HomeMy WebLinkAbout0022 MERIDETH WAY - Health 22 MEREDITH WAY, CENTERVILLE
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UPC 125n3 , , ;'
No
HASTINGS, VN
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Rpplitation for MispoBal *pstrm ConstrUCtion Permit
� r
Application for a Permit to Construct( .) Repair(If"Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No.
C&V+-r✓V11 Y culti�� ,e .
Assessor's Map/Parcel 4 14 5
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
`1�S\&�,, A )3 cow N T_-� S o9� e,,4 yr - 5-3 J
Type of Building:
Dwelling No.of Bedrooms .3 Lot Size 1 G,f6 2 sq.ft. Garbage Grinder( )
Other Type of Building jnUySY No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 'j:3 0 gpd Design flow provided �3�/T. 9 gpd
Plan Date /,2 i y/// Number of sheets Revision Date
Title
Size of Septic Tank 2r1 f c Type of S.A.S. A& ( AL
Description of Soil A�•-
Nature of Repairs or Alterations(Answer when applicable) f ni S fG /1 ✓✓es 5,A, S
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 by this Board of Jlealth,
Signed �'— Date
Application Approved by `- Date
Application Disapproved by Date
for the following reasons
Permit No. f Date Issued r ' f
n
X
No. y�dl ' 1 _ - Fee
THE COMMONWEALTH OF M4SA HUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABE, MASSACHUSETTS Yes
ftplicati n for Disposal 6pstem ConstCUrtion i3ermit
Application for a Permit to Construct( ) Repair(,,,,,upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 9 2 Mr!r 0e P- (,Jc.Y Owner's Name,Address,and Tel..No.
��Yr✓Vr�l Y Lot.,\fi
Assessor's Map/Parcel � ( -� 1 S � �
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
D,05\e,5 A, j fl,,c3 to 1 N c
;09•kCo--7i5-5 ,/ks S •yam- 5-3)
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size /G, 6 2 sq.ft. Garbage Grinder( )
Other Type of Building VUv5Y No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) :3'�p gpd Design flow provided -3 415, y gpd
Plan Date /2h6 // Number of sheets `g„ Revision Date
Title
Size of Septic Tank G xrs Type of S.A.S. Ar :3
Description of Soil
I
Nature of Repairs or Alterations(Answer when applicable) A/S fG
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 by this Bo�ofalth
Signed Date /Z S /
Application Approved by Date 1.2 -/S -
Application Disapproved by Date
for the following reasons
i
Permit No. a0 L 2- Date Issued S -
---- --- __ -=----- _ = _____. =_ -_ _ === _ =
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certifitate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(Vl-- Upgraded( )
Abandoned( )by El, % I e- A 17(caw L r-C
at 2 2.. /LC r✓, e,).r i i s kAJ ^ -t/✓,, P has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.a0I �I� dated
Installer A S�rcg s-u,- 1-1 ri c Designer r
#bedrooms Approved design flow y S, g gpd
The issuance of this permit shall not be construed as a guarantee that the system will-funcc-onsde igned.
Date 2�l 5- // Inspector
--------------------------
Fee
THE COMMONWEALTH OF MASSACHUSETTS `
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction 1ermit
Permission is hereby granted to Construct( ) Repair(✓r— Upgrade( ) Abandon( )
System located at 2 z til r ✓i Jr t 'A L O-- rv, I Y
r
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions. �----
Provided:Construction must be completed within three years of the date of this permit!' `
Date _ Approved by �'
TOWN OF BARNSTABLE
LOCATION - r SEWAGE# `a011 - 4;LLI
VILLAGE 6"J-p( ASS SSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. 1Q�• Bk ` t�t�r�-,t c
'SEPTIC TANK CAPACITY L-y-5 f-I ki
LEACHING FACILITY:(type) Afc ,SG !;C/d-20 (size) �A&Sf\60
NO. OF BEDROOMS
OWNER
PERMIT DATE: 1A COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. -Sete INN 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 Zma-
„� . ,
`SAC K �
J —�3 3—67, r o
y y
�a
CITY/TOWN;
APPLICANT: -P,A
2.Z �'.Gwt 1Nc
ADDRESS:; FF
DESIGN-FLOW:. gPd
REVIEWED BY;
DATE: U
NIA OK. _NO
Legal boundaries denoted [310 CMR 15.220(4)(a)] i✓
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
components) 310 CMR 15.220(4)]
Easements shown 13.10 CMR 15...220(4)(b)]
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 dirpensions of system components and reserve areas. ✓,
310 CMR 15.220(4)(e)]
System Calculations 310 CMR 15.220(4)(f)] ✓
daily flow
septic tank capacity (required andprovided)
soil abso Lion system(required andprovided)
whether system designed for garbage grinder ✓
North arrow 310 CMR 15.220 4
Existing and ro osed contours 310 CMR 15.220 4 ✓
Location and log of deep observation holes (existing grade el. on
each test) [310 CMR 15.220(4)(h)]
Names of soil evaluator and BOH representative [310 CMR
15.220 4 h and i
Location and dale of percolation tests (performed at proper
elevation?) [310 CMR 15.220(4)(i)]
Percolation test results match loading rate? 31.0 CMR 15.242]
Certification statement by Soil Evaluator [310 CMR 15.220(4)0)]
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 9
f
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 suppliesand gravelpaqW ublic water.supply.
