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HomeMy WebLinkAbout0042 MADISON AVE - Health (2) 42 Madison Ave Centerville F/R A = 247 097 IN Z UPC 12543 No.53LOR ° -CO HASTINGS,mN i CW- TOWN OF BARNSTABLE LOCATION �� J4�oJ'�«' � _ � SEWAGE # SfsII_LAGE C-�c�1?��lVtLIEASSESSOR'S MAP& LOT ��� INSTALLER'S NAME&PHONE NO. c //'� ��"�®�Gr� 27 SEPTIC TANK CAPACITY i.EACHING FACILITY: (type) (size) _ -10. OF BEDROOMS BUILDER-OR OWNER PERMIT DATE:_ r—la olA' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) _ / Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) / Feet Furnished by CT� C � a �o�� O� �vs� ' CJ � Vi 8 � � �� � � �� 8 f �® � . �� � � �, r� No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYtcatiou for 33igozal *pgtem Cow5truction Permit Application for a Permit to Construct( )Repair(l,,yUpgrade Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. q�f'B � Owner's Name,Address and Tel.No. 07 �? — / � A �k1k (irn �—�f '/O 6� Assessor's Map/Parcel e / Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building � �; No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title i Size of Septic TankS'7�'"'S /�®y 6 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued d of Health. Sign Date Application Approved by,�R� Date Jr /Ole, Application Disapproved for the following reasons Permit No. Date Issued So — No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes a PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS, 2pplication for Miopaal 6pgtem Construction Permit Application for a Permit to Construct( )Repair(jyUpgrade Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. N v Owner's Name,Address and Tel.No., a � - 97 �t� ll� �-- /o Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms..-' Lot Size sq.ft. Garbage Grinder( ) Other Type of Building, No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date r Number of sheets Revision Date Title i Size of Septic Tank <-`xi "' oo ,rL ' Type of S.A.S. IgreO 13-Y 3 X Description of Soil Nature of Repairs or Alterations(Answer when applicable) 4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue thi d of Health. Signe Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued —————————————————————————— ——————————— �r'� }P�rr �---� .� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( ) Repaired ( VUpgraded(� Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer , �i h- ����`�/� Designer 4J .-A rO, "J ^ The issuance of this permit shall not be construed as a guarantee that the sy function as designed. Date ^�--�.III�i>'a Inspector- --------------------------------------- No. aU©y — �� Feer..— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Mh5pogal 6pmem Con$truction Permit Permission is hereby granted to Construct( )Repair(Upgrade(6(bandon(" ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions- Provided: Const`ruc 4i'on it st be completed within three years of the date of this pe it. Date:___T��/ y Approved by } TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 2 P,7` INSTALLER'S NAME&PHONE NO. //� ��"�e� '/� . 27 SEPTIC TANK CAPACITY. LEACHING FACILITY: (type) (size) - X3y � NO. OF BEDRUOMS BUILDER OR OWNER PERMITDATE:_ r �.c1� COMPLIANCE DATE: Separadon Distance Between the:. . Maximum Adjusted Groundwater le to the Bottom of Leaching Facility Feet Private Water Supply Well.and Leach\iing Facility (If any wells exist on site or within 200 feet of leaching facility) ,/ Feet. Edge of Wetland and Leaching Facility`(If any wetlands exist within 300 feet of leaching facility) / Feet Furnished by Cam-'- I B G p ,o �� 4e r Town of Barnstable Regulatory Services Thomas F.Geller,Director 9 MASS� P Public Health Division i639 Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Fax: 509-790-6304 Office: 508-862-4644 Installer& Des i ner Certification Form Date: Designer. Installer: Address: GUAG1e, 7� Address: On_ , was issued a permit to install a (date) (installer) septic system at VA lkTDJ 50'`J /Jv based on a design drawn by (address) - U� UlON �5 dated (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. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State &Local Regulations. Plan revision or c ed as built by designer to follow. � MIR!) : (Installer's Signature a° t 7A (Designer's Signature) Affix DesignersStairip Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE BUILTCT MPRD� E BY THE BARN STABLE UBLIC EALTH DIVISION. BULL THANK YOU.. Q:Health/SepticiDesiper Certification Form i T 'd LTTT - SLL (80S) jneoga-i wir •jW dLg :Lo t►0 oa Uer MLED INSPECTION COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION /gip -/-,RCEL =V7 -OT Y TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 42 Madison Avenue Centerville, MA 02632 Owner's Name: Jim Eldredge Owner's Address: Date of Inspection: April 7, 2004 RECEIVED Name of Inspector: (Please Print) James M. Ford MAY 0 5 2004 Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 T�WHEALTH DEPT.BARNSTABLE Telephone Number: (508) 862-9400 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 the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Purther Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: Date: April 14, 2004 The system inspector shall subm' 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I ' Page 2 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 42 Madison Avenue Centerville, MA Owner: Jim Eldredge Date of Inspection: April 7, 2004 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: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If"not