HomeMy WebLinkAbout0036 LAWRENCE LANE - Health 4 LAWRENCE LANE, CENTERVILLE
A= 190 252
TOWN OF BARNSTABLE
LOCATION 5& Jr*wr r jt—e L.y SEWAGE#?ni q— 3C J
�,NMLLAGE v�)YY ASSESSOR'S MAP&PARCEL o¢2 S�--
INSTALLER'S NAME&PHONE NO.-Q6,0.t\ti fs A a fauu.y 1Ay
SEPTIC TANK CAPACITY �x 5
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS
OWNER P
PERMIT DATE: 0)J s4;-h N COMPLIANCE DATE:
,��
Separation Distance Between the: AVNG e-"i—Per
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
/ t /
�- -38 S �.
a
No. � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in c puter:
jn PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplitation for Mispo8AY 6pBtem Construction Fermat
Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or�Lot No.JC I_C W/C/vr_P �M Owner's Name,Address,and Tel.No.
6e.-,it-C✓'Vi6-C
Assessor's Map/Parcel S 9 Pa.-
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
VC900fi s '64 ,om,-- =Nf 6p$-4I00-7®S`9 eAlV jv-e Y✓i.tiC
Type of Building: ✓
Dwelling No.of Bedrooms Lot Size /l���f3/ sq.ft. Garbage Grinder( )
Other Type of Building de t,/)cm,4:1a p No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3e> gpd Design flow provided 3A/5=77 gpd
Plan Date F3 Number of sheets Revision Date f
Title
Size of Septic Tank jC)�p,5}legs Type of S.A.S. x m G l6y Ck boo I
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) SO)S�-Ce N 1 k Soo 8pe,(� •.� l��.w�l,CJ fl S Q�Jj d�A
ei-Ave A,,d mpg a) -
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 b is Board of Health.
C U Date d
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. J Date Issued
' No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered m co puter:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
vl
21pplicatlon for Disposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair(N6pgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address otiLot No.36 Low✓CNC r `N Owner's Name,Address,and Tel.No.
r el-j- I1-e 'Pao,It 1
Assessor's Map/Parcel j _ T 2 ( 4
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
���51G3 l,(CJ Znx 50B-g00-7/ti`/ riiv51.✓ tYdrNC /�CS
Type of Building: /
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building (Y r t)r�r 1 ,o No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3n gpd Design flow provided 3</e?j 7 gpd
z Plan Date - —J y Number of sheets 2 Revision Date
'R ' Title
Size of Septic Tank ('y: S 1 lryS Type of S.A.S. X—_�00 Ra1IGNS'tOn►C
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) WSJG j1 -j- boo
0� S+b/vr° c d ivru) x) U(7x
Date last inspected: - d
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 Board of Health.
g e a d Date
Application Approved by ' �r Date
Application Disapproved by +A0 + Date
1 for the following reasons
l
Permit No. a -- —Vf
Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(Upgraded( )
Abandoned( )by`,III ,A&S A (ow•� S(Vr
at SG La i cyeL%jCC L ti [Pit}F���,�� has been cons ucted in acc e
with the provisions of Title 5 and the for Disposal System Construction Permit No /�j ed
Installers ��c< A _Z nw N L.jc Designer -;,<,—r r✓ tiJ r/c s
#bedrooms f3 Approved design flow 3 In gpd
// O
The issuance of s ermit s ll o be construed as a guarantee that the system will ltio as esigne //
Date � Inspector
,�` �� f� •''� ✓
--------- -------------------------------------------=--- = ------------------------------- --------�-
, 1 Fee
61 THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Disposal *pstem onstrUctlott flermit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at -ex< `N �.�Y✓✓i���
i
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
i
Title 5 and the following local provisions or special conditions.
I
Provided:q
s f on mot► be mpleted within three years of the date of this permit.
Date Approved by /
r
Town of Barnstable.
-I"¢'b Regulatory Services
P
Richard V. Scali, Interim Director
BARNs�SS ' Public Health Division.
^p s6gg. �w
ATco?A Thomas McKean, Director,
200 Main Street,Hyannis,l4lA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: 1 Sewage Permit# A01Y-. Cv0 _Assessor's Map\Parcel 0 O -- Z�rZ
Designer: FE r ^ ,, g AA,n a . �.�� Installer:
Address: p 2 ,Cit'v, � e (c V 2el
Address:
On 2 ,.le ) vac= was issued a permit to install a
(da e) (installer)
septic system at�;Ca LzLw rkvt.Ct__ IL—�, (Based on a design drawn by
,PJI (address)
<!�nCJ; n.ter l n-r, t N�t�(f a.> ,.n c_ dated L CL
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) Was inspected and the soils
were found satisfactory.
I certify that the septic, system referenced above was installed with major changes (i,e.
greater than 10' i-ateral relocatioii of the SAS or any vertical relocation of any coanponent
of the septic system) but in accordwice with State & Local Regulations. PIan revision or
certified as-built by designer to follow. Strip out (if required)was inspected and the soils
were found satisfactory.
., 1 certify that the system referenced above was constru with the terms of
the IAA approval letters (if applicable) PE
1-4:TLilR--(1 i l�
_ "� 411cFN"Tl^Ev
civil.
staller's Signature) 3' ; fi �A
N nL
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF CONEPLIANCE WILL NOT BE ISSUED UNTIL, BOTH—THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY T BAIuNSTAL3LE PUBLIC ALTH DWISION.
THANK YOU,
QASeptic\Designer Certification Form Rev 8-14-13.doe
i
Assessing As-Built Cards Page 2 of 2
http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=123 050&seq=2 10/2/2014
Town of Barnstable P#
I
kI Department of Regulatory Services
Public Health Division DateZ00 Main Street,Hy is MA 02601
Date Scheduled Time Fee Pd.
Soil Suilaility Assessment for S a 's s
Performed By: witnessed By: p /
LOCATION&GENERAL INFORMATION
Location Address 3 7 LG W reyC,� r Owner's Name
Address
Assessor's Map/Parcel: Engineer's Name � •.%-i. /'vi C �Pf �-Q
NEW CONSTRUCITON REPAIR U✓ Telephone# �5_e V —73 7— 7,
Land Use, ��h_ �` ` Slopes(%)_____�
/ Surface Stones �—
Distances from: Open Water Body !
