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HomeMy WebLinkAbout0084 MONOMOY CIRCLE - Health 84 Monomoy Circle Centerville FIR A = 190 195 i i t F No. 42101/3 ORA 10°l0@ No. — t J Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppfication for Miopomf *potem Construction 3permit Application for a Permit to Construct( )Repair(grade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. E3 4_,Mp/)0 010 Y C/&. Owner's Name A d d Tel��•vro. 4�erfr�cr�/f/l-_, M+• Zvevi S Assessor's Map/Parcel Inst er's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �JR.4-n/Ge LTh�tv/�'f/ar✓ SOPS Isn.`t So 33z1�`7 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(AJ� Other Type of Building Via'& No.of Persons 4- Showers(Z) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow O gallons. Plan Date '3-3d-o Z Number of sheets i Revision Date Title Id 8 f/*1 o ly` ,°y C e�. Size of Septic Tank eZr s 7s n z /0 a 0 Type of S.A.S. Description of Soil /O ` Sgn `7 L.�mow, Nature of Repairs or Alterations(Answer when applicable) Alec f ax *2214 /,e-.,c 4L 4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued t ' Board Health. Signed Date �3��� Application Approved by (3- C_ Date Application Disapproved for the following reasons Permit No. q2- Date Issued u TOWN OF BARNSTABLE rc - LOCATION Z ,/ MO n Q CAI �ESEWAGE # Qboa-I vI1 LAGE C�/y/11- -'04J-r /V)469SASSESSOR'S MAP & LOTI�o"`�� INSTALLER'S NAME&PHONE NO. W O-1-/14-n'1 �� ��'�o'�tP A ',2%16 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (,AJ- L. C, (size) J � NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: U2 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 1 13 der o r- Hcws' I f w a3 A-3A-, 13-Y 53 - � 5/ a°r .. ��94, 4 r tcomputer: Lam.No. FeeL"ll THE COMMONWEALTH OF MASSACHUSETTS Enered t;in compuer: — _ Yes PUBLIC HEALTH-DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ZIpprication for 33igpogar bpgtem Congtruction Permit Application for a Permit to Construct( )Repair(Ugrade( )Abandon( ) ❑Complete System ElIndividual Components Location Address or Lot No. S�,Mo n wo y C-/A.. Owner's Name,Add d Tel.No. �er %-V-V1Il< , m,} . /J/- p4lev/ S Assessor's Map/Par ei_ 5'/t-J;)1-J"CLr 1-1,4 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. .S.Sd AA-?VC �-��t vA're.✓ i�il�v�,� ,3 .,„,r sds� 71nfiev 5_0 3 Z 177 Type of Building: Dwelling No.of Bedrooms 3 Lot Size�s000 " sq.ft. Garbage Grinder('Vq Other Type of Building /�c S No. of Persons Showers(Z) Cafeteria( ) Other Fixtures P1�A ,-N Design Flow ,gallons per day. Calculated daily flow 3 4 gallons. Plan Date 3-30-o Z Number of sheets / Revision Date G✓'/� �- Title�` 8 4 in 0'V o/""1 K C Size of Septic Tank Type of S.A.S.t'Z ) S'1,e b' die o*.r c-1 ► t?i u Description of Soil ry Sin �1 `'p'`' 3¢ S , LT Go,+^v 1"31 r M o-� - C aoflc lke., Nature of Repairs or Alterations(Answer when applicable) AJ&4 r --zx 2_ 3 X ��✓ /��. , o Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued-by t ' Board of Health. Signed _ Date -3,o 2 Application Approved by 11_ 0 l Date Application Disapproved for the,following reasons Permit No. "D ll - Id_1 Date Issued ------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(Upgraded( ) Abandoned( )by (24A�,r � C. at 104 has been constructed i accordance with the provisions of Title and the for Disposal System Construction Permit No. 2 dated t Installer Designer The issuance of this plbrmit shall not be construed as a guarantee that the sy will function a designed. Date y ' L 1 - Inspector --------------------------------------- No:') i)_ h/ Fee= L THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migpogal *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair(/ )Upgrade( )Abandon( ) System located at .� 0p and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of,this permit. n Date: ��/`��(`�2 Approved by C4t TOWN OF BARNSTABLE Fc - LOCATION f v t v 0 0 M L��L� �IG SEWAGE # ,oboa—h4l- VII LAGE /V�'SASSESSOR'S MAP & LOT10"/?- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACII:ITY: (type) �fi66 rAL L, ca (size) A NO.OF BEDROOMS BUILDER OR OWNER ��� ��! PERMTT DATE: C'1 COMPLIANCE DATE: 2 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 Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by F: 13 4Gr ot- HooSr 1POCCt# I p-3 - 9� 63 -59 COMMONWEALTH OF MASSACHUSETTS u W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAL.RS- �Aff i5,f= � r l S- f Ehc.1tE d DEPARTMENT OF ENVIRONMENTAL PROTECTION FEB 21 A��l 10: 19 q Spa. 4tisioN TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 84 Monomoy Circle Centerville MA 02632 Owner's Name: Maribeth Desley Owner's Address: Same Date of Inspection: February 8,2006 Job# 06-31 `J Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Appr ving Authority K Fails p ;v b'C Inspector's Signature.• Date: 2/8/06 '.