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HomeMy WebLinkAbout0006 MANNI CIRCLE - Health 6 MANNI CIRCLE, CENTERVILLE A= 169 118 j ylhllp/�(� gECY[tFp IIII UPC 12543 0 �Q No '�'stco HAStI NQS,MN No. gOO Fee�Vv THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppYt.cattou for �hgpo5ar 6p.5tem Cou.0tructiou Vermtt Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components o�f /Location Address or Lot No %4v-j / C "" Owner's Name,Address,and Tel.NoA4/,$1 Adn yak j� a 2A_ Assessor's Map/Parcel�f �/' 1199 /4( &11 f 1PY 411 It i C/ LTG Ir` I ICE- /'Z Installer's Name,Address,and Tel.No6�xU r ���� Designer's Name,Address and Tel.No. A . AFe- Type of Building: Dwelling No.of Bedrooms "" Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ��j d gpd Design flow provided �U gpd Plan Date %°Z�Z 6�G 7 Number of sheets / Revision Date Title Size of Septic Tank /0CJ0 9-4 L �Tyspe of S.A.S. -SCAR P / EA-A-3®" Description of Soil ,���y `' �'ie!0�, c�r�•1 rD Nature of Repairs or Alterations(Answer when applicable) Abh in Q Atj,/ 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 th Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this rd of ealth. Signed J0 Date Application Approved by Date d Application Disapproved by: Date for the following reasons Permit No. Date Issued No. � Fee t , THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION-'=TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for �BiopogaY i§potem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No.06/ Owner's Name,Address,and Tel. Assessor's Map/Parcel/Uj(p 119 A4 J&,1 Z A- 16— ¢ Installer's Name,Address,and Tel.No,5�41'f-C.-�+/��f"IRAO Designer's Name,Address and Tel.No"7.4 Y 0,6 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft.. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ?j C7 gpd Design flow provided �� gpd Plan Date ;/2/ z e/07 Number of sheets / Revision Date Title Size of Septic Tank /ZC)O r, 4c. Type of S.A.S. �iylC� ✓ T .� o.,� S i "Description of Soil (� �[ �� l6 '` !'��.-� 4) - 1 Nature of Repairs or Alterations(Answer when applicable) fJ� r � { 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 th Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this d of ealth. Signed Date •—)0—04 Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued ---------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT��IFFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( )by L. �j at i has been constructed in accordance I' with the provisions of Title 5 and the for Disposal System Construction Permit No. 00 ` 41 S � dated Installer _a tot t4i4t►-aAed Designer #bedrooms Approved design flow o gpd The issuance of this permit hall t e con t ed as a guarantee that the system will nc 'on as designed. Date Inspector_ / ---- -- --------------------- ---- ----1. No. v" Fee f70 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS M!5po5at *p!5tem Construction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located at C7) I A ...Z Cal and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction ust be completed within three years of the date of this pit Date —j0— Approved by TOWN OF BARNSTABLE LOCATION �`''+�ywP C ;'ecze' SEWAGE # gn26 VILLAGE OnraTeg—' ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) tA- NO. OF BEDROOMS �/� // BUILDER OR OWNER ✓ IdWi LT k01e1 /�,g.,e1 y1tap- PERMITDATE: 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 ® ® 8 e 0 �A OD A R L' TOWN OF BARNSTABLE L ICATiON Co OVA INN ( ,fix_t C SEWAGE # 'VILLAGE GioCiAui ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I.Qd n Ia1 LEACHING FACILITY: (type) Q I (size) fib_00 l NO.OF BEDROOMS_ BUILDER OR OWNER SJ,0 U Mkt l-J of ATE: 12'L` 5 �� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) j* Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching.facility) Nf�' Feet Furnished by - ® t ® Z �1 3 37 0 03, q , - LIS f Bk 22597 FS137 `1620 01-10-2008 at 01 = 42p DEED RESTRICTION WHEREAS, KVIE , NIOU..1 lQ�� }...�Q lylE of nameLr M41k41,41 eA._4TZ0\A Uf- MA (address) is the owner of (o Rl4UAV4 I located (address) at CT�(LV MA (hereinafter referred to as and being shown on a plan entitled "Subdivision of Land in MA, Property of et al, duly recorded in Barnstable County Registry of Deeds in Plan Book 9� , Page ; .Or on Land Court Plan Number NAq WHEREAS, � � iQ �� as the owner of said lot has (owners name) agreed with the Town of Barnstable Board of Health to a restriction as to the number.of bedrooms which can be.included in any home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction of a-single family home on this property, is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document, deedr r ID�IQV� NOW <0 W,v , THEREFORE, , Fbes hereby place the (owners name) following restriction on his above-referenced land in accordance with his agreement with the-Tzwmof , whieh,res#fietion run with the land and be binding upon all.successors in title: (address) y have constructed uppq the lot a hose containing ore than=t-2,2) bedrooms. (owner's na Qu agrees that this shall be permanent deed rn�restriction affecting located on WWI ! ��""`9 , and being shown on the plan recorded in Plan Book /A/!4. , Paged . Or on Land Court Plan For title of ID l'�� see the following deed: Book . 