_ ft Possible Wet Arear R Drinking Water Well
Drainage Way R Property Line I ft Other ft
tl%
7
SKETCH:(Street name,dimensions of lot,exact locations of test hoolles�&pem tests,locate wetlands in proximity to holes) j
L
r..a
32! z
Q-)
52
i�
Parent material(geologic) E ,,.1�s Depth to Bedrock N
Depth to Groundwater: Standing Water in Hole: ^Q6 a%_JL_ Weeping from Pit Face
Estimated Seasonal High Groundwater �.� -t
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well p Reading Date: Index Weil level Adj.factor Adj.Groundwater Level_
PERCOLATION TEST Date Time
a Observation
Hole# 2 Time at 9"
Depth of Perc -J �H1 Time at 6"
Start Pre-soak Time Q n Time(9"-6')
End Pre-soak 1�M
Rate Min./Inch G-
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN)
Original:Public Health Division Observation Hole Data To Be Completed on Back -----
***If percolation test is to be conducted within 100'of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:VSEPTICIPERCFORM.DOC
DEEP OBSERVATIONH:OLE-LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
sistenc ° Gravel)
a L
17
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mwsen) Mottling (Structure,Stones,Boulders.
Consistenev.° Gravel)
Q_ A, sL- r�N�
Z sc-
Z - G 0-CSA„,J 2•SY4 c �a
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
Consifftencv.% el
t. t
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
s'tenGravel)
Flood Insurance Rate Map:
Above 500 year flood boundary No_ Yes X
Within 500 year boundary Nox Yes_
Within 100 year flood boundary No� Yes,_,_
Denth of Naturally Occurrine Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
Hoot,what is the depth of naturally occurring perv' us material?
CerttIIcation �y
I certify that on i"1 (date)I have passed the soil evaluator examination approved by the
Department of Enviro ental Protection and that the above analysis was performed by me consistent with
the required trainin xpertise and experience described in 310 CMR 15.017. /
Signature Date�Z�1 I
Q:\SEPTIC\PERCF0RM.t00C
TRANS. NO.:
CITY/TOWN: CtA�vI qe
APPLICANT: 2 (-\,. Zd-OV1�1
ADDRESS: -v Co �-aW crsncsi. (g,�y_
DESIGN FLOW: -5;-30 gpd
REVIEWED BY: .o_QA-e✓�N� -►n1-2�e , - DATE:
N/A OK NO
GENERALSY� t r R F $, x d \5 «
.d.�.�4./1".A.,F s" �.,'4�dt{'�6'34 . :� �:'Y`Y'r@�� ��a°'v.Tin..
Legal boundaries denoted [310 CMR 15.220(4)(a)] ✓
Street, Lot,tax parcel number and lot number noted on plan [310 ✓
CMR 15.220(4)(u)]
Locus Provided 310 CMR 15.2204(t)]
Plan proper scale? (1"=40'for plot plans, 1"=20' or fewer for
com onents) [310 CMR 15.220(4)]
Easements shown[310 CMR 15.220(4)(b)] a/
System located totally on lot served [310 CMR 15.405(1)(a) for
upgrades]-if not, a variance is required [310 CMR 15.412(4)]
Location of impervious surfaces (driveways,parking areas etc.) ✓
[310 CMR 15.220(4)(d)]
Location all buildings existing and proposed 310 CMR ✓
15.220(4)(c
Location and dimensions of system components and reserve ✓
areas. [310 CMR 15.220(4)(e)]
System Calculations [310 CMR 15.220 4
daily flow
septic tank capacity(required and rovided ✓
soil absorption system(required andprovided)
whether system designed for garbage grindei
North arrow [310 CMR 15,220(4)(g)] ✓
.Existing and ro osed contours 310 CMR 15.220(4)(g)]
Location and log of deep observation holes (existing grade el. on
each test) [310 CMR 15.220(4)(h)] v
Names of soil evaluator and BOH representative [310 CMR
• 15.220 4 (h) and i
Location and date of percolation tests (performed at proper
elevation?) [310 CMR 15.220(4)(i)]
Percolation test results match loading rate? [310 CMR 15.242
Certification statement by Soil Evaluator [310 CMR 15.220(4)0)1
Observed and Adjusted groundwater(method for adjustment
given or indicated) [310 CMR 15.103(3) and 310 CMR
15.220(4)(n)]
Address Sheet 1 of 7
r
N/A OK NO
Location of every water supply,public and private, [310 CMR
15.220 4 k)]
within 400 feet of the proposed system location in the case
of surface water supplies and gravel packed public water supply
within 250 feet of the proposed system location in the case
within 150 feet of the proposed system location in the case
of private water supply wells
Location of all surface waters and wetlands located up to 100 ft. l
beyond setbacks listed in 310 CMR 15.211 and any catch basins /
located within 50 ft. [310 CMR 15.220(4)(1)] v
Water lines and other subsurface utilities located [310 CMR
15.220(4)(m)] (if water line cross see 310 CMR 15.211 1 [1]
Profile of system showing invert elevations of all system
components and the bottom of the SAS 310 CMR 15.220(4)(o)]
.Stamp of designer [310 CMR 15.220 1 and 310 CMR 15.220(2)]
Stamp of Registered Land Surveyor(required if construction
activities within 5 ft. of lot line) [310 CMR 15.220(3)]
Test Holes adequate (two in each of the primary and reserve
unless trenches as permitted in 310 CMR 15.102(2) or as
approved for an upgrade under LUA at 310 CMR 15.405 1 k ]
Test hole adequate to demonstrate four feet of suitable material?
1310 CMR 15.103(4)] +�
Test Holes adequate to confirm adequate groundwater separation?