` ' �FRT �0' 01 -i IFS!;`JSPEG����C The system inspector shall submit a co of this inspection report to the A ��copy p p Approving Authority(Board of Hea�' b�t��' DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Leaching chambers have no standing water and tank is not in need of pumping at this time. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. f Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 84 Monomoy Circle,Centerville Owner: Maribeth Desley Date of Inspection: February 8,2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 84 Monomoy Circle,Centerville Owner: Maribeth Desley Date of Inspection: February 8,2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 84 Monomoy Circle,Centerville Owner: Maribeth Desley Date of Inspection: February 8,2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool — _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool — _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone I of a public well. — —X— Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma _No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ — the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 84 Monomoy Circle,Centerville Owner: Maribeth Desley Date of Inspection: February 8,2006 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health — _X_ Were any of the system components pumped out in the previous two weeks ? _X_ _ Has the system received normal flows in the previous two week period ? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(if they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up _X_ _ Was the site inspected for signs of break out? _X_ — Were all system components,excluding the SAS, located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_ _ Existing information. For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)J Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 84 Monomoy Circle,Centerville Owner: Maribeth Desley Date of Inspection: February 8,2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2 years total: 75,000 gal.= 102 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: None Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 4/5/02 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 84 Monomoy Circle,Centerville Owner: Maribeth Desley Date of Inspection: February 8,2006 BUILDING SEWER: XX (locate on site plan) Depth below grade: 2' Materials of construction:_X_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 2' Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:8.5'long x 5.2'wide—1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:28" Scum thickness: trace Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees are intact and clear,liquid level at bottom of outlet invert Tank is not in need of Pumping at this time,recommend Pumping every three to five years depending on use GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): f Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 84 Monomoy Circle,Centerville Owner: Maribeth Desley Date of Inspection: February 8,2006 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): No solids or high stains present PUMP CHAMBER: No (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.): Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 84 Monomoy Circle,Centerville Owner: Maribeth Desley Date of Inspection: February 8,2006 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _leaching pits,number: _X_leaching chambers,number: Two 500 gal drywells. _leaching galleries, number: _leaching trenches, number, length: leaching fields,number,dimensions: _overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Chambers have no standine water and no sidewall stains CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 84 Monomoy Circle,Centerville Owner: Maribeth Desley Date of Inspection: February 8,2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Mono moy Circle Water service ::. 3 37 40 60 Page 11 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 84 Monomoy Circle,Centerville Owner: Maribeth Desley Date of Inspection: February 8,2006 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 20 feet Please indicate(check)all methods used to determine the high ground water elevation: _Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) _Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.35 and topo map shows property above el.50. Page 10 of I 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 84 Monomoy Circle,Centerville Owner: Maribeth Desley Date of Inspection: February 8,2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Monomoy Circle ater ervice. RX X. 37 40 60 TOWN OF BARNSTABLE 1,01C,ATION �7 InO,116 t2 SEWAGE #X-,A T 7::� ""rLLAGE � ���'� l�— ASSESSOR'S MAP & LOT INS� / R'S NAME&PHONE N6 g-ric-lL C J1 .o n as t 4'198 172 5 `SEPTIC TANK CAPACITY /y� LEACHING FACILITY: (type) Ate►+bvr5 (size) 600 NO. OF BEDROOMS- BUILDER OR _r)'rIA✓�� ed h PERMITDATE: CQ1;tPh*ANC-E DATE: !6/®G 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 Hb 3� :E ]ED COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF DEPARTMENT OF ENVIRONMENTAL PROTECTION d � Q Z95 h , 0 FAILED INSPECTION O,,M Sy TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART'A CERTIFICATION r, Property Address: 84 MONOMOY CIRCLE CENTERVILLE,MA 02632 q S 37� Owner's Name: DUPUIS Owner's Address: C/O REALTY EXEC. 1330 PHINNEYS LN HYANNIS 02601 Date of Inspection: 2/26/02 15 ® Name of Inspector: (please print) JOHN GRACI PARCEL • 95 _ Company Name: SEPTIC INSPECTIONS 3 Mailing Address: P.O. BOX 2119 TEATICKET, MA.02536 Lo? Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes _ Conditionally Passes _ Needs Furth valuation by the Local Approving Authority X Fails Inspector's Signature: Date: 2/26/02 The system inspector shall submitXpy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM FAILS TITLE V INSPECTION. LEACH PIT IS FULL OVER PIPES. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under t::e same or different conditions of use. Title 5 Incnartinn Fnri-n 6/1 5/)nOn Page 2 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 84 MONOMOY CIRCLE CENT ERVILLE,MA 02632 Owner: DUPUIS Date of Inspection: 2/26/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM FAILS TITLE V INSPECTION. LEACH PIT IS FULL OVER PIPES. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a f Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 84 MONOMOY CIRCLE CENTERVILLE, MA 02632 Owner: DUPUIS Date of Inspection: 2/26/02 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in ordcr to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone l of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance n/a **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution Gon,that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a i Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 84 MONOMOY CIRCLE CENTERVILLE,MA 02632 Owner: DUPUIS Date of inspection: 2/26/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n/a. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone l of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma X _ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of i;ry large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. d f Page 5 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 84 MONOMOY CIRCLE CENTERVILLE, MA 02632 Owner: DUPUIS Date of Inspection: 2/26/02 Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks'? X Has the system received normal flows in the previous two week period X Have large volumes of water been introduced to the system recently or as part of this inspection '? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up`? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum `' X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] S Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 84 MONOMOY CIRCLE CENTERVILLE, MA 02632 Owner: DUPUIS Date of Inspection: 2/26/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons-- How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1976 BY AGENT Were sewage odors detected when arriving at the site(yes or no): NO CA I Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 84 MONOMOY CIRCLE CENTERVILLE,MA 02632 Owner: DUPUIS Date of Inspection: 2/26/02 BUILDING SEWER(locate on site plan) Depth below grade: 22" Materials of construction:_cast iron _40 PVC Xother(explain): 20 PVC Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage, etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 16" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: IOOOG L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottorn of scum to bottom of outlet tee or baffle: 16" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): SEPTIC SYSTEM FAILS TITLE V INSPECTION. LEACH PIT IS FULL OVER ALL PIPES. RAP: locate on site Ian GREASE T _( plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition.,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 84 MONOMOY CIRCLE CENTERVILLE,MA 02632 Owner: DUPUIS Date of Inspection: 2/26/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): n/a PUMP CHAMBER: _ locate on site Ian ( plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Page 9 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 84 MONOMOY CIRCLE CENTERVILLE,MA 02632 Owner: DUPUIS Date of Inspection: 2/26/02 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation nGt,required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 „/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,daifip soil,condition of vegetation,etc.): LEACH PIT FAILS INSPECTION, PIT IS FULL OVER ALL PIPES. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 84 MONOMOY CIRCLE CENTERVILLE, MA 02632 Owner: DUPUIS Date of Inspection: 2/26/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Act e(Le-"A P`�ch �6 3H m in Page I 1 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 84 MONOMOY CIRCLE CENTERVILLE, MA 02632 Owner: DUPUIS Date of Inspection: 2/26/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a IN Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 10+FT. 7,4 klocT10� 5 �JC,� PERMIT WO. VILLAGE IhlSTGL t S 0M1L�DRESS — — — bU1LDER5 QOME O� laDADORESS A OIaTE PERMIT ISSUED DATE COMPLILa1.►CE ISSUE . r i ,5.3 No........ Fimic Z.0................ THE COMMONWEALTH OF MASSACHUSETTS BOARD HEA�LTH :.....OF......... ..' .... ........................... Appliration -for 13hipmat Worko Tatuitrurtion Vrruift Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System ..... .... . .. ............... ................................................... ................ �em ---------------- tion-Address -;L------------------------ ------- ot .......... -------------------------- . .. ................................................................... ........................... er I Address r ------­----------------- ....... ................................................................. Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Exp............ ansion Attic Garbage Grinder ( ) P4 Other—Type of Building ----------------------_---- No. of persons..._....._......_.........._ Showers Cafeteria ( ) Pa Other fixtures . Design Flow................. -------------gallons per person per day. Total daily flow.__.._.. ----------_---.---gallons. 94 Septic Tank—Liquid capacity------------gallons Length................ Width..___........_.. Diameter__-.-...--....._..... Depth_...--_----.---- Disposal Trench—No. .................... Width._.._.__............ Total Length_.._.__.____........ Total leacliing area....................sq. ft. Seepage Pit No------w------------- Diameter..._.__............_ Depth belo inlet_______ ......... Total eaching area------------------sq. it. I Other Distribution box Dosing tank ... 7 Percolation Test Results Performed by................ ......................................................... Date---------------------------------------- Test Pit No. I................minutes per inch Depth of Test Pit_..---_--_-_--__-__- Depth to ground water....-- .--_---.--.--.-. �14 Test Pit No. 2------------ --mmutesper inch Depth of Test Pit-._-__-____-_______- Depth to ground ater-_--------------------- Ix .................. r Z..... ..... ......................................................... ----- ----------- ---------------------------------- 0 Description of Soil... ... . .. ...... ........ ....... ...... ...... I- -------------------------------------- U -----------------------2------- ------------- . .......................... ........0 ......... .-i------------------------------------- ----------------------------------------------------------------------------------------------------I------------------------------------------------------------------------_...................... 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 Article X1 of the State Sanitary Code— The undersign o further agrees not to e the system in operation until a Certificate of Compliance has been issued by the board,4f health. ign .................. ------------------------------------------ ------------------------------- Da;e Application Approved By......__.._ ...... .. .... Date ---------------------- ot top e the....k.. .......... Application Disapproved for the following reasons------------------------------------------------------------------------------------------- --------------•---- ---•----••----------------••----•-•-•-----•---------•--------•-••--------••-••-------••--••-••-----•--••-••----••---•---•--•----•-••-----•-------•-------••------------------------•-----------•-...... Date PermitNo......................................................... Issued....................... ................................ Date ------------------------------------------ -------------- - ----- ---- - No. ...... ........... Fimic l...d............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... .........OF........ .- .��. ��G .......... Appliratiun -fur Iinpu. at Workii Tunitrnrtiun Punift Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System �: L6esYion-Address (f U '-----/-/•'--or.Lot Nto?/^--•--------------•---._....._..-.•-- w 1 .-Owner / Address Installer 1 Address Q Type of Building J Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms----------- --------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ----..___________________ No. of persons............................ Showers ( ) — Cafeteria ( ) QOther fixtures --------------- -------------------------•-----------------------------------------------•----------------------------------------------------------- w Design Flow------------------�o----------__._gallons per person per day. Total daily flow.......... ...................gallons. WSeptic Tank—Liquid capacity------------gallons Length-----------_-- Width................ Diameter................ Depth....--__--.-_. x Disposal Trench—No- -------------------- Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet................... Total leaching area-----.------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) U �J ,G 1 • �_ a�`7�- aPercolation Test Results Performed by-------------------------------------------------------------------------- Date....................................... Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water....----.------.-.-----. fT4 Test Pit No. 2----------------minutes per inch Depth of "lest Pit.................... Depth to ground ater------------------------ ---- ------------- �� .._.... --•------------------------------------- Descri Description of Soil__ . _ Zr._�_._ ___. _.. �.__?._1'r,/. _'f _ O P �1----' " ------ -------------------------------------- 1.----------------------------------- w / . 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 Article 1I of the State Sanitary Code—The undersigned7further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. / . . ----•------------- ••------------------- -----�-----------------.. D t Application Approved By........... �l. G�f�f�--------------------- __ / Date Application Disapproved for the following reasons----------------------------------------------------------------------- ........................................ .....................---------------....._...---.....---------------------------------------••••-----•----•--•--•...--••-------.........•---------•------......--•--•--•----•-----------------------_.. Date PermitNo......................................................... Issued----------------------........................................................ Date 'S '777 THE COMMONWEALTH OF ETTS BOARD Oi- HEALTH ............... .......OF............ ...... ..................................... Tatifiratr of Toutphatta THI(S-�IS C TIFY, That the Individual Sewage Disposal System constructed or Repaired by........ ------ ......................................... -------------------- --/............................ ............................ at. ...... n 00 Instal Z4 01- Vx--.!W—,I of The State Sanitary Co(je as described in the -- --- --- --- --------ee.W.,(.....�L...1(--- ,,-r-o . -"-.L�l..... -------------------- --- has been installed in accordance with the provisions of <, application for Disposal Works Construction Permit No-2 ........ ---------- dated..... I(K............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM w'LL FUNC ION SATISFACTORY. DATE. ........................ Inspectors --------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD,?F HEALTH (76) o2 ...... ..............OF.... ..................................................... N FEE.... . ......... (4jpitrurfivn Pr IT rmit�T Permission reby granted.------- --,--- --------- -------------- ------------------------------------------------------------- to Con;sZtr or R,Aer an Individual S �ge rfisposal S?y /l-e ," ..... .. . .. at N ------7- .....? .............................................................................. as shown on the application for Disposal Works Construction Per Street i ect NQ o...*.-......... Dated...i-17,1- -;76 �e ................................... ---------- --------- ------------------------------- Board of Health DATE....... ----- ...4 FORM 1255 H0813S & WARREN. INC.. PUBLISHERS 1 O - oo 3? ' I a �R� Q o '` � f i MA CERT►F I E D RLai Pt.� Are, L � ���� •�"c y ____r__— C�.�T'��;�'�+�:.s: MASS LOT 3-7 PL 2>1< Z 7 z PG s- L3,,Nx s F.Q i� NyE !N c.. . 7vAVfty ox- R� I sTE QED LA N t> SvR v Ya�:s 0 STERViLLE P47W ' +� " Pr---T t T 10,4 E�- /�.LAP1 ASSESSORS MAP : TEST HOLE LOGS i'4/v74 � PARCEL : 7 j FLOOD ZONE : SOIL EVALUATOR : A\A �d W I TNESS : o� ic7 A fG►45L.e— v REFERENCE l% t_I� -' 7b 3/� !'�I�� #�` 3Z DATE : /1'1�,h2-G 14 3© 2,0O -`�- - PERCOLAT 0 r RATE : jz� O, K, 2 S G , �' �. ' - T H --� _ Z > -1" L ► S�'�t �r�(L S V� � TH-277 / c LOCATION MAP (�k T,5, ILA lZk-FlOt^� p I oy- �4O Svc'. (2, SEPTIC SYSTEM DESIGN ' '7L __v LOW ESTIMATE ('4 'J ` ,:6 BEDROOMS AT Id GAL/DAY/BEDROOM - GAL/DAY SEPTIC TANK 10GAI-/DAY x 2 DAYS �GAL ` I I USE 1600 GALLON SEPTIC TANK I ! SOIL ABSORPTION SYSTEM I IV) .1 " S +: DE AREA: .2 X Zy -f /3 x 1 BOTTOM AREA: Z x /3 ' X Cam, 7" -- 230, � a 108bo a Mj �0� P V 3 - ._ ------___s.E P T I C SYSTEM SECT I ON K 1� 9W►31 kA H- ,L2 1-2 1 Cc - �3� wV loco o I � I wq LikI'� 7 ff �� 1/ /G� 0GAL BOX �f� I � ;l SEPTIC TANK ram. 4Y&4.� '�I,��j •''l4"- ►�Z' � . l�v�gl-�►�t,� /j `I�(, SITE AND - SEWAGE PLAN LOCATION : c' ?` G �GC-Lo-', PREPARED FOR 0 SCALE : DAV I D B . MASON DATE : DBC ENVIRONMENTAL DESIGNS W EAST SANDWICH . MA DATE HEALTH AGENT IL ( 508 ) 833- 2177