192 ; Page Or Land Court Ce ificate of Title Number._ /IA Executed as a sealed instrument /_day of Owner's si nature Owner' signature Owners signature COMMONWEALTH OF MASSACHUSETTS i Iss Then personally appeared the above-named / / known to me to be the person who executed the foregoing instrument and acknowledged the same to be free act and deed, before me, � Public Notary r 2S DEBORAH A. POOLE. Y M commission expires: Notary Public S! i Commonwealth of Massachusetts �'"—� My Commission Expires April 18,2008 (date) deedr 4, Town Of Barnstable ��•.��:j"E T o Regulatory Services Thomas F.Geiler,Director �tR1Y.S]'Ai$LE, a Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Designer: � � Installer: G/ • C� _ Address: . Address: On f//0 10:r was issued a permit to install a (date) (installer) septic system at �J � � based on a design drawn by (address) � dated (desi er :certify that the septic system referenced above was installed substantially according'to , 'fflie design, which may include minor approved changes such as lat 0a.relocation of the 6tribution box and/or septic tank. I cer.W,Ahat the septic system referenced above was ins+aticd with' major changes greater than-10' lateral relocations of the SAS or any vertical.ireiocation of any componen of the sep6C system)but in accordance with State &Local Regulations. Plan revision of certified as-1;i design' esi t o er to 1: y follow. . �N10 UMgs (Ifistaller'V,SijnZure) B. r �►9AS.ONrM . FQ�ST�P� SgN1 T-A (ll er s Signature) ( $x gne ' Stapp Here) PLEASE RETURN TO BARI,9TADLE PUBLIQ.HEALTH.DIVISION: 'C RTII+' C TE OP', COMPLIANCE WILL °N®T <$E'ISSUED= RM uNrII� F BOTH T$asa _ BUELT CARD ARE RECEIVED lB'YR: `�[E:Bar. STABLE PUBLIC R E G. f D SIOI�1 THANK,YOU. �, Q:FlealtidSeptic/Designer Certificafion'Fonm {, ; n Town of Barnstable P# Department of Regulatory Services ,sT�BtE : Public,Health Division Date $o M.� � 200 Main Street,Hyannis MA 02601 I � Date Scheduled r, P Time /0—T Fee Pd.- - Soil Suitability Assessment for Sewage Disposal Performed By: Witnessed By: LO•CATIGN& GEENEI AL INFC1R1V1 11]OJNY( Location Address � �Y/; n j�r�l`'"'�� Owner's Name �rtl��y� �r, Address L-131`/ / , V ,Clt /Assessor's Map/Parcel: �/� l r /� Engineer's Name Da IO ,"fAWIV NEW CONSTRUCTION 5� ! REPAIR �J/ Telephone# Y� / �� Land Use r r i°�" Slopes(%) 7— Surface Stones �N Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way s— ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 1j, Z i`2,A� C 0 r-- Parent material(geologic) OmLovd4 Depth to Bedrock Depth to Groundwater: Standing Water in Hole: — Weeping from lit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH vVATER,OL Method Used: Depth Observed standing in obs.hole: in. Depth to sell mottles; Depth to weeping from side of obs.hole: In. Groundwater Adjustment.__� ._ ____ft• Index Well# Reading Date: Index Well level__ Adj.factor:_ Adj,Groundwater Level y ICE+.R COI'ATION `TE 1 ce i�n� _ Observation Hole# _ Time at 9" Depth of Perc Time at 6" - Start Pre-soak Time @ +ll' Time(9"-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) 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-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) A(Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel �—, C ,c1 H2 DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel DEEP ORSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other -- Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. f14 _ .Consistency,To Gravel) L2 Flood Insurance Rate Mai): 1 Above 500 year flood boundary No_ Yes Within 500 year boundary Nov Yes Within 100 year flood boundary No +! Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious in erial exist in all areas observed throughout the area proposed for the soil absorption system? 7 If not,what is thWdepthof lly occurring pervious material?Certification I certify that on (date)I have passed the soil evaluator examinatio approved by the Department of Eotection and that the above analysis was perfor d by me consistent with the required training,exper 'se d ex erience described in 310 CMR 15.017. Signatur `Zi Date /Z Q:\.SEPTIC\PERCFORM.DOC I J 1�10\_"'EAL C0 TH OF NIASSACHUSETTS EXECUTIVE OFFICE OF E\\TIRONMENTAL AFFAIRS - DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE't%INTER STREET. BOSTON :ALA 02106 (617) 292.5.5oo TRUDYCORE Secretan- ARGEO PAUL CELLUCCI DAVID B. STRLHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION ii / Property Address: b 114w% C �+-kG f Ui'kG Name of Owner(j61ny1MICt� /o 7 Address of Owner: k*1 Z kof IfL1t, ' Q.4 /` O Date of Inspection: 1-2 z� 50,E`^ \��w,Name of Ins or:(PIase nrrtl t C 1 C vklv 1 am a DEP approved system inspector pursuant to Section 15.340 of T-rde 5(310 CMR 15.000) Company Name: �-jL I u f,-F C 1n v 1►•0 U "-Q- !djC.