determined", please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 i Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 42 Madison Avenue Centerville, MA Owner: _Jim Eldredge Date of Inspection: April 7, 2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I 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 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,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 42 Madison Avenue Centerville, MA Owner: Jim Eldredge Date of Inspection: April 7, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"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 '/z 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 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 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, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 42 Madison Avenue Centerville, MA Owner: Jim Eldredge Date of Inspection: April 7, 2004 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: Yes No ✓ 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(3)(b)]. 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 42 Madison Avenue Centerville, MA Owner: Jim Eldredge Date of Inspection: April 7, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): n/a DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 440 Number of current residents: 6 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): 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/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped approximately 1 year ago-per owner Was system pumped as part of the inspection (yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed(if known)and source of information: Installed 4113188-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 42 Madison Avenue Centerville, MA Owner: Jim Eldredge Date of Inspection: April 7, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. GREASE TRAP: None (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(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity; liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 42 Madison Avenue Centerville, AM Owner: Jim Eldredge Date of Inspection: April 7, 2004 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. PUMP CHAMBER: None (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.): 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 42 Madison Avenue Centerville, MA Owner: Jim Eldredge Date of Inspection: April 7, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits, number: ✓ leaching chambers, number: 4-4'x 4'galleys (10'x 22') -per as built card 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.): The galleys were full. Liquid was above the inlet pipe. The leach field was in hydraulic failure. CESSPOOLS: None (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 or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: None (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.): 9 Page 10 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 42 Madison Avenue Centerville, MA Owner: Jim Eldredge Date of Inspection: April 7, 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. a 3 y o a 3 L�a. a°� 10 0 Page I 1 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 42 Madison Avenue Centerville, MA Owner: Jim Eldredge Date of Inspection: April 7, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators, installers- (attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and water contours map the maps were showing approximately 25'+/-to ground water at this site. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the,future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 1l No..nn r2„ Fps....... .G°1........`.. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH �—rr-u .,. ...OF............. ..:..-.......: ---••----•----------------.----------_-- Appliration for Uiopoottl Work i Tomitrurtion runfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: - �& 2q7 - o � 7 ........!r. ... _ a' Ad ess �cr i et-ido M?7114 (Q • .... ........ .. ..... . ................ ........... ....... ---------- ..................... -• -•. ... ........... ne... ...�................... '�1 dress^-_.. In alley Address � T f Building Size Lot............................S q. feet Dwelling—No. of Bedrooms.._.. --------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ............................ W Design Flow............................................gallons per person pg day. Total daily flow............................................gallons. W Septic Tank—Liquid capa+Diaete allons Lengths,............ Width.5............. Diameter---------------- Depth.6............ x Disposal Trench—No. idth--------_------_- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No............ ...... ....._....._....... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1­' Percolation Test Results Performed bY.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ L� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -.• . ..._..---••••--•--•-•--••-•---•••-••-•---•••......-••--•-••--•---••-••••••...............•••••••••••••....•••---•-••---•••••-••••....•••-- 0 Description of Soil..... ... V •••••--•••-•-•-•...............•••••-••••••---••-•••••--•-•••--........•-•••--•-••-••---••-----•-•••-•...........-•-•••----•--••...•---••••......--•--••-•••-•---•-••-•----•••-......••-••......--•••... -----•---------------•--------.._......---------.....----------------•--•------......------....._...