[310 CMR 15.103(3)]
Benchmark within 50-75' of system 310 CMR 15.220 4
Materials specifications noted? [various sections of 310 CMR ✓
15.000
System components not> 36" deep (unless Local Upgrade /
jApproval or LUA requested) [310 CMR 15.405(1(b)]
Address Sheet 2 of 7
I
N/A OK NO
x
;SEPTIC TANK,
Size OK? [310 CMR 15.223(1)]
Inlet tee located ten inches below flow line [310 CMR 15.227(6)]
Outlet tee 14" or 14"+ 5" per foot for increase ft depth [310 CMR
15.227(6)]
Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)] ✓
Note regarding installation on stable compacted base [310 CMR
Separation between inlet and outlet tees (no less than liquid
depth) 310 CMR 15.227(2)]
Inlet/Outlet elevations at least 12" above high groundwater
(except as described 310 CMR 15.227(5)) or permitted for
upgrades under LUA [310 CMR 15.405 1 k ]
Minimum cover 9" (Tanks buried more than 9" must have risers
on all openings and on the d-box) [310 CMR 15.2228(1) and 310
CMR 15.232(3
Three access covers (inlet and outlet must be 20" or greater) - /
middle access at least 8" b 7/07 310 CMR 15.228(2)]
Access to within 6 " of grade - one port for systems<I000gpd,
two fors stems>1000 gpd [310 CMR 15.228(2)]
All at-grade covers secured to unauthorized access? [310 CMR
15.228(2)] ✓
> 10 ft from building foundation [310 CMR 15.211(1)]
Buoyancy calculation Required/Done 310 CMR 15.221(8)]
H-20 Where appropriate? 310 CMR 15.226(3)]
Setbacks from resources [310 CMR 15.211] LIX
Required when other than single-family dwelling or flow>1000
d 310 CMR 15.223 1 ]
First compartment 200% daily flow; Second compartment 100%
daily flow [310 CMR 15.224(2) and 3 ]
"U"pipe through or over baffle, outlet of each compartment with
gas baffle or approved filter [310 CMR 15.224(4)]
Address Sheet 3 of 7
N/A OK NO
B
e .�
s DING rSEWER ANDOTHERl'I;PING
Located at least ten feet from any water line? [310 CMR V
15.222(2)]
Disposal piping at least 18" below water line(when water and
sewer cross, see 310 CMR 15.211 1 1]
Cleanouts required/provided? 310 CMR 15.222(8)]
Thrust blocks specified in force mains? 310 CMR 15.221(6)(c ] 1
Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable
[310 CMR 15.222(6)]
Proper pitch on all runs? (.005 within gravity-distributed trenches
and beds [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] r/
.Siphon problem/ leachfield below pump chamber
Endca s or vent manifoldspecified?
Size and orientation of discharge holes specified? (not smaller
than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310
CMR 15.252(2)(h)]
Materials specified (310 CMR 15.251(5) specifies various pipe /
types allowed)
e fi �t_r 'YkF £ ° akauF a' t 9 fed =a i xx sK{
D!ISTRIBUTIONBOXMS`tnZ�°»T.. �A,�ri
Stable compacted base [310 CMR 15.221(2) and 310 CMR /
15.232(2)(a)] ✓
Splash plate or baffle tee required on inlet/provided? (when /
pressure sewer to d-box or steep pitch of gravity sewer) [310 ✓
CMR 15.323(3)(a)]
Riser if deeper than 9" 310 CMR 15.232(3)(f)]
Inside minimum dimension 12" [310 CMR 15.232(2)(b)]
Minimum sum 6" [310 CMR15.232(3)(e ]
Watertight cover if<2000gpd); waterproof manhole if>2000gpd /
[310 CMR 15.232(3)(d)]
6PUNIPCHAMBERS r' . " #
,4` .., - . .."F,.,,.@.:: °{t;. e'..4rx..�.*z� r"'{i� r ktik
_ :'"Y�..a.,. . ..-s �.
Capacity(emergency storage above working--design flow)? [310
CMR 231 2 ]
Proper setbacks [310 CMR 15.211 (same as septic tanks)]
Watertight 20-in minium access manhole at least 20" MUST BE
TO GRADE [310 CMR 15.231(5)]
Service components accessible (not too deep with piping,
disconnects accessible
Alarm floats- alarm on circuit separate from pumps specified?
Exceeds two units must have two pumps operating in lead-lag
mode. [310 CMR 15.231(6) and(8)]
Stable Compacted Base [310 CMR 15.221(2)]
Buoyancy calculations needed?Provided? [310 CMR 15.221(8)]
Address Sheet 4 of 7
N/A OK NO
j$QH,V A185'ORPTrON SI'$1, ,SAS GENE � ` N
Calculations correct?
4 feet of naturally occurring material demonstrated? [310 CMR
15.240(l)] ✓
Required separation togroundwater? [310 CMR 15.212)
.Aggregate specified as double washed 310 CMR 15.247(2)]
System Venting required/provided? (system under driveway or
>36" deep) 310 CMR 15.2411
Inspection ports specified and within 3"final grade? [310 CMR ✓
15.240(13)]
Breakout requirements met? (No violation of breakout elevation
within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and
Guidance Document
GA+I.pLERIgES PITS C ERS341OCMR�15
Chambers and Gal. in trench configuration supplied with inlet
every 20 ft. [310 CMR 15.253(6)]
Each structure with one inspection manhole (if>2000 gpd must
be tograde) 310 CMR 15.253(2)]
Xggregate I'minimum- 4'maximum. [310 CMR 15.253 1 b)]
2' sidewall credit maximum [310 CMR 15.253 1 a ]
In bed confi ation, inlet eve 40 s . ft. 310 CMR 15.253 6 ]
p :, '.x 1zc R.'Ft ✓'AR {-ir 'pr }zfi` Y f T Yt
o, ,. .^,.' ,�.,.' ..�� ,..� .�.���`': x.z7°!YJ'S*,?t,�itl �'"�' h''x y -.N'� f �r,s. f,1, 2, .T r •`"�'Y +. f l
REN S 310 CMR�
Width 2'minimum 3'maximum [310 CMR 15.251 1)(b)]
100 feet-maximum length [310 CMR 15.251 1 (a)]
Minimum separation 2x effective depth or width whichever
eater 3x if reserve between trenches [310 CMR 251 1 (d)]
Situated along contours [310 CMR 15.251(2)]
Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document] v'BD,SAS(Mazunum size ofbed4orfield°5000 d *� k" {
minimum 2 distribution lines [310 CMR 15.252(2)(a)]
Maximum separation between lines 6' [310 CM R15.252(2)(d)]
Maximum separation between lines and outside of bed 4' [310
CMR 15.252(2)(e)]
Aggregate depth below discharge pipes 6" minimum, 12" /
maximum. 310 CMR 15.252(2)(g)] l/
Separation between beds 10'minimum. [310 CMR 15.252(2)(f)]
Bottom area used in calculations only [310 CMR 15.252(2)(i)]
Address Sheet 5 of 7
e
N/A OK NO
DIDTH+ PLANINiVOO LVE ram` '` t � �
w.k
Pressure Dosed System ? Provided pump and piping
calculations as required [310 CMR 15.220(4)(r)]
Pressure dosing required on all systems>2000gpd or alternative
systems under remedial approval [310 CMR 15.254(2) and I/A
Remedial Use Approvals]
If used in gravelless system-make sure jet is directed as not to
scour soil interface [Guidance Document]
Inspections once per year(systems<2000 gpd) or quarterly
>2000 dgood to note on plan 310 CMR 15.254(2)(d)]
Construction in fill -Did the plan specify that the fill shall meet
the specification of 310 CMR 15.255(3)?