within.250 feet of the proposed-s "stem location in the case
within 150 feet of the:proposed system location in the case
of private water "wens
Location of all surface waters and wetlands located up to 100 ft.
beyondAsetbacks fisted 1'in 30"CMR 15.21 Land any.:catch:basins.
located within 50.ft 31Q=CNM 15 220 4 -,
Waterlines and other subsurface utilitiesaocated [310 CMR
15:220 4 m water line cross see 310"CNy 15:211(4)[1 ,
Prof le of system showing.invert:elevations of all.system
com onMts and the"hottom of the SAS 310 CMIZ15.22. 4 .o,
Stamp of desi .er 310 CMR 1 5.220 1 andy310 CIVIR 15.220 2'
Stamp of Registered Land Surveyor.(required if construction
activities within ft. of lot lute 310 CMR"T5 22Q 3
Test Holes adequate (two in each of the primary and reserve
unless trendies as permitted-in:310 CNM, 1.5.102(2)'or as
a roved for an u tide under LUA at 310 CMR-`1=5'A05 1" k`
Test"hole adequate to demonstrate four feet of suitable material?
310 CNM 15.1 3(4
Test"Holes adequate.ta confirm"adequate groundwater separation?
310 CMR 1:5.103 3
13, hmark.within,.5045' of s stem. 310 CMR.15..2.20 4, "
Materials specifications noted? [various sections of 310 CMR
15.0001,.. f
System compongnts not> 36".deep (unless Local Upgrade
A "royal or LUA:re"uested)" 3:10 CMR ,
Addess Sheet 2 of 9
N/A OK NO
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
15.228(l)]
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 descriped 310 CMR 15.227(5)) or permitted for
upgrades under LUA 310 CMR 15.405 1 k
Minimum cover .".(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)(0]
Three access coyers (inlet and outlet must be 20" or greater) -
middle access at least 8" 7/07 310 CMR 15.228(2)] L/
Access to within`6 of grade -one port for systems<1000gpd,
two fors sterns;>1000 gpd 310 CMR 15.228 2
All at-grade covers secured to unauthorized access? [310 CMR
15.228 2
> 10 ft from buil foundation 310 CMR 15.211 1
Buoyancy calculation Required/Done 310 CMR 15.221 8
H-20 Where a rop riate? 310 CMR 15.226 3
Setbacks from resource.s 310 CMR 15.211 ✓
Required when ether 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.1.5.224 2 .and _3
"U" pipe through or over baffle, outlet of each compartment with
as baffle or approved filter 310 CMR 15.224 4
Address Sheet.3 of 9
F
N/A OK NO
Located at least ten feet froiu any water line? [310 CMR-
t/'
15.222 2
I
Disposal piping at least 18" below water line(when water and V
sewer cross, see 310 CMR 15.211 .1 1 :
Cleanouts r uired/ rovided ? 310 CMR 15.222:8'
Thrust blocks s ed in force mains? 31 0 CMR 15.221(6)(c)]
Slope of sewer line not less than 0.01 (1/8"/ft) 0.-02 preferable
V/
1340 CMR 15.2 ° .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)]
Siphonproblem/ eachfleld below pump chamber
Endca"s or vent manifold ilied? =�
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 (31.0 CMR 15.251(5) specifies various pipe
types allowed
r
Stable compacted base [310 CMR 15.221(2) and 310 CMR
15.232(2)(a)]
Splash plate'or bale tee required on inlet/provided?(when
pressure sewer to d-box or steep pitch of gravity sewer) [310 ,f
CMR 15.323(3)(a)]
Riseraf deeper than:9".. 310 CMR 15.232 3
Inside minimum dimension 12" f3,10 CMR 15.232 2
Minimum sump 310 CMR15.232 3 e
Watertight cover if<2000gpd)' waterproof manhole if>2000gpd
310 CMR 15.232(3)(d)]
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 3.10 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 unio must have two pumps operating in lead-lag i
mode 310 CMR 15.231 b and 8 1
Stable Com Bd Base 310 CMR.15.221M] I
Address Sheet 4 of 9
I
f
Buo anc. calculations needed;?Provided? 3IQ CMRFLS 221 8
Address Sheet,5:of 9
r f
y
N/A OK NO
Calculations correct?