(_Q Mailing Address: 0 Telephone Number: C_.fEo��E C,�� - !L f—• ZS� 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: xPasses Y _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails A"� Inspector's Signature: ' & Date: A L The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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 ttre system owner and copies sent to the buyer,'if applicable, and the approving authority. NOTES AND COMMENTS �EryfD ,0 �. 1998 TOWN OF AR 4yv S y revised 9/2/98 Page Iof11 n f�� Pr.r.red or Regrlcd Faper f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION (continued) "roperty Address: Jwner: Date of Inspection: INSPECTION SUMMARY: Check A, B, C, of D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are in 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. 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 complying septic tank as approved by the Board of Health. box is due to broken or obstructed pipe(s) _ Sewage backup or breakout or high static water level observed in the distributionP or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). 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 pipers). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Ij .11l revised 9/2/98 Page2oflt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A — CERTIFICATION (continued) Property Address: !� Owner: r' Date of Inspection: i• i C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: r J Conditions exist which require further evaluation by the Board of Health in order to determine if the ystem is failing to protect the public health, safety and the environment. i 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310¢MR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SA AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt maish. j: r/ • i 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 AND SAFETY AND THE 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 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 systel�h 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 I i i r revised 9/2./9.8 Page 3of11 i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART A CERTIFICATION (continued) — f Property Address: Owner: i Date of Inspection: l D. SYSTEM FAILS: `You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CM ''15.303. The basis for this d be contacted to determine what wilt be necessary to correct the failure. determination is identified below. The Board of Health shoul Yes No Backup of sewage into facility or system component due to an overloaded or clogpd 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 over)3ded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Required pumping r Req p P 9 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�'nalyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, am zhecriteria a nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition t o/ above: �. The system serves a facility with a design flow of 10,OA0 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one of more of the following conditions exist: Yes No the system is within 400 feet of a sur ace drinking water supply the system is within 200 feet of a ibutary to a surface drinking water supply the system is located in a nitro n sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system sh upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further informaf n. I'"�`'°"' revised 9/2/98 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST — Property Address:& iwtq6G`j Owner:51AUC11(t" Date of Inspection: 11 21 15� 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. X _ 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. A _ As built plans have been obtained and examined. Note if they are not available with NIA. _ 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: Existing information. For example, 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) 115.302(3)(b)] The facility owner (and occupants,if different from owner) were provided with information on the propermaintenanc-s-0f SubSurface Disposal Systems. revised 9/2/98 Page 5ofII i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION — 'roperty Address: b ,7Olm Owner.