Impervious barrier and/or retaining wall? [Guidance Document
Impervious barrier installation must be supervised by
.designer[310 CMR 15.255(2)(b)]
Retaining wall must be designed by Registered Professional
.Engineer 310 CMR 15.255(2)(a)]
Side slope not exceed 3:1 ? 310 CMR 15.255(2)]
Breakout requirements met? [310 CMR 15.252(2) and
Guidance Document]
At least 5 ft. from impervious barrier to edge of SAS (10 ft.
recommended) [310 CMR 15.255 2 e
Check DEP Approval letters for credits and design conditions
If used with pressure dosing do not allow pressure discharge
to scour soil interface
s.. _P. :,� PPaO SJ�t.':t ��,. a2.x".c,a�; a,Y���-�, •�'', ` �
Was DEP Approval Letter provided and/or have you J
reviewed the letter for conditions? ✓
Is the technology being properly applied and does it meet all
DEP Approval Conditions?
Is there a note on the plan regarding the requirement for
perpetual maintenance agreement?
Any alarms involved on separate circuits
Did the applicant submit an operation and maintenance
manual?
Has applicant submitted a copy of a maintenance
a Nr4
rVariances f "` (,.�,e
s' t�,.fr;:. '� .V
Are the variances listed on the plan ? [310 CMR 15.220
(4)(g)]
RLS Stamp necessary on plan if a component is within five
feet of property line [310 CMR 15.412(4)]
New construction or increased flow proposed- [Refer to 310
CMR 15.414
Address Sheet 6 of 7
•
v
N/A OK NO
t .ar:.` *mx7r i a• xP � v k .%' ..,�a s V`.'x7r � A Y s 'H 'C^�� � # �a`ar
Is the system in a Designated Nitrogen Sensitive Area(Zone H for
a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 5
310 CMR 15.216- also refer to Policy regarding upgrades of such
existing systems]
Is the system proposed on the same lot as served by private well ?
1310 CMR 15.214(2)]
Are the nitrogen loads proposed in compliance? [310 CNM
15.216 1
`� r t �wa'+A 5n s}.,�"Yrr � �"$-.•"�#- 1 2�N,n t+.- 1 '' g� .� 'k '� . �`�.'� y'�� f x ,a�a t ""+r�s t� �. r .,�i..�.� s:
Purnping to septic tank ? [310 CMR 15.229
Shared System [310 CMR 15.290]
Address Sheet 7 of 7
�.
Town of Barnstable P hl
lledLDepartment of Regulatory Services
Public Health Division Date200 Main Street,Hy is MA OZ601 f!}Date Schedu Tune !a Fee Pd.
Soil Sui ility Assessment for S a 's s l
Performed By: per' ' tin � Witnessed By: 0
LOCATION&GENERAL INFORMATION
/
Location Address Owner's Name
Address
Assessor's Map/Parocl: f V" Engineer's Name .j-t.,iM r
NEW CONSTRUCTTON _ REPAIR (.Y Telephone# j G '-73"1--r_ 7, c
Land Use.
I`t-h A,—` Slopes(%)--4----5�Surface Stones
Distances from: Open Water Body _ft Possible Wet A ft Drinking Water Well'1!-
Drainage Way eV�14— ft Property Line_f ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test�boolle*&'p=retests,locate wetlands in proximity to holes)
. i
1
Parent material(geologic) ` Depth to Bedrock N
Depth to Groundwater: Standing Water in Hole: .5 n1,- Weeping from Pit Face ir.n
Estimated Seasonal High Groundwater ! !&Z 1-\
DETERNHNATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well N Reading Date: Index Well level Adj.factor Adj,Groundwater Level_
PERCOLATION TEST Date Ttma
Observation �Ip
Hole# Time at 9^
Depth of Perc � Z� 7 �1 Time at 6"
Start Pre-soak Time Qa n Time(9"-6'D
End Prv-soak
Rate Min.Mch
Site Suitability Assessment. Site Passed Site Failed: Additional Testing Needed(YIN)
Original:Public Health Division Observation Hole Data To Be Completed on Back------
***If percolation test is to be conducted within 100'of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTIC\PERCFORM.DOC
DEEP OBSERVATIONMOLELO.G Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
Consistenev.° Gravel)
?o
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (M®sell) Mottling (Structure,Stones,Boulders.
%
a- A sL- ytyl
Z 5� YrG Y/
Z - G #M-CSa,J 'Z-5YGI Lj a:� �a 1
DEEP OBSERVATION HOLE LUG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
Consistency.° Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
° Gravel)
Flood Insurance Rate Mao:
Above 500 year flood boundary No— Yes
Within 500 year boundary No Yes_
Within 100 year flood boundary No.4— Yes T.
a
Depth of Naturally Occurrine Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring perv' us material?