4 feet of naturally occurring material demonstrated? [310 CMR
15.240 1
Required separation to oundwater? 310 CMR 15.212
Aggregate specified as double washed 310 CMR 15.247(2)]
System Venting required/provided?-(system under driveway or
>36" d 310 CMR 15.241
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) f 310 CMR 15.211(l)[4] and
Guidance Document
Chambers and Gal. in trench configuration supplied with inlet
every 20 ft. 310 CMR 15.253 6
Each structure vYith one inspection manhole(if>2000 gpd must be
tograde) 310 CMR 15.253 2
Aggregate 1' minimum-4' maximum: 310 CMR 15.253 l
2' sidewall credit maximum 310 CMR 15.253 1 a
In bed configuration, inlet evM 40 N. ft. 310 CMR 15.253 6
Width 2' minimum 3' maximum P10 CMR 15.251 1 ✓�
100 feet-maximum length 310 CMR 15.251 1 a i/
Minimum separation 2x effective depth or width whichever greater
3x if reserve between trenches 310 CMR 251 1 d
Situated along cpntours 310 CMR 15.251(2)]
Breakout OK? [ 10 CMR 15.211 1)[41 and Guidance Document
NOR 11,
minimum 2 distribution lines 310 CMR 15.252(2)(a)]
Maximum se ar,.u .between lines 6' 310 CM R15.252(2)(d)]
Maximum separation between lines and outside of bed 4' [310
CX% 15.252 2 e 11
Aggregate depth below discharge pipes 6" minimum, 12
maximum. 310 CMR 15.252 2
Separation bet we,bn beds 10' rr}ii*,num. 310 CMR 15.252 2
Bottom area used in calculations only 310 CMR.15.252(2)(i)]
Address Sheet 6.of 9
N/A . OK::;. NO
Pressure Dosed System ? Provided pump and piping calculations
as required 310 CNIR 15.220(4)(r)]
Pressure dosing fequired on all systems>2000gpd or alternative
systems under remedial approval [310 CMR 15.254(2) and I/A
Remedial Use ovals
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 barripr and/or retaining wall ? Guidance Document
Impervious bamer installation must be supervised by designer
310 CMR 15.2552 b
Retaining wall must be designed by Registered Professional
Engineer 310 CW 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 10 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
Was DEP Approval Letter provided and/or have you
reviewed the letter for conditions?
Is the technology being properly applied and does it meet all
DEP Approval Conditions?
Is there a g1ote on the plan regarding the requirement for /
perpetual maintenanceagreement?
Any alarms involved on separate circuits
Did the applicant submit an operation and maintenance
manual?
Has lic�nt submitted a co of a maintenance agreement.
OEM
Are the variances listed on the plan? [310 CMR 15.220
4
RLS Stamp-necessary on plan if a component is within five
feet of propn[ine 310 CMR 15.412(4)]
Address
Sheet 7 of 9
New aongftdtion.or mereased flaw proposed:-.[Refer to.310
ClR}15#t4.iq:
{
Address S '8 of 9
tl!K.._
Is the system in a Designated Nitrogen Sensitive Area(Zone II for
a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and
310 CMR 15.21¢ - also refer to Policy regarding upgrades of such
existing systems]
Is the system proposed on the same lot as served by private well ? ,
310 CUR 15:214 2
Are the nitrogen loads proposed in compliance? [310 CMR
15.211w...:
OEM
Pumping to septic tank ? 310 CMR 15.229
Shared System 10 CMR 15.290
1
i
Address Sheet-9.of 9
Town of Barnstable
m,q Regulatory Services
Thomas.F. Geiler,Director
Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Date: /A b Sewage Permit# 2-011-q Assessor's Map/Parcel 19 14
Installer&Designer Certification Form
Designer: >✓� ; rt Q,a,r.,� War 4 s, Inc . Installer: A ro—^, 1 c
Address: z W. Cc,, 5 S e lel 12_*4- Address: �'O � ►`{.S
4-4 l� M� az�yy �°'�� G�26;2
On 5D-A �b �r� 1,.c t was issued a permit to install a
(date) (installer)
septic system at 22 Mer cr�c� V`?u..,/ 6iir�,01/1 lac based on a design drawn by
(address)
Fe'k--r- �Z� 'P 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. Stripout (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' 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
certified as-built by designer to follow. Stripout (if required) was ' cted and the soils
were found satisfactory. H OF'
qc
PETER T. �N
staller's Signature) MCCENTEE
9 No:35109
Q
(Designer's Signature) (Affix Design re)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION.. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
q:\office forms\designercer ification form.doc
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~�No............ - F IB2 fir...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H.,E.A►LTH
............. OF...............
Applir ation for Uhip o al Works Tomitrurtion pamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location-A dress or Lo
---
W Owne •----Address
_ ................ 1.. t
a Installer A dress
Type of Building/ Size Lot__ _.�_ __`�...___Sq. feet
Dwelling t—No. of Bedrooms......... .................._----------__Expansion Attic ( ) Garbage Grinder (10)
Pk Other—Type of Building WT.L_4LJ[------ No. of persons____________________________ Showers — Cafeteria ( )
a Other fixtures -------------------------------- -- -
W Design Flow--------- _________________________gallons per person per day. Total daily flow______�31�_________._.__.________gallons.
WSeptic Tank-L Liquid'capacity_ _.gallons Length................ Width---------------- Dia __.-_-__.__----- Depth................
x Disposal Trench—No. ____________________ Width.................... Total Length------_--_------ Total leaching area....................sq. ft.
Seepage Pit No-----------l-------- Diameter________________ Depth below inlet...... Total leaching area__.`l._�qf......sq. ft.
Z Other Distribution box ( / ) Dosin tank ( )
'„' Percolation Test Results Performed by _ �y�( . -•'•.----- .-�,rV49 ,71-:e-5__._ Date_. `.__7�!-----------
Test Pit No. 1----------------minutes per inch Depth of Test Pit_____________.. _ Depth to ground Water.....................__.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_______________________.