*, U WM Date of Inspection: f I FLOW CONDITIONS RESIDENTIAL: Design flo— g•p•d.!bedroom. Number of bedrooms (design):. Number of bedrooms (actual): Total DESIGN flow_ Number of current residents:_ Garbage grinder(yes or no):i Laundry(separate system) (yes or(O:_: If yes, separate inspection required Laundry system inspected es r no) Seasonal use (yes or no):_ Water meter readings, if available (last two year's usage(gpd):�v Sump Pump (yes or no):� Last date of occupancy: , k rl 054c, COMMERCIALANDUSTRIAL Y Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow 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 ins ction: (yes or no)_ If yes, volume pumped: gallons Reason for,pumping: F SYSTEM Septic tankrdistribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed lif known) and source of information: Sewage odors detected when arriving at the site: (yes or no) revised 9/2/96 I1agcb(of II i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corrtirwed) 'roperty Address: 16 Owner: ' Ww1a " Date of Inspection: ;, n`C BUILDING SEWER: t, 1 (Locate on site plan) Depth below grade: Material of construction:_cast iron 40 PVC_other (explain) Distance from Rrivate water supply well or suction line Diameter�_ C� Iments: (condition of joints, venting, evidence of leakage,etc.) JL SEPTIC TANK:i. s (locate on site p an) N Depth below grade:17, Material of construction: Aconcrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: (000 9 W I Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle: 3�✓bi 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: How dimensions were determined: &4A.QAAk 1__ o J 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of Ili_uid level in relation to o tlet invert. truc I irate ty, evid nce of leakage, etc.) _ (� f iN r G 1,v oaw G GREASE TRAP._Q .0 (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explainj 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 9/2/98 page 7orII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ; PART C SYSTEM INFORMATION (continued) _ 'roperty Address: �2 f R UIV Owner: yv Date of Inspection: Lt `ZZ 5 S U , TIGHT OR HOLDING TANK:MZ (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 present 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 BOXAo (locate on site plan) Depth of liquid level above outlet invert:4 c C( 0 `IL �y(�NV e Y t Comments: - (note if level and distri utio i ual,`evidence of solids carryover, deuce of leakage int or out of box, etc.) a Y� 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 9/2/98 PagvNofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) toperty Address: Owner:%U6mw Date of Inspection: (92, SOIL ABSORPTION SYSTEM(SAS)*S (locate on site plan, if possible; excavation not required,location maybe approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: l Sp leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (no a condition of soi, signs of hydraulic failure, level of onding, damp soi, on i on of vegetati etc.) 6 CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth 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.) PRIVYILb (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 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Iroperty Address: Jwner: TkOVA kr--1 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to,at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) i nn i of A3'3Z `1o/ f0`� 0"u, - Sz revised 9/2/96 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) _ roperty Address:& M h FJO J Owner: Date of Inspection: Ll NRCS Report name NCB, Soil Type_ - Typical depth to groundwater USGS Date website visited poQ Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope PG Surface water('-�d Check Cellar c,r) Shallow wells tJO Estimated Depth to Groundwater- Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators. installers Used USGS Data 'Dnes(crirb�e�h1ol w you established the High Groundwater Elevation. (Must lbeA completed) ,n}� h 4 revised 9/2/98 Page 11of11 M cC7 � -# TOWN OF BARNSTABLE L-0CAT10N��1 - NWA1 _SEWAGE # 1 v1Y.I.AGE yl i.�-� .A SSTISSOR'S MAP Ori LOT-.1 C'Cj 1lB INSTALLER'S NAME 'S: PHONE NOL� SEPTIC TANK CAPACITY l0QQ"M _ LEACHING FACILITY:(type) �i ' (size) C NCB. OF BEDROOMS �rRIVATE WELL OR U�WATE BUILDER OR OWNER DATE PERMIT ISSUED: r _ DATE COMPLIANCE ISSUFP: _— VARIANCE GRANTED: Yes No �^ a9 3, IL ASSESSORS_M.A�.'P-pr6:- PARCEL n0.1. No..O..Q........... FF, ..................... THE C9,MMONWEALTH OF MA I SSACHUSETTS BO" RD OF HEALTH ........................................OF.....................................---------------.................................... Apparatiou for Uhsp4.oal Morks Tonstrurtion romit Application is hereby made for a P tO_eornrstrruc or Repair an Individual Sewage Disposal System at: .. ............................. .1. . ........ .... ............... ......... __ �t�.............................................................. ...... ....... ........ tio -A dWs Lot N........... 0. ................................. .......... .. ..... ................................. ................ _._F. ...... ... ............. Owner Address ................ ....................................... .................................................................................................. Installer Address Type of Building Size Lot__-/ 2'�.q._Sq. feet U Dwelling—No. of Bedrooms--_--_-----:�>..........................Expansion Attic Garbage Grinder (AkD Pk Other—Type of Building -----------------_-------- No. of persons............................ Showers Cafeteria Otherfixtures .................................................................................................................................................... Design Flow---------------:::�: ....................gallons per person per—Liquid capacity gallons Length.Wl;�."day. Total daily flow............ _...........gallons. 04 Septic Tank en .. Width(,C/ .... Diameter________________ Depth___.____._..._.. Disposal Trench—NTo. .................... Width ....... Total Length.................... Total leaching area....................sq. ft. -- --------- Seepage Pit No------/--- --------- Diameter----&Z......... Depth below inlet---67........... Total leaching area.-ZAtZ.).....sq. ft. Z Other Distribution box (.111'r Dosing tank ( ) Percolation Test Results Performed by-------- --- Date........ 1_4 " ------------------ ............................... Test Pit No. I.....Z------minutesperinch Depth of Test Pit.................... Depth to ground water.,A (T4 Test Pit No. 2................minutes per inch Depth of Test Pit............_....... Depth to ground water_.__..__-__-__-..--__--..............................I............................................................................................................................... 0 Description of Soil--..- .......... n�......Stnn__:5en-/L-���.................................................. ................... ......................................................... --------------------------------------------*----------------------------- .................jk ........................-------------­----­----- _)L........ ------------------------------------------------------------------------------------ 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'L!1=:,, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i��the board of health. Tf� .................. I ------61--------------­--­---- --- --- ---------------- --------***---------------- D t Application Approved By-------- ............ . ........................................................... Date Application Disapproved for the following reasons:............................................................................................................... ........................................................................................................................................................................................................ ­�S- -- —>— I Date PermitNo......................................................... Issued....................................................... Date No.4,7�S... Fmc............................. } THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................... ---.........OF..........................------....... Appfiratiun for Uiipuial Worka (nun itru.rfiurt Vautit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at ... 7% . ------� ------------------------------------------ L-catioc - ddress or Lot 11 - ...................%�T" �� jc r �------------------------------ ....c��U _ Owner Address Installer Address U G (/l_q/Type of Building Size Lot_�_-�-'- .-l _..Sq. feet ., Dwelling—No. of Bedrooms...............�__•..........................Expansion Attic ( ) Garbage Grinder (il/ Other—Type of Building No. of persons............................ Showers a YP g ------•--•------------------ P ( )--- Cafeteria ( ) Otherfixtures ...............•-----................_..------------.......---------------•--------...................-•-•-••-•----- ......•••. W Design Flow............. .....................gallons per person per day. Total daily flow-----_.....................gallons. WSeptic Tank—Liquid capacit�p72 ..gallons LengthH-_•4r�..... Width...�o....._ Diameter________________ Depth................ x Disposal Trench—No. .................... Width_7..______.____..... Total Length............................. Total leaching area.........._---------sq. ft. 3 Seepage Pit No-----------------/.... Diameter... ._-.._-__--_ Depth below inlet_.�r?. � ._.._...._.. Total leaching area. ......sq. ft. 4 Z Other Distribution box ) Dosing tank ( ) `-' Percolation Test Results Performed by....... ....................................... --------- � Test Pit No. 1... ........minutes per inch Depth of Test Pit./ .. Depth to ground water:!A�b_`,10re'� (Z., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+' -------------------------------------------------••---�: O Description of Soil.... ........... -.6��t'4....±.....-=�`~��-- s C-?f�' r ------------------------------------------------------------- : .. ``-�-.-fir•��------------------------------------•----------------.._..-----------•._................ V 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-• - 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. -`Signed............. / Application Approved By...... s�___ Date Application Disapproved for the following reasons----------------•-•--......_..----...