Certification
I certify that on qq (date)I have passed the soil evaluator examination approved by the
Department of Envlro ental Protection and that the above analysis was performed by me consistent with
the required ttainin xpertise and experience described in 310 CMR 15.017. /
Signature Date�Z�!
Q:\SBPT1 C\PFRCFORM.DO C
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AF
C! DEPARTMENT OF ENVIRONMENTAL P ' TIO 9��
/ ONE W'ItiTER STREET. BOSTON. MA 02108 617-2 _ 00
NO
V
N'ILL1A'�f F.WELD 19 RUDY CORE
Governor
`9R �t Sevetar�
ARGEO PAUL CELLUCCI � 1D R.STRtUrHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION Cormmissineer
PART A
CERTIFICATION
Property Address: 3C 1Aw0Pe1eC .cni, ellwTwviq-LF Address of Owner:
Date of Inspection: /v,p N=y'f— (If different)
Name of Inspector: A ca Xrr1T-
I am a DEP approyqo y i peicipr.A��eLtjQ. 15.340 of Title 5 (310 CMR 15.000)
Company Name: J 0. 11�CITY w
Mailing Address:
Telephone Number: r
MA 02747
CERTIFICATION STATEMENT
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails- &�)Inspector's Signature: Date: /0—a-4-
"98,
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owtner
and copies sent to the buyer, if applicable, and the approving authority. S� C mrVIC, JW �O w��KM,(r� +
INSPECTION SUMMARY: Check A, B, C, or D: A—t3 OX tw 6:.Oob tv0►E'Ctk6- 600%,077WN
AI SYSTE ASSES: 6-�Ae1Y P/T'/V.5 S
G�
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page l- of 10
DER on the World Wide Web: http:dwww.magnet.state.ma.us/dep
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 3 G '"
Owner: wr2��.�vN }'NOR ray S epTT
Date of Inspection: /6 —a Y--9 t'
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed'pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
s
(s*vised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 3(c �/�w/el �°� 'Z�� eA%17,V7QV1;-L/'
Owner:
Date of Inspection:
D] SYSTEM FAILS: G
You must indicate ewer "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an 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 112 day flow.
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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
hA
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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 11 of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Fags 3 of 10
WAGE DISPOSAL SYSTEM INSPECTION FORM
SUBSURFACE SE S L S E
PART B
CHECKLIST
Property Address: 3` L "R� itRV 1
Owner: W%L�- ��'^� /vt)�2 va ri S 9D TT
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the.system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
_ /✓/Q_ As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
/ The size and location of the Soil Absorption System on the site has been determined based on:
(/ _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
(revised 04/25/97) Pago 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: frw a rw a lZ 4 rt'
Owner: F. VORM11
Date of Inspection: �6_a 91-
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 3 30 a.p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents:
Garbage grinder (yes or no):-2-075
Laundry connected to system (yes or no):�S
Seasonal use (yes or no): Ab
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no):A4 '
Last date of occupancy: CUrgq%e*%7—
COMMERCIAUIND USTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no) e*-O
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
VSeptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
A4 Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
.,APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 25 04 7
/ /9 ) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
' SYSTEM INFORMATION (continued)
Property Address: 36 I- 4wrPJ-^e,' LN✓. eB.✓T11'iPVt2�1�
Owner: t.i►ZL�'/) ti n.oR�^'r/'► S C9D TT�
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _ cast iron _40 PVC _other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_v
(locate on site plan)
`0
Depth below grade:
Material of construction: —concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance —(Yes/No)r_RAo)Z/ /c'�
Dimensions:
c..
Sludge depth.
(.'
Distance from top of sludge to bottom of outlet tee or baffle: Sc�,M _ •� I _
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: �br.
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined:
Comments: L V ID b-a — H
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) C1-o coo -erav��^/ L-/Quz i0 L ze.U►7L
GREASE TRAP:ffz 1
(locate on site plan)
Depth below grade:
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/2S/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3� LAui/>'�i✓e/� LN ��.✓7RVi��2
Owner: c.,,z�irfi�-► v naQrti�► Sao ri
Date of Inspection: J(Tank
TIGHT OR HOLDING TANK: must be pumped prior to, or 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/day
Alarm level: Alarm in working order _ Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
t�
Depth of liquid level above outlet invert: o
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
G-e -n
PUMP CHAMBER:_/
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 G L A w 0/n/e C L r✓• e—rV17T*4C V/<t iF
Owner: 9-"x-0 SrT-
Date of Inspection: /o —2T-9 S /
SOIL ABSORPTION SYSTEM (SAS). l_l//
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type. D r jo x 7 D ��
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
6-c >o Oep n/DI*P 4 X/ s S�/�CiCi/F✓T'✓o�-wti� /1J�//rj� A�L/�.
CESSPOOLS:
(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 (cesspool must be pumped as part of inspection)
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.)
(revised 04/2S/97) rage a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'Property Address: R•w0?rTrve Li✓ C1IA,17ITRV12-L/£
Owner: u-itL��7°9 9` /t"Wl"14 Sep7-7'
Date of Inspection: 7,— 6,
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (locate where public water supply comes into house)
LAWAanle's Ln/
F/t v nT
K-7' %
7
s3
i it
34
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: tN- crTVTiiP✓iyLar
Owner: tw•; LiI9✓rl 9-NORMA S�71
Date of Inspection: ._ I T_��
Depth to GroundwaterajeFeet
Please indicate all the methods used to determine High Groundwater Elevation:
C,-f-Obtained from Design Plans on record
(/Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
t,'-.-Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
D ITSi 6
4�liP 7M
�,e ,•,��v v� •mom � b•o•/!�
(revised 04/25/97) Page 10 of 10
LSO C AT ION o` ��--�� S E W A G E PERMIT NO.
1 el �7 j - mod
VILLAGE
INS A LLER'S NAME i ADDRESS
� G fi' 6 tiST
3 U I L D E R OR OWNER
DATE PERMIT ISSUED S �
el
DATE COMPLIANCE ISSUED ��- 7-
a
sj
34
�g
Fss.... ...
...........