......................................................... -------------------•----
ODescn Description of Soil_________ ................................---• ----_----------- -•-- -�--�-••.-------�-.------•--•----•-----•
W -------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------=-----
UNature of Repairs or Alterations—Answer when applicable_---------------------------------_..........................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Se
wa Disposal System in accordance with
•-
the provisions of TI:IL 5 of the State Sanitary Co — ie undersi
mT gne t11er agrees not to place the system in.
operation until a Certificate of Compliance has bee • sue a ar ealth.
S' e ----- ----- .................. ..............................---•-•-•-- ................................
Date
Application Approved BY _rx 2 _ � t ---------------------•-- �..... --�-v----
Date
Applieation Disapproved for the following reasons___________________ •--------------------•-•-------------------•-------------------- ----------..._
....------•------------------------••---•----------.-----•---•••-'------------•-------------•----------•--•---•---•----------.......................................------..........................
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS;
k
j BOARD OF HEALTH
............. ......OF".... . .... ................................
%arrutira tr of TumpftFanrr
T IS I ..G Y That the Individual x Disposal,Sy �lf constructed ( or Repaired ( )
b3�-•- -. ------•--- ----------------------------------------------------
Install
er "
at __XA4. - 4-- = ( � �'� -------------------------------- ---------------------------------------•--
has been installed in accordance with the prow' ons of T 5-of The State Sanitary C de as described n the
application for Disposal Works Construction Permit No. ,,r_:___._41__ ....
.... ............. dated----- '_- ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �f� 1 y
DATE...... - "T- � ;` Inspector b° . -LrrR ;' `s 51~a ?
. --- _• -._..._._
THE COMMONWEALTH OF MASSACHUSE-T_TS
BOAR F HEALTH ~
7_7,0'441.........OF.......1 =r
No.........----•V...' FEE........................
Permission Alfiereby granted_.___
to Constru f ( ) or Re ( ) 4 ivid�al/Sewage D �sal tern f
f „ Street _
as shown on the application for Disposal Forks Construction Permit Igo_____________ ated__�__.2.-_� _.' �_:__.._.
„4..
__�LrF�r _•r N ::' _____________________„
/ ... I Board of Health O
DATE
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
Town of Barnstable P# 3g
�TMe
Department of Regulatory Services
.,OWAB , : Public Health Division Date 1 'Z2J u l
KAM
bsp.��� 200 Main Street,Hyannis MA 02601
Date Scheduled / / Time ® Fee Pd. 0C)`
Soil Suitability Assessment for Se e Disposal
Performed By: J Cif/' l�C- �,.�� —(_� 1�r. Witnessed By:
LOCATLON& G'ENERAL-INFORMATION
Location Address 22 filer,_1 w Owner's NZ, h e I 4 LI cAl nP
Addressti mS Q
Assessor's Map/Parcel: $ lA q' 01 Engineer's Name
NEW CONSTRUCT10NQQ REPAIR Telephone# -�5-I6 T- 7 -7 ? (p T
Land Use �i i�il(jlc� ¢' ^�I I ° 1i" Surface Stones slopes � —
Distances from: Open Water Body Possible Wet Arej;�3! 'q ft Drinking Water Well
Drainage Way T� ft Property Line ft Other ft I
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
z
. 2Y Gib
I
v
Parent material eolo i S W'
(g g�s) Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face o _
Estimated Seasonal High Groundwater t
N.3
DETERMINATION.FOR:SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: y;,- r l
Depth to weeping from side of obs.hole: in. Groundwater Adjustment LftJ J
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level r'
Observation PERCOLATION TEST Date Time
Hole# F CrC 01^ Time at 9"
Depth of Pere ` `L k Time at 6"
Start Pre-soak Time @ ` ?�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) (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.
Consistency,%Gravel)
K s
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 OBSERVATION HOLELOG- Hole Al
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
Flood Insurance Rate Map:
Above 500 year flood boundary No Yeses \
Within 500 year boundary No Yes
Within 100 year flood boundary No! Yes
Depth of Naturally Occurring 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 pervious material?
Certification
I certify that on �date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required riiexpertise and experience described in 310 GMR 15.017.
Signature 44ADate , t3I )
Q:\SEPTIC\PERCFORM.DOC
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
�) DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. MA 02108 617-292-5500
WILLIAM F.WELD TRUDY COXE
Governor
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: 22 Meredith Way, Centerville Address of Owner: Linda Peterson
Date of Inspection: /l—A/-17 7 (If different)
Name of Inspector: Wm E Robinson Sr
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: W111 E Robinson Septic Serv; p
Mailing Address: PO Box 1 089 , CentArvi 1 1 `, A4A 02632
Telephone Number, 5 0 8 7 7 5—R 7 7 A
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 trainin expenenc oper function and
maintenance of on-site sewage disposal systems. The system:
SPasses
Conditionally Passes �( y
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: eej Date: 7
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 owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
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:
B] STEM 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.
Indi ate 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 1 of to
DEP on the World Wide Web: http:ltwww.magnet.state.ma.us/dep
e'j Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 22 Meredith Way, Centerville
Owner: Peterson
Date of Inspection: //—dL/—g-7
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
Q C] FUR HER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
ublic health, safety and the environment.