---••---••. .-- ---------- -- ----------- - ----- U Nature of Repairs or Alterations—Answer when applicable_.._._.__� 014.4— _ �.............................. --•............................•-••---•--••-•••••--••••-•--••••--•••-•••-•-•-•••-••••....._..•••-•-•••••-•.....--------••••-•-••-•••--•-••....-•--•-•-•---•----••-•-••••••-•............-•-•-•••.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL% 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued bv the boa d of h th. �/ Signed•• ...•. _ . .. ..--•••.............. . .•----••---•-•--•--•-•--- ..../--�� ... Application Approved B Date PPPP Y---••...---•- ----_ .a�.-•'--=,-•-•-------•---•--•----------------•- -----------��4-5-.--g--sir--- Date Application Disapproved for the following reasons:-------•----------------------------------------------------•--------------------............................ •-•-••••••••-•••-•••••••--•--•••-•-•-•---•--•---•---••••••.........•••-••-----••--•-•-••••-•••••---••-•--...••-••-•---•••-•-••-•••-•-•---•--•••----•-------•---•-•••---••-------..... ...-•-•••••-•- Date PermitNo.......... .--14C -------------------- Issued....................................................... Date Fas.......s Q THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................I.................•--....O F.......................................-----.............................................. Appliratiun for Disposal Wurks Tonstnutiun rrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: - C ------•--. . P.`. . ..................... ....•••----------....---------....--•••••-- ••-•-----....•---.._.................-- ... .... .. . -. ... -- --- a' d ess or Lot No. ........ =-- .. •.. •.. ............•••••_.......• •..... -•••............. ................_._..... • ner ddress a - ---- ..... .... .............. , .7 �� ........... In alley� Address UT of Building Size Lot............................Sq. feet �. Dwelling—No. of Bedrooms..._.7................:....................Expansion Attic ( ) Garbage Grinder ( ) a'14 Other—T e of Building No. of persons............................ Showers YP g --------••---•-----•---••-•- P ( ) — Cafeteria ( ) dOther fixtures ---------------------------------------------•--------.-.--.------•---------•---------------------•-------•---•----------------.-.-------------------- W Design Flow............................................gallons per person pgr day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capa t gallons Length./e........... Width..?.`'..._....... Diameter................ Depth.!�............ x Disposal Trench—No. idth.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No..................... Dia eter........_........... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..................... 4.1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 .•.All •• -------•................••••••----.........._.._---------.---•-------•----.-.._.. ..._.. 0 Description of Soil..___ __._ . V --......---•------••••...................•-... .•---•-•..... -•------.......---•---•--.........----•--•----•----•------------........•..---•----....------•----•............-••---- VW -•-------•--- -------_--- ............................... Nature of Repairs or Alterations—Answer when applicable......... 0_1� :._.:.. . ..... _...•.......................... --------------------------------------------------•.......................---------••------------...---••----•-•------------------------------------•-•-....-----.....----------...---------•--•••--•••- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE' 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued the boa d of h th. Sig 3 ned.. ... .. •... .C................•---•- ..........--••-....._...... ....l4.fz...:. - Date Application Approved BY "- = .-�.. .... ._.... _ ........... =---8.rk. Date Application Disapproved for the following reasons:............................................................................................................. --•••....................•--••-••---------......---•-.....---•------....---•--------------•----•------••-.•-...........••••••-•...••-•-•-••-•......_.......-------•-------.......•-•-•-•............_.._. Date Permit No.......... - ............._.._ Issued............................. ............._..... Date THE COMMONWEALTH OF MASSACHUSETTS -�- BOARD y�,.OF HEALTH .........../..0..!.3..:..........OF..........t d........ ... ............................................... (Irrtif irate of faumphana THIS IS T CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY- �a T..........1-CQ{'^ z =n,^ ...............................................:.................................•...................•......7........... Installer._..-_-_.-_. has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......F.. _:__l _t.......... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................-.................................................................. THE COMMONWEALTH OF MASSACHUSETTS o BOARD OF HEALTH No.....D .:11c... C,f ..............OF........... .f.. .?C......................................... �t FzE..........0......... Disposal Works Tunstrnrtiun f rrmit Permission is hereby granted.....----- � a:_. ........ .......................... .......... to Construct ) or Repair ( ) an In Dispo System atNo.............. ----- street as shown on the application for Disposal Works Construction Permit No. �_:.. �.... Dated.......................................... ............................... .........