THE COMMONWEALTH.OF MASSACHUSE77S
BOARD OF HEALTH
Appliration for Uwvoii al Marks Tonstrnrtion ramit
Application is hereby made for a Permit to Construct ( >e) or Repair ( ) an Individual Sewage Disposal
System at:
...L.�9.�YI %Y.4° .....G..��i./E• 7- G T...... --•------- -..•..-•--------------------------------
/v Location-Address or Y o.
i.4..G..r......��. �...'.......... .........C� v l.......... ...................
Owner /a Address
WIC-,�
...........
Installer Address
Type of Building 3 Size Lot./8f-_-- /....Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (�)
p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures -------------------------------•-
.133.i�'.Di�aivia+ ..................
Design Flow............1/1-�........................gallons per4sen per day. Total daily flow__._..._......_. 3-® ............gallons.
Septic Tank—Liquid capacity.&It?.Q..gallons Length.&. Width.!1��/4.. Diameter................ Depth....r-�=.'�i'`.
W Disposal Trench—No. .................... Width.................... Total Length.....................Total leaching area....................sq. ft.
x 3 Seepage Pit No....../------------- Diameter...O...Ar Depth below inlet....6..FT... Total leaching area..4�2...sq. ft.
Z Other Distribution box ()<) Dosing tank ( ) _
'-' Percolation Test Results Performed by._ !9?fT f ...._ _..AlY.E.................... Date-. / 5 ...............
Test Pit No. l...G........minutes per inch Depth of Test Pit.../..�g......._ Depth to ground water.......`
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ----••-•----•-•----•----•--•----• ..... ..... ...0
Descr;ption of Soil--O-----=�-�-------�1�r91n---- --�---�C/P3 Svc.-----------�--- ---��----�--.. 9�5�-------����-
W
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 TIM2 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of ComplianceZb�eeiqlby boar of health.ASig -••-••---••-•••-••-•••---••-•----•-• --•-------•-------------
Application Approved BY •------------------------•----- ----/----�---------_----------
Date
Application Disapproved for the following reasons:----•--------- - -------------------------------•---•-------------------••---------------...
.............................•---•-•-••--•-----------•---•-•--•-••---••---•••---......-----••-•---.....-------•---•--....-------•----------------------------.....,ti "
...........-------------•-------------
Date
PermitNo..............................................................__.._--------•-•-•---•------.. Issued...4ee',�(/-------------•--- - ......
Date
N .............................
THE COMMONWEALTH OF-MASSACHUSETTS
t,ROARD OF HEALTH
OF......../3./9 -�.IVS .... 3
CT
................ .........................................
Appliration foi Disposal-Vorks Tonstrurtion ramit
'Ir
Application is hereby made for a Permit to Construct (A) or Repair an Individual Sewage Disposal
System at:
..........
1 ......... .. .... ................1q-cI 17o- .70,
..
.i.�................. .........
Location-Address
= / V ............
Ri _ ....".........A..............................................
a 0_4 on _1V111< .)ddress
Installer Address
Type of Building Size .......sq.Aept
U
1_4 Dwelling—No. of Bedrooms...._._.....5................ ...........Expansion Attic Garbage Grinder
P-4 Other—Type of Building ............................ No. of persons.............______..__.____ Showers Cafeteria
P-4 Other fixtures .................................
t� --------------------------------------------------------------------------------------------
Design Flow..........12_0.......................gallons per-persan per day. Total daily flow.........._3.36...................gallons.
9 Septic Tank—Liquid capacity/aW.gallons Length�=4... Diameter---------------- Depth... *......9.C '-
Disposal Trench—No..................... Width..................... Total Length............._....._ Total leaching area....................sq. f t.
Seepage Pit No.....j............ Diameter..«/--_771. Depth below inlet.._En... Total leaching area---1?0.7..sq. ft.
Other Distribution box (X) Dosinj"ank ( )
Percolation Test Results Performed by..Z:�z9Z.7e..a...... ............... Date...
Test Pit No. 1... ...minutesper inch Depth of Test Pit---ZZ......... Depth to ground water.........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit................... Depth to ground water___.._..............___.
P4 ........................................ :----�
0 Description of Soil...<:?. .............eo.,9zn...../.... .
01
, -.4 7
. a. .. .?........ .:? � !.......7✓"
. .... ...............
..........................................................................m............................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable._..................................................•.._._.._..._...........__..._..._......._..
......................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T!Z- 5 of the State Sanitary e—The undersigned fuytler agrees not to place th; systyn in
State
Sanitary
operation until a Certificate of Compliance has bee ued b A L ig
Signee ...... y
d..............*---- --------------------------- -----------------------------
Date
Application Approved By.......... .... . .... .............................. ....
Date
Application Disapproved for the following reasons:..............7.......................................................................................
.............................................................................................. ........................................................................................................
Date
PermitNo......................................................... IssuedL.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
l�t,�/h BOARD OF HEALT
Vcr t-nS TO
..........................................'OF..............7'**,*...*..............................................................
Tntifiratr of Tompliaurr
iq` k-1
I ual Sewage Disposal System constructed ) or Repaired
by...j.�o.T�...........7.........Z:--a l
----- ----- ------.... - ------------ii----------- -------------- ------------
1_
at................................................................................................... .........................................................................................
. 11
has been installed in accordance with the provisions of __(] 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N ........ .....fl.7_9.............. dated.__..9--A/-_-...k.d.................
THE ISSUANCE OF THIS CERTIFICATE SHAVLBOT BE CONSTR AS A4UARANTEE THAT THE
SYSTEM WILL FUNCTIO TISFACTORY.
inspector. ..........................
DATE.... .......4..........................
...................................................... ..
/ ...... ........ .........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD/,bF HEAL
oe
.........................................OF.....................................................................................
......... FEE........................
Permissioneereby uall oe 4r an granted..............................................................................................................................................
I C
to Construyt �.), ludivad Sea Z-�� A.4., ge4P*�F&P)r_L1.$
atNo.......I...........................................................I.............../........................................................................................................
Street
as shown on the application for Disposal Works Construction Permi No----- Dated.......I ............
............
DATE...............f—� fc) Board of Healt
................................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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-LEGEND .