1), .SY•STEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS 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
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 22 Merbdth Way, Centerville
Owner: Peterson
Date of Inspection:
] SYSTEM FAILS:
Y must indicate ei;!,er "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 1/2 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] LA E SYSTEM FAILS:
You mu t indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
he system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
ublic 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 II of a
public water supply well)
The ownE r or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirem nts of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 22 Meredith Way, Centerville
Owner: Peterson
Date of Inspection: //—a0—y 7
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.
_ 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.
4 _ 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.
L _ 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) Page 4 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 22 Meredith Way, Centerville
Owner: Peterson
Date of Inspection: 7
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 3 3 a g.p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents:
Garbage grinder (yes or no):_Z- O
Laundry connected to system (yes or no):Y"3
Seasonal use (yes or no):A- IJ
Water meter readings, if available (last two (2) year usage (gpd): 1995 - 68, 000q
Sump Pump (yes or no):A-6 1996 — 28, 000g
Last date of occupancy: ;L/^Q '1
C AMERCIAUINDUSTRIAL•
Type f establishment:
Design flow: gallons/day
Grease rap present: (yes or no)_
Indust4 I Waste Holding Tank present: (yes or no)_
Non-sa itary waste discharged to the Title S system: (,yes or no)_
Water eter readings, if available:
Last ate of occupancy:
OT R: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECO S and source of information:
Syste pumped as part of inspection: (yes or no)_A�e J
If yes, volume pumped: gallons
Reason for pumping:
TYPE 0 SYSTEM
1/ 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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: ,=S
r �
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/25/97) Page 5 of 10
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
BUIL NG SEWER:
(Locate n site plan)
Depth b low grade:
Material of construction: _cast iron _40 PVC _ other (explain)
Distan from private water supply well or suction line
Diamet r
Comme ts: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK: 1/
(locate on bite plan)
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)
Dimensions:
Sludge depth: </
Distance from top of sludge to bottom of outlet tee or baffler
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: ® 14 '�—
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.) /Q o -0 Q
(3 i1
GRE E TRAP:
(locat on site plan)
Depth elow grade:
Materia of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimen ons:
Scum ickness:
Dista a from top of scum to top of outlet tee or baffle:
Dista ce from bottom of scum to bottom of outlet tee or baffle:
Date o last pumping:
Comme t5:
(recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integri , evidence of leakage, etc.).
CIL
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 22 Meredith Way, Centerville
Owner: Peterson
Date of Inspection: //—Xf— 4 '7
HT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(lo to on site plan)
Depth below grade:
Materi I of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dime ions:
Cap rty: gallons
Desig flow: gallons/day
Alarm level: Alarm in working order _ Yes; _ No
Date f previous pumping:
Corn ents:
(condi ion of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:k
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of soliA carryover, evidence of leakage into or out of box, etc.)
A-y a
PUM CHAMBER:_
(locate on site plan)
Pump in working order: (Yes or No)
Alar s in working order (Yes or No)
Com nts:
(note c ndition 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: 22 Meredith Way, Centerville
Owner: Peterson
Date of Inspection: ���d—�`7
SOIL ABSORPTION SYSTEM (SAS):_
(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:
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 ve'getat�Pn� etc.)
CE POOLS: _
(loca a on site plan)
Numb r and configuration:
Depth- p of liquid to inlet invert:
Depth f solids layer:
Depth f scum layer:
Dimen ions of cesspool:
Mater Is of construction:
Indic tion of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comm nts:
(note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRI
(Io a on site plan)
Materia of construction: Dimensions:
Depth o solids- _
Comme s:
(note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 22 Meredith Way, Centerville
Owner: Peterson
Date of Inspection: cl 7
V—
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
4g 13 jC
3�
VJ
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 22 Meredith Way, Centerville
Owner: Peterson
Date of Inspection: l�a�"4 '7
J�
Depth to Groundwater 1A Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
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 dV jiS ) Lt/c:l�S
� r
(revised 04/25/97) Page 10 of 10
...........
THE COMMONWEALTH OF MASSACHUSETTS
I
BOARD OF HEALTH
.................OF...............................-........-.......... ................................
Applir ation for Uhipatial lgvrk� Tontitrurtion Urrmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
S tem at,
.............. ....V*Y...............40Z......:*,?...............
lbocation-Location A dress o I No,....... .................._I
................ ........... ..........J.1 .........
O��ner 's
............................. .. ...... ---------- ----------------------------------
Installer Address
Type of Building,,,— Size Lot.-A/e ......Sq. feet
rooms.........3................................Expansion Attic ( , )Dwelling—No. of Bed Garbage Grinder (11,14)
44 Other—Type of Building ...... No. of persons............................ Showers Cafeteria
P4Other fixtures .....................................................................................................................................................
Design Flow......_-
.........................gallons per person per day. Total daily flow-------�132........................gallons.
IY4 Septic Tank L Liquid capacity.1W.gallons Length................ Width__............._ Diameter___-____________ Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No-----------/-------- Diameter-----�----------- Depth below inlet......4.......... Total leaching area-9IO......sq. ft.
Z Other Distribution box Dosin tank - 2-7- 7C
Y.? X1
Percolation Test Results Performed b- . .....::7:....�4��4.21.A..... Date..---- ......... .... .......