•�..� ..----,r ............................. Board of Health DATE...----_---•- f _ ."._ ....................................... FORM 1255 A. M. SULKIN, INC.. BOSTON TOWN OF BARNSTABLE LOr,AllON0- SEWAGE VILLAGE ASSESSOR'S MAP 6i LOT INSTALLER'S N--Mkt HONE NO. r SEA°TIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS P IYATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: LZ DATE COLIPLIANCE ISSUED: 0 VARIANCE GRANTED: Yes No o � _ � . A I � � P ------,�*mc'. ---|Y���� TO THE INSPECTOR OF BUILDINGS: ' The undersigned hova6y applies for p permit according to the following information: � . � Location /� .-- ,==—��---��'*~..:`----.��� . ....xz�n���������.��*/�t"./i��.. � ProposedUse --' ---_-------._____--------------_—_—._____________. Zoning District ----------..~------------Roe District ------- .............. Name ofOwner ____��^,��=��___�*�����—`-----A66res --���..������ --.-----'--------' Name � 8vi|de�f8\— �� /-� "' '`'--,~.—���*��°--_---------.A6Jremx ..... _______________ Nome of Architect � _______________------°ooress ---------------------------- / � j..Num6a, of Rooms —`---- /�//�^------------'Foun |o�ion ---' � —4i8 . .............. Goe,ior v// ^-/� -------'��'«�*�---------------Roofing _____ .. ................................................... " Floors ���*------'�—..�.- .------------,.|nte,ior .................. Heating ^----- ___________________—_------.P|um6ing .���==----------------'. Fireplace ........................�����..................................................AppvoximotpCost / ----. Di finkive Plan Approved by Planning Board lQ----' �Mlo Diagram of Lot and Building with Dimensions � c c c�� ~--- \\ \` ' A ' /\N[) [} x ^�' R ^,,/ ' ' ^ ~ `.�� �}F �/\�M�[AS[E .9{)A R[l OF HEA L'T' / -- / . A L!�Ey{SED �����L�E� |��|!"T 0�TAl0 SEWAGE PE�6�|T. D � / | hereby agree to conform to all the Rules and Regulations of the Town of Bornmhz6/e' regarding"the above � construction.. Nome ..... .................................................. � 1 � Eaton, Alice 14 ?8 add to No ......... ...... Permit for ............................single ........ family dwelling . ............................................... ............................... Location ...42 Madison Avenue (off Strawberry Hill Road) ............................................................ Centerville ............................................................................... Owner Alice Eaton ........................................................... Type of Construction .......f rams ............................................................................... Plot ........................... Lot ................................ February 23 72 Permit Granted ........................................19 Date of Inspection " Date Completed ...... ... .. ......19 PERMIT REFUSED ............................................................. 19 ............................................................................... i .................................................................... ................................. ....................................... ............................................................................... Approved ................................................. 19 ............................................................................... ............................................................................. ASSESSORS MAP : .�� ---- _ __ - - 1"E S T . H 0 L E L 0 G S PARCEL : . J o FLOOD ZONE: n'T 'q ._ -- --- - -- -- SOIL EVALUATOR : ` V'VAC NOTES: !� WITNESS : 1 (2` M�a I REFERENCE: i - "� / G� / ~' 5tx� __�� .. DATE: -1 PERCOLAT ON `RATE: ;4 UAt , I 1) The installation shall comply with Title V and Town of Barnstable Board of ell Health Regulations. 2) The installer, shall verify the location of utilities sewer inverts and septic TH- , TH-2 40 components prior to installation. 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. 4) This plan is not to be utilized for property line determination nor any other Y) �' 'ko ! — - --- - purpose other than the proposed system installation. ) All 5 septic components p must meet Title V specifications. LOCATION MAP �l�� '� /i - 6) Parking shall not be constructed over H10 septic components. 6 / l ---- -- 7) The property is bounded b property corners i � p p Y y p p and property lines as depicted. 8) The property owner shall review design considerations to approve of total number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed approval of the d1 �� number of bedrooms. 9) The existing cesspools shall be pumped and backfilled per Title V } �a Abandonment Procedures. 01 1" �`� (� 'J�K� 10)Proposed leaching is to be within 36 inches of grade or provide venting or cut / grade as permitted by the Board of Health. 11)System components to be 10 feet from water line. / SEPT C SYSTEM DES E E I G N (T, 6), J Y, t "fit FLOW ,EST I MATE I ! BEDROOMS AT //0 GAL/DAY/BEDROOM - LeOGAL/DAY S TIC TANK � GA!-/DAY x 2 DAYS 06Q SL LtSE1500GALLON SEPTIC TANK �I o O Oil ABSORPTION SYSTEM- it S 1 DE "AREA: �5 n .�. BOTTOM AREA: EPT C; SYSTEM SECT I ON / / � � In►r►M��, Gl�yy "w� 3q�a� / GAL W6,b� r - eI �_ I i � �G K1 SEPTIC TANK �� ' ( (ram �t�� I - 3�� - ! �_. aL7_! ._l j W1 .- SITE AND , SEWAGE PLAN LOCATION PREPARED FOR AM le,6 Z6fl4e C 0 SCALE : J DAV I D B . MASON;RS DATE: o _ D DBC ENVIRONMENTAL DESIGNS z EAST SANDWICH . MA DATE HEALTH AGENT ( 508 ) 833- 2 1 77 Z .