EXISTI.NG SPOT E 10 UVArl
EXISTING CON' 00R.- 0 T
'SPOT ELEVATIONS
H ED S
FINISHED N. R 0': ,�-60 TOO
"PROPOSED PLOTlp
Ap'PROVEIDI; BOARD OF HEALTH LAN,
MAS
DATE AGENT 4)7— .
R, -
R. 0 HEAARN,.INC..,
1348 ROUT E 134
EAST DENNIS MASS.,
DATE ; SCALE:
RIICHA�D
JOB N 0. CLIENT
DR. BY 1s SHEET Z OF �_
....................
7
F
ATIONS NOTES:
TEST , Ei -
SOIL S T
INVERT
7s
0
ALL, WORKMANSHIP. AND MATERIALS.
;,
DATE OF SOIL, TES, 'Q INVERT AT BUILDING FT.
SHALL CONFORM TO D.
INLET SE-PTiC. TANKF T Q.1t. , TITLE
WITNESSED BY5
E�PTt HE_� TOW N OF 13.,-v
PERCOLATION RATE L2 MIN./INCH OUTLET S -.TANK K: 9 FT AND 71 4zfR U L E S-AN.D _-_REG.U,,LATIGNS FOR�, SUB-SURFACE
INLETbl:STR.IBUT 0 FT. SANITARY.ON HOLE 2 1 ll.�
OPSERV 16N�, HOLE OBSERVATION _NDISPOSAL l . o Y SEWAGE
OUTLET, -8 Ul I ON1 BOX_
?5 FT ET, TRI
ELEVATION ELEVATION
.-
INLET LEACH! NG ' PI FT.4
.s:�/'o BOTTOM., LEACHING :PIT FT.77
-CALCU' ATIONS
DESIGN
A NUMBER - ,OF BEDROOMS ,
-;v
GARBAGE DISPOSAL UN'lTi.. .
TOTAL ESTIMATED . F LO-W� (_LLLGAL./BR./DAY X BR.)_ 5.20 GAL./DAY
REQUIRED SEPTIC . TANK , CAPACITY. . .,. . . . . . . . . 6 GAL.
0:ACTUAL, SIZE OF SEPTIC TANK TO BE INSTALLED.,.. .
GAL.
LEACHING AREA REQUIREME_NTS
I SIDE WALL AREA. GAL.:/S.F.
BOTTOM - AREAL GA L.1&17.
'
-7
-Vl LEACHING - CAPACITY. . ( -BOTTOM -,'�SIDEWALL GAL.
I j r :Z7,
RESERVE -LEACHING - -CAPACITY. . . GAL.
TOP OF
, FOUND.-
7' 4.' SCH. . 40 .
:CONCRE El CLEAN SAND.
PVC' PIPE
CONCRETES.
- COVERS
PITCH
7- 1 8 PER R FT COVER 114 0
6.�MIN.:.PITCH So
lz MAX. RICHARD
AR
JAAE Zi O'HEARN,
2 LAYER.. OF 0-HEkR 27871
FLOW LINE
WA-SlHE-D STONE
b Z '
o
41' CAST IRON
RVE
WA
PIPE MIN. PITCH w SHED .STONE sq
-CAST ACHING.
ca
T
1/4' F
Dl OR LE
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B -7 BASIN 00 EQUIV.
MASS
GAL
'TIC
7 LL
SEP
TTA R 4
RS
' 0 HEARN Q RLS
N
191 MAlU ST '(R
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TE 28)
WESTDENNIS� MASS J
-E'.-PRO 'I'L OF -GROUND WATER"TA-BLE.
B jol CLIENT
F
SEW
L. 'sy-s T
_3
A.
_ . 44.
It T b ATIE
T
I&
LEGEND o s N
—— 58 —— EXISTING CONTOUR o a
x 56.82 EXISTING SPOT GRADE w
0 o
—W EXISTING WATER SERVICE Y
—G EXISTING GAS SERVICE
H. — OVERHEAD WIRES
TEST PIT Woodvale L keton �n
BENCHMARK PB 333 — PG 54 n a
carlet°n �.
0
O °
6 v)
u'f
9
o Great Marsh Rd
EXISTING LEACH PIT FOUND
TO BE PUMPED, FILLED WITH
SAND AND ABANDONED
BENCHMARK SET Locus
CONRNER/CONC. LANDING
EXISTING SEPTIC TANK EL.=50.95 LOCUS MAP
TOP OF TANK, EL.=49.93 NOT TO SCALE
INV.(OUT)=48.60f(VERIFY)
52.01 s° N 00'14'50" E l 52,01
50.12 fx4qvi 100.00' 48.85 I
x � I
TP-1 S--12.8' '�.Q20 49.51
Chain link fence Jig l
P-2 Q
50.41
(n: O =^: LOT 7 x
mn 'W
0 N� ( MBL 190-252
50.6 :O'
a0 A_`I 5 ,30 _ 18,381 S.F.t
51.61 54.02['�
10 PA TIO -i 5
x 51.66 0.47 51.16 (below)
BM
0 0 50.95 DECK LOT-9
—
LOT 5 52:51 x 51,0 (above) �
TOP OF S.A.S. IS 53,59X 56.3
LOWER THAN THE
CELLAR FLOOR. 1EX1S1 TNG
rn HOUSE(#36) z
N P /T.O.F.58.6f 57.53 OD
rn
N �_ J Cellar Floor, EL.=51.3f
0 N�1
58.02 m
-7169•:*
x I x WAdK
57.66 0 58,15 x 8.31
PAVED .
x 58.10
G� 57,92 ` '
LAMP `:-` ' ` `•<:':
58,82
—5�— Ste. ... :.. 58.4
PAVED LANE TO 56,78 edge of pavement 57,23 `
LA W1�EI�TC�' LA
58,30
GREAT MARSH RD o �(30' EASEMEN T)
73.65' 0.00
S 03"43'35" W
LOT 6
LOT 8 LOT 10
y 3
o PETER T.
MCENTEE CV Z Q-�
CIVIL "'
No. 35109 ^ O J rn OD
OD
PROPOSED SEPTIC SYSTEM UPGRADE PLAN
36 LAWRENCE LANE, CENTERVILLE, MA
1— Prepared for: D.A. Brown, Inc., P.O. Box 145, Centerville, MA 02632
OWNER OF RECORD O O
PORKKA, DAVID T & J O Engineering by: SCALE DRAWN JOB. NO.