0-1 Test Pit No. I-----------------minutesperinch Depth of Test Pit-________--__-. Depth to ground water------------------------
Test Pit No. 2................minutes per inch Depth of Test Pit-_______--.-____---. Depth to ground water______.............._._.
P4 ................... --- ./..... ---?
...................... 2--------- -----------:' ----------------
0 ..........
.t........ .................... .........Description of Soil.......... ...-;z..m- .....................2:.... .. ..... ...
...*-------------------*-----------------------***-------------*---------------------*------------------------------------------------I--------------------------------*-------------------------------
-------------------------------- ....................................---------------------------------------------------------------------------------------------...................................
U Nature of Repairs or Alterations—Answer when applicable---------------- ...............................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual SewaK__"�Disposal System in accordance with
the provisions of'TTLE 5 of the State Sanitary C — e undersigne t er agrees not to place the system in
operation until a Certificate of Compliance has bee sue e ar ealth.
S* e .... ...... .... .................. ......................................... .............................
Da
te
t..,14a e
....................
Application.Approved By... ',- ai. . ... .... . .. .... .... .. ........................ ......;Z
Date
Application Disapproved for the following reasons:.................................................. ............................................................
....................................................................................................................................................----------------------------------------------------
Date
PermitNo--------------------------------------------------------- Issued.......................................................
Date
No.. ...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................OF.........:......................................................
Appliratiou for Dhipaiial Morko Tomitrurtiou rjernfit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
S :stem at:
...............
............ ......
Location A dress or Lot No.. .. ........ ..... _3. .........
........... .... .. .......
Owner
wne Add—
.........................
..................
Installer Jdr
Type of Building Size Zsot..A.� ......Sq. feet
U ki 1�1111 P
1.
Dwelling No.No. of Bedrooms.........3................................Expansion Attic Garbage Grinder
A/A
04 Other—Type of Building )k0F1.Li.JV...... No. of persons____________________________ Showers Cafeteria
04 Other fixtures -----------------------------------
--------------------------------------------------------------
< ': .. __......._..__.__.._....gallons.------------*****--------
Desij�n-.Flow....... .........................gallons per person per day. Total daily flow---
1:4 Septic'., "Flow.....,
-4 Liquid capacityl&.gallons Length................ Width................ Diameter------------_- Depth.....__.._......
Disposal Trench—No..................... Width..............._._.. Total Length_................... Total leaching area....................sq. ft.
�4
Seepage 0 Alt No._-__----_-)........- Diarneter._-.,?----------- Depth below inlet------4.......... Total leaching area.-94?�......sq. ft.
* �i
z Other Distribution box Dosing tank
as 7 3 74.X. .. .... -C Percolation Test Results Performed I _------?4..rV��_A$--- Date..A/���?7---------/
Tf ,� . ..........
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........................
.................... . ../ ,
..... --- ---- ----1;�z-------------------- zz-------------- .................
z 0 Description of Soil.......40.— .. ............................... ...
......................................... .......................................................................................................... ........................................
U
W
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable------7_---------------------------------------------------------------------------------------
-----------------------.............................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual is Sewy posal System in accordance with
F
the provisions of'TTL— 5 of the State Sanitary Co e undersigne ),Der a grees not to place the system in
operation until a Certificate of Compliance has bee i sue e b r o alth.
SISH24..... .. ..... . ... ................ ......................................... ................................
d Date
Application Approved By.... . . .. .. ........................ ......
Date
Application Disapproved for the following reasons:................ ................. ......................................................-----------
................................................................................................
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS_
BOARD;�F HEALTH
............. ....... ........OF...... ..444. 1....................gt
(9rdifiraft, xzf Toutphaurr I
71 is IZY.,-That the Individual e_,DisposalASystel5k constructed 1_-�or Repaired
....................................................
------- ......Installer
a ..... ...... .. .....................................................................................
7Z
has been installed in accordance with the pro ons, o il 5of The State Sanitary C de as described In the
d A---/-----7 d
�_ ...........
application for Disposal Works Construction Permit No. ...............�; d-ate ------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. o
at Z?_DATE... #7�=gz......................................... Inspector-.-.- --------- ��-�V-------------....... ........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR HEALTH
. ........... . .........0 ....... .0.4.4......t..........................................
N FEE.....k-ld.
g Tonatrurtion Pam-
Permission is hereby granted...
�--
�Sp9s -
to Construef ( K) or Re I ivdual ewage Lall
�temat No../W.1. _.L..... .. . . .... . ........ --- ... .. ......................................................
Street
as shown on the application for Disposal Works Construction Permit ?,ated..7�--------- -- ........
............ V,.....................
Board&. eea.1h
DATE......... ............................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS kw
i
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SME.VVALL AtZE-A = Iso 'S P.
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$UT-TY M AarA `~1 FIT
TOTA!_ �ESIGIJ = d42G G.Q . \&
-T-oTQ L dt t_�f FLOW = 330 6.PD. ( a-- �l'g r I?