------------------------•------------------•----------------------•-------•- --•---•--•-•-•--••••-•--••••--•-•••-•----••--•--•-••••-•-••....---•-•-•---••-------------------••------•••---•-------•-••--•••••---•••-----•-••--•--------••••-------•••-------••-•-------•-------•---- .. —•— ' Date PermitNo. ........... ...................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................................OF..................................................................................... Tprrtifiratr of Tampfinnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( } by----------------------------------------------------------------------------------------------------------------------------- ------ ----Install (.............................................•---.-........._...----- at _= -< --------------- has been installed in accordance with the provisions of iL41,4— Hof The State Sanitary C{de ts, dezribed in the application for Disposal Works Construction Permit No �__�........____2__•....... .....dated---------- -- -�'__.--�-f�_.........._._... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL rF�UNCTION SATISFACTORY. DATE.•....--•------...V... 1S.-.(IS/--------------•-•--------•--- Inspector........;......... � �.D................................................ L THE COMMONWEALTH OF MASSACHUSETTS _- -- BOARD OF HEALTH tj, �l.}' f Tom, �. .._ ©F.. �r0. l = ..::. FEE............2........... Dispnoa1 19orkv Tunotr ion ami . Permission is hereby granted-----== = -t r---•---. ---------------------•-•--•r-----------..........-----....-----...-•--••-----•. to Construct ( ) or Repair ( ) am Individp-1 Sewav Disposal System at No � ..,.,, � L P--1 j`5.-� -�... i\ A , y ,t 'j.c � I;�. ". �. := ......................•----.....------•----...---------------•-•-••........................ street c-y'� -- as shown on the application for Disposal Works Construction-Permit fNo::_'_:.` ,_:_.. Dated._.._=;��.% .......................... .. -- T`ATE i Board of Health . Al E-•----•-••........ ....... == — ..................•-••-•... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS - IYAe �7r-e*yAl (47 -- _. 8 8 c-;W- --'I 10 9s 2_ q = I9g f P?-IA his j r n/,e �tN of MAR ��L }y MORAN ASSESSORS MAP - __ - . ---- I I TEST HOLE LOGS4- PARCEL.:-- - 4/0 1 1 NOTES: FLOOD ZONE: SO I L EVALUATOR : Ayl , MA� 6�6 WITNESS .' ► 14t i )c9. -1 Q REFERENCE: C 71-1 1) The installation shall comply with Title V and Town of Barnstable Board of _+� . .. ._ =. ' �L-C�/ DATE: i L �1'��• � _ Regulations. Health Re<r =..l t1 , G, C �/ PERCOLATION RATE: - u1 &__ 2) The installer shall verify the location of utilities, sewer inverts and septic " �,1 components prior p p or to installation and setting base elevations. I TH- 1 TH-2 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first Gl�� A LD A U, *too two feet out of the d-box to the leaching shall be level. �+ �N0VA f _ t I 4) This plan is not to be utilized for property line determination nor any other IVIVAALf SakAV purpose other than the proposed system installation. ( 1�4 5) All septic components must meet Title V specifications. � -- -- -. 6) Parking shall not be constructed over H10 septic components. LOCAT I ON MAP(f'; , 7) The property is bounded by property corners and property lines. d 8) The property owner shall review design considerations to approve of total design flow and number of bedrooms to be considered for design. Receipt I / of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall Y� { 4u( �!� p [ uDt be removed along with contaminated soil and replaced with clean washed sand per Title V specs. �0 10)System components to be 10 feet from water line. Sewer lines crossing the SEPTIC SYSTEM DESIGN water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if applicable. 11) if a garbage grinder exists it is to be removed and is the responsibility of the FLOW EST I MATE owner to ensure such. ' 12)The installer is to take caution in excavation around the gas line. BEDROOMS AT GAL/DAY/BEDROOM GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer + ) 1 ti ►��� l � ` . /W2Tz lines exiting the dwelling prior to the installation. -- C Crrtt"k SEPTIC TANK R r GAL/DAY x 2 DAYS - ' GAL 1 � - --� USE E GALLON SEPTIC TANK A SOIL ABSORPTION SYSTEM _- Pq I t� �' �.+.......' Vi c, { f ( SIDE AREA: Z 2�45 X pry` r .,t aE,i - ' '' ' BOTTOM AREA: I e � D = 2530 SEPTIC SYSTEM 3ECT10N wv�c Ott, p a DAV{D c', .;aa ,,,�ti:���<., .�{ i B y t�?4. JAB . _ MAS6�j r _ ` p No. 10C.6 y BOTX__ �35) b o 7 a Sr�Rti GAL s� SEPTIC TA K + ° f -� �' �� ° 53 D QTw 41 __.. w.qy �JZ4q_170A/ lk5 . ..__,. .. T lttE, Lam` 2 .. 77 cep H Zp l �. b } SITE AND SEWAGE PLAN GI �" L� �/ 5 LOCATION . � �Q ! Vim . �MM�- � C'�-Lc v�...�1 T7d 414 JIM �. C/Z18 'Z ' 7 .�1 v A PREPARED FOR :�"Co `JP6f ., tS `CG �7j3pk SCALE 0 . DAV I D B . MASON I; DATE: /2 -Z J ` r DBC ENVIRONMENTAL DESIGNS W EAST SANDWICH MA 000 DATE HEALTH AGENT ( 508 ) 833- 2177