JUDITH L Engineering Works, Inc. 1"=20' P.T.M. 157-14
36 LAWRENCE LANE 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
CENTERVILLE, MA 02632 (508) 477-5313 8/19/14 P.T.M. 1 0f 2
i
.�r
NOTE: TO PREVENT BREAKOUT, THE PROPOSED
FINISH GRADE SHALL NOT BE < EL:48.0
SEPTIC TANK FOR A DISTANCE OF 15' AROUND THE
PROPOSED D-BOX PERIMETER OF THE S.A.S.
INSTALL RISERS & COVERS OVER INLET &
OUTLET AND SET TO 6" OF FINISH GRADE INSTALL RISER & COVER PROPOSED S.A.S.
SET TO 6" OF GRADE INSTALL RISER & COVER OVER EACH CHAMBER AND
TLF.G.
.6t SET TO 3' OF F.G. TO SERVE AS INSPECTION PORTS
.=51.Ot F.G. EL.=50.5t F.G. EL.=51.6t F.G. EL.=51.Ot
LKOUT)
3'(max.) L = 16' _
p S-1% (MIN.
4"SCH40 PVC 4-SCH40PVC) 2" LAYER OF 1/8" TO 1/2"
s" n DOUBLE WASHED STONE
io"I 6 as $ as
14^ (OR APPROVED FILTER FABRIC)
6a9 a6B
aaaaaaa
EXISTING 48" LIQUID aaaaaaM -3/4" TO 1-1/2" DOUBLE
LEVEL ADD J PROPOSED 4' 4.8' 4' WASHED STONE
GAS BAFFLE INV.=47.72 INV.=47.55
INV.=48.60t D-BOX EFFECTIVE WIDTH = 12.8'
EXISTING 3 OUTLETS INV.=47.50
EXISTING SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS
SURROUNDED WITH STONE AS SHOWN
H-10 RATED
NOTES: TOP CONC. ELEV.=48.3t
BREAKOUT ELEV.=48.00
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INV. ELEV.=47.50 NO
ease
ease
INVERTS, PRIOR TO INSTALLATION. a9aadh
ases
aaaaases
2) D-BOX SHALL BE SET LEVEL AND TRUE TO BOTTOM ELEV.=45.50
GRADE ON A MECHANICALLY COMPACTED SIX 4' 2 X 8.5'=17.0' 4'
INCH CRUSHED STONE BASE, AS SPECIFIED 4' OF NATURALLY OCCURRING EFFECTIVE LENGTH = 25.0'
IN 310 CMR 15.221(2). PERVIOUS MATERIAL
3) INSTALL INLET & OUTLET TEES AS REQUIRED.
5' (MIN.) ABOVE G.W. LEACHING SYSTEM SECTION
4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE BOTTOM OF TP, EL.=39.2
AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. (NO GROUNDWATER)
SEPTIC SYSTEM PROFILE
SOIL LOG
DATE: MAY 23, 2014 (REF#14,369
GENERAL NOTES: SOIL EVALUATOR: PETER McENTEE PE(SE�1542)
WITNESS: DONNA MIORANDI R.S. HEALTH AGENT
1 ALL CHANCES TO BOARD OF HEALTTHTHIS PLAN MUST AND THE DESIGNBENGINE APPROVEDR BY THE LOCAL ELF-v. TP-1 DEPTH ELEV. TP-2 DEPTH
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 50.2 A 0 50.5 A 0"
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE SANDY LOAM SANDY LOAM
LOCAL RULES AND REGULATIONS. 49.7 10YR 4/2 50.0 10YR 4/2
3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR B 6" B 6"
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER. SANDY LOAM SANDY LOAM
4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 47.7 10YR 5/6 30" 47.8 10YR 5/632"
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN C C ENGINEER BEFORE CONSTRUCTION CONTINUES. PER PERC
C "
5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 11
48
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF M-C SAND M-C SAND
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 2.5Y 6/4 2.5Y 6/4
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. >20% GRAVEL >20% GRAVEL
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE.
8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 39.2 132" 39.5 132"
9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS PERC RATE <2 MIN/IN. ("C" HORIZON)
AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE NO GROUNDWATER ENCOUNTERED
DIRECTED BY THE APPROVING AUTHORITIES.
10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
CONSTRUCTION. �--12.8'--1
11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS
IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND
REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). ' w
12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE O 69. $�
INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. tJ a Q
13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND d -P.U) ,1 4'
NOT CONSIDERED TO BE A PROPERTY LINE SURVEY.
6 5.7' ,
52.9
63.9'
S
0, N DECK
DESIGN CRITERIA (obove)
NUMBER OF BEDROOMS: 3 BEDROOMS
SOIL TEXTURAL CLASS: CLASS I (LOADING RATE=0-74 GPD/SF)
DESIGN PERCOLATION RATE: <2 MIN/IN
DAILY FLOW: 330 GPD ,EXISTING
DESIGN FLOW: 330 GPD HOUSE(#J6)
GARBAGE GRINDER: NO-not allowed with design
LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF.74 GPD/SF S.A.S. LAYOUT
EXISTING SEPTIC TANK: 1000 GALLON CAPACITY
PROPOSED D-BOX: 1 INLET, 3 OUTLET (MINIMUM), H-10 RATED PROPOSED SEPTIC SYSTEM UPGRADE PLAN
USE 2-500 GALLON LEACHING CHAMBERS IN SERIES
SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES 36 LAWRENCE LANE, CENTERVILLE, MA
SIDEWALL AREA: 2(12.8' + 25.0') X 2 = 151.2 S.F. Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632
BOTTOM AREA: 12.8' x 25.0' = 320.0 S.F. Engineering by: SCALE DRAWN JOB. NO.
TOTAL AREA:.............................................................. 471.2 S.F. Engineering Works, Inc. N.T.S. P.T.M. 157-14
12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD (508) 477-5313 8/19/14 P.T.M. 2 of 2