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L-OCAT10* SEWAGE# PE NMI N
Y-41LLAGE
INST LLER'S NAME i ADDRESS
w Ayr
BUILDER OR O NER
DATE PERMIT ISSUED _ -
DATE COMPLIANCE 1SSUEO
. ti
�1 X
r
v
'
TOWN OF BARNSTABLE
BOARD OF HEALTH
��pp�� rr�� ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
Date AD G 0 Time: In Out
Owner L LQ y/U C �k) 1 (�/ Tenant L` j V1
Address 2 MnLIQ z 6 T Address 7-2- M C-PP I—M W ffi
yo W C K-A�1
Compliance Remarks or
Regulation # Yes NO Recommendations
2. Kitchen Facilities
+- - -
3. Bathroom Facilities --
4. Water Supply p i p
5. Hot Water Facilities _
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal `� n
16. Sewage Disposal
17. Temporary Housing
18. Driveway Width J S 1/O (Z-Z ev pl—z
19. Number of Tenants Observed
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms '? Number of Vehicles Al (max)
Number of Persons Allowed (max) 5'
Person(s) Interviewed PCs Inspector
If Public Building such as Store or Hotel/Motel specify here
F/Y) Roten
1�Y1 � y` v9 �; 9 lPDd�
v
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� .
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i
� �U �� �pap�
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J1�a � 46-
,y
x 100.98 EXISTING SPOT GRADE
——103—— EXISTING CONTOUR N Ra Ra
103 PROPOSED CONTOUR ® cear�c G J\\to1a
—0.•H.•W.— OVERHEAD WIRES ��
W EXISTING WATER SERVICE N Prean S. P<e o�
e
TEST PIT 302 reoEl
BENCHMARK S Prey\opt Rd LOCUS �o
LEGEND 0(. S`
erid
eh WY Ot
M RoSernofj k-o m eroora Cr �o�t`��rocr
•� o La
0 D0000n
RV
f awry\ p
Q�
LOCUS MAP
NOT TO SCALE
S 60'49'46" W
x 100.00' c�--102
x 102.43
x 101.26 ,E
li�TP-1
VENT 102,43,,'
--�-�--T--�- 1 22,
��-- --1--LPR�PO (S S.T--r-->
18' TP-2 1--L- --
102,8 103 � 1 4.33~
y x \104,11
b EXIS77NG LEACH PIT
chain link fence I
—�{a�— / \\� 104 \\ TO BE PUMPED, FILLED
BENCHMARK SET -103,03 x 10 ,23- WITH SAND & ABANDONED� \
Outside Bulkhead Corner 1 3.9\8
EL.=104.13 (Assumed) \
O
103.44 \
O \
't 21 \ SPIKE EXISTING SEPTIC TANK
} f (o "\\ 104.28 (TO REMAIN)
I ( \ + Z TOP OF TANK, EL.= 102.21 f
N _ 103.87 .__ D CK� .._ � _ Q — V.(OUT) _. �100.
N IN 88f
Z 103.77 o
104.1 rn
103,53 x 103.7 BM x 103.661 N �
GARAGE
x 103,27 x �03.9EXISTING '
HOUSE (#22)
T.O.F.=104.13f
103.65
I
103,57 I
- J I
-STONE.
EWA Y. x 103.65
xDRIl/ 10 I
O / m
+ WALK + 103.97
•Z 103.66 _ ""��
104 9
\ x / I
(LOT 8) I
APN 148-149
16,962±SF I
�\ 103,32 x
\ .t: 103,37 3 103.71
I
�\ -106 00' �\
UP S 60' 9'46"'W�,
102.18 102.35 102.49 edge of pavement 102.95 103.22
MERIDE TH WA Y
O F M4s04
PETER
McENTEE PROPOSED SEPTIC SYSTEM UPGRADE PLAN
� _',
U VIL
NoC135109 N 22 MERIDETH WAY, CENTERVILLE, MA
Prepared for: D.A. Brown, Inc., .P.O. Box 145, Centerville, MA 02632
S E OWNER OF RECORD Engineering by: SCALE DRAWN JOB. NO.
WHITE, ALLAYNE V 1"=20' P.T.M. 261-11
I ALLAYNE V WHITE IRREVOCABLE TRUST Engineering Works, Inc.
,7 �`I I ( 44 LEGEND DRIVE 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO.
CENTERVILLE, MA 02632 (508) 477-5313 12/14/11 P.T.M. 1 Of 2
L _
e
t
NOTE: TO PREVENT BREAKOUT, THE PROPOSED
FINISH GRADE SHALL NOT BE < EL.98.8
FOR A DISTANCE OF 15' AROUND THE
PERIMETER OF THE S.A.S.
SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S.
INSTALL RISERS & COVERS OVER INLET & INSTALL INSPECTION PORT OVER END UNIT CHARCOAL
OUTLET AND SET TO 6' OF FINISH GRADE INSTALL RISER & WATERTIGHT VENT
T.O.F. COVER SET TO 6" OF GRADE
EXISTING F.G. EL.=104.2t F.G. EL.=103.0t F.G. EL.=102.8(MAX.)
/ MAINTAIN 2% GRADE (MIN.) OVER S.A.S
A .
