12�c € S 7./ �1� � J VF+2 / TIGN 1 q sf 30 s�.�� v 14 e FL 17.9 t q rHy2 - / T* /7, 4, NIAl ti l44 FL >e ./ F-� F ---- - �j,`�' ELEV. TOP O UANHOLES AND COVER TO BE BUILT WITHIN Q 1 '•:'` .-�- t2" Of FINISHED GRADE . _i till o,:: FOUNDATION ' .- AA ) LOP ,� 52Prt :•ti; F! �► ISHED 6RADE �� ''� . .' N 2� SLOPE 0` �•r 1�. f i •. YANK e e 4 C AST I RO .. iIt p L o .. . .... _• 4 S w . IST ' E,' `Z t Oar PVC 4 /t - ,. .� O R V N Gp �• Ffi)rritl:yp if•X ' o , .TZ "C� r/ r3 : PVC SC H. 40 _ ..� ' PITCH I�q, FT. 2 LEVEL' ++ MIN. 2 LAYER w'F �l!/�/ a c:' L tA- -�+/ti./. � / J' - -N i" f�`�L I/6" _ 12" PEA S TO N E 1 4 _ ` 4 29.0 O.o vv r r,+_. o; P I M C H 23 C1 4, 3 4• _' i n1 E� :e'' I/ F T. O c O $ I TN 7 X3Z INVERT GALLON NV X.1 DtST. INVERT :Q a �� o 4 2B. 75 I 4 � � iD I p ,� •� + tNVE RTBOX ! C] . : 3/4 _ t/2 - = - 4' . C4rX2 .LE', iG/f SEPTIC TANK 2 ?.4� = pa 1 D �► � . ..• ;.d WASHED STbNE 7"Cc'`F`�C H t ry v E R T u �D ars 1 NV n,AO < O� ALL AROUND . - �• W 10 3 pi r� A J E L E V. BOTTOM G R I N DERe^_;l c # -- --� OF PIT - 2 •'¢' # , �'" ' T- -cccs 0 _ _ ! 42 O' • 2= j PROFILE OF GROUND WATER 'TABLE .; �.,., � ,, � • S A N I T A R Y- D I S P O S A L SYSTEM � ,3 �2• T 33 NOT To SCALE DESIGN -DA , A BEDROOMS * CONSTRUCTION O SANITARY S P DESIGN AL DAY � CON RUC N OF SA TAR Y D1 OSAL ' - SYSTEM HA ONFO O MA S 3 LEA W � CH R TE SHALL C RM T S • EO - I - _ ENVIRONMENTAL CODE TITLE V: (REVIS 7 77� T . MIN. INCH ry sT>913 L�' - REGULATIONS. PROPOSED DEH CAPACITY : AND THE O20 1 x 8 2, HEALTH NK - D HIN _ r SEPTIC TA DISTRIBUTION BOX -AND LEACHING - P GAL/DAY ITTO 8E OF REINFORCED CONCRETE : �� / . t A/0 � � T© F�4 pi_=re, :,pt_ .� -may z3 �axT�;� 4� lvv:�' /n/G. M1N. CONCRETE STRENGTH 3000 PSI G.l , `TE'R�'p L,9NA ;5U1'Lvl=-- v /t.S; 45r �l��.:t J. MIN.N. STEEL STRENGTH 2O00OPSI 7�,�e H 0 DESIGN LOADING t DRIVEWAYS NOTTO BE LOCATED OVER SYSTEM UNLESS .H - 20 DESIGN LOADING IS USED. ALL PIPES AND FITT I NGS TO BE WATERTIGHT AN D ' TO BE OF CAST IRON OR SCHED 40 P.V. C. SITE T E PLAN SHOWING PROPOSED CONSTRUCTION SH.�OF _.SHS L E G E N D L b C AT l O N: f�lZ,r✓STA1 L.�(CE'NT�"12V/LL � ; !'�G4. F O R �- L3 `,�. --• .. c'L t...cr.,w"S "s►f'�"L . d 1't ram• APPROVED ! 9 SCALE: DATE : �Z � BOARD OF HE A LT +, i BUILDING SETBACK. REGULATIONS PER . EXISTING CONTOUR ---16--- REFERENCE: L + �' !.�' As Sf•,� pv✓n� � w BUILDING INSPECTOR OR BUILDP,NG 7 e)/ ! 23K 404 Pr,7 36 COM MISS IONE-R . ZOn/E" : RC PROPOSED CONTOUR 16 DATE AGENT MIN. FRONT SETBACK 2 © EXI STING .SPOT ELEVATION 17. 6 MiN.` .S ( DE SETBACK PROPOSED WATER SERVICE 1A/ F(efi,. lVIiN: REAR SETBACKTEST HOLE LOCATION T .5 ! Ir Qa0 s VIL v No. 27483 C . R . SHORT INC . 9 0 �F FOISTER� PROFESSIONAL LAND SURVEYORS L ' ENGI NE ERS SS/ONAL 4N�' 1586 MAIfq STREET (RTE. 6A) EAST DENNIS, MASS. 02641 J N _, �_ r M n.a, ,..-_ ..«.v...1....E+7i.kc.S^ .;1§..;r:.5'4... .:i,:-..< -. r __.... _ .r.. •. ._. _ ro.. .-. _._-.. ... ..r _. ..,-.... ... .. - . • .. _ ... _ _. _.. -....