L = 28' L = 2'
MM
® S=1% (MIN.) ® S=1% (MIN.) INSPECTION PORT
4"SCH40 PVC 4"SCH40 PVC
6"
IL
to"I
t 14" 6 10.75" TO
EXISTING 48' LIQUID INVERT
LEVEL INV.=99.40
GAS�BAAFFLE INV.=99.67 PROPOSED INV.=99.50 1 TRENCH W/12 ADS Arc 36HC UNITS ® 5'/UNIT = 60'
INV EXISTING
88t D-BOX SOIL ABSORPTION SYSTEM (PRO
)
EXISTING (��
EXISTING SEPTIC TANK UNITS MUST BE STAMPED H-20
ESTABLISH VEGETATIVE COVER
BACKFlLL WITH CLEAN NATIVE OR
PERC SAND TO TOP OF CHAMBERS
NOTES:
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE
INVERTS, PRIOR TO INSTALLATION. TOP ELEV.= 99.83
f 2) D-BOX SHALL BE SET LEVEL AND TRUE TO INV. ELEV.= 99.40
GRADE ON A MECHANICALLY COMPACTED SIX s"
INCH CRUSHED STONE BASE AS SPECIFIED IN BOTTOM ELEV.= 98.50 �.
EC
_ 310 CMR 15.221(2).
3) INSTALL INLET & OUTLET TEES AS REQUIRED. 5' MIN. ABOVE BOTTOM OF
4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE T.P. EXCAVATION OR G.W.
AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. EXISTING SUITABLE
NO G.W., EL=91.3 = MATERIAL
SEPTIC SYSTEM PROFILE ADS Arc 36HC UNITS TO BE INSTALLED IN
TRENCH CONFIGURATION WITH NO STONE
N.T.S. TYPICAL SECTION
' GENERAL NOTES: SOIL LOG
DATE: DECEMBER 13, 2011 (P#13,489
1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL SOIL EVALUATOR: PETER McENTEE PE(SE 1542)
BOARD OF HEALTH AND THE DESIGN ENGINEER. WITNESS: DONALD DESMARAIS R.S. HEALTH AGENT
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE ELEV. TP- 1 DEPTH ELEV. TP-2 DEPTH .:
LOCAL RULES AND REGULATIONS. 102.4 A 0" 102.8 A 0"
3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR SANDY LOAM SANDY LOAM
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN-ENGINEER`"" 61OYR 4/2 8 102.1 B -$ -+-- -�-- -
- -1 OYR- 4/2
4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 101.7
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN SANDY LOAM SANDY LOAM
ENGINEER BEFORE CONSTRUCTION CONTINUES. 10YR 5/8 10YR 5/8
5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM. 99.9 C 30" 100.1 C 32"
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. M-C SAND M-C SAND
8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 2.5Y 6/6 2.5Y 6/6
9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS
AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE
DIRECTED BY THE APPROVING AUTHORITIES.
10, IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY 91.9 126" 91.3 1 138"
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING PERC RATE <2 MIN/IN. ("C" HORIZON)
CONSTRUCTION. PERC RATE ON RECORD 1 1/27/79 (IN SAND)
11. WHERE REQUIRED, CONTRACTOR SHALL .REMOVE ALL UNSUITABLE SOILS NO GROUNDWATER ENCOUNTERED
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).
12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE
INSPECTED BY A CERTIFIED SOIL EVALUATOR PRIOR TO BACKFlLL.. 63.25"
13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND
IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY.
16"
34.5"
DESIGN CRITERIA
M 1
NUMBER OF BEDROOMS: 3 BEDROOMS TOP VIEW
SOIL TEXTURAL CLASS: CLASS 1 60"
END CAP END CAP
DESIGN PERCOLATION RATE: <2 MIN/IN FRONT VIEW SIDE VIEW
DAILY FLOW: 330 G.P.D. END CAP
DESIGN -FLOW: 330 G.P.D. REAR/TOP VIEW
oming
GARBAGE GRINDER: NO NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT SIDE VIEW
TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY
LEACHING AREA REQUIRED: (330) = 445.9 S.F. DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE.
74 mmpzr)s
4640 TRUEMAN BLVD
HILLIARD, OHIO 43026 Are 36HC DETAIL
EXISTING SEPTIC TANK: 1000 GALLON CAPACITY AWANCED DRAINAGE SYSTEMS,INC.a
PROPOSED D-BOX:: 1 INLET, 3 OUTLETS, H-10 RATED
PROPOSED SEPTIC SYSTEM UPGRADE PLAN
t.1.
SOIL ABSORPTION SYSTEM 22 MERIDETH WAY, CENTERVILLE, MA
USE ADS Arc 36HC UNITS IN STONELESS TRENCH CONFIGURATION Prepared for: D.A. Brown, Inc., P.O. Box 145, Centerville, MA 02632
(GENERAL USE APPROVAL FOR 7.79 SF/LF IN TRENCH CONFIGURATION)
12 UNITS = 60.0 FT Engineering by: SCALE DRAWN JOB. N&-"
60' x 7.79 SF/LF = 467.4 SF Engineering Works, Inc. N.T.S. P.T.M. 261-11
12 West Crossfield Road,' Forestdole, MA 02644 DATE CHECKED SHEET NO.
DESIGN FLOW PROVIDED: 0.74(467.4 S.F.) = 345.9 G.P.D. (508) 477-5313 12/14/11 P.T.M. 1 Of 2