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HomeMy WebLinkAbout0308 MONOMOY CIRCLE - Health 8 i O `OMOY CIRCLE Centerville A = 190 - 212 KmMEAD® No.2-153LOR UPC 12SU .madoom • Made in Usk► AM) 4w mmol sma" OIN `� TOWN OF BARNSTABLE LOCATION30 /J/fo (±e91 4GiiVch, SEWAGE# 20-tOL-©�A3 VILLAGECe✓----f-V1,Ile f ASSESSOR'S MAP&PARCEL Lbf (7 INSTALLER'S NAME&PHONE NO. Cali de. t-:nfeOpN Sty 5-08'-,f77_n 7 SEPTIC TANK CAPACITY 4EX 6 11,0C1 /00 C,,,- , /6 A�C, HG, Na16 LEACHING FACILITY:(type) /„t Arr 3C 11C Side Po,4 (size) d3o5 X )1,3 �ple�^s NO.OF BEDROOMS 3 OWNER �T©hV1 and KafArl t n be-pe® PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: no 6roahrt ctzt4evr Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility oCLee� a} lab 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 t ckz- yi5xQ5 L L f Nov;e 1 A �7`, L3=1= a6.7 cd3�a6, A -2= 7,3 3-a= 30:a` c` -if=a5, 0 3-3= a9''I,- = 4�, U No. r�-� {3 Fee /00. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yr Yes PUBLIC HEALTH DIVISION -TOWN OF BARN,STABLE, MASSACHUSETTS RppliCationjDr jBisposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(Xi Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. oN or46_1 e jejQ ,Ljg' Owner's Name,Address and Tel.N Assessor's Map/Parcel 190 off 308 6110 At® C( lLLJ.S- Installer's Name,Address,and Tel.No. 5'0% -477-897°7 Designer's Name,Address,and Tel.No. .'08°-477-531 3 dAPC-"6Q7 64J7a¢l'V_/SS75 L1,0 1 0 k0Q; ' I Ia Caro F, Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building P.E3( A,5�No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 p gpd Design flow provided ikINSWOM3 gpd Plan Date a,--pXt'o1OL;. Number of sheets C4�1 Revision Date Title— 36!� 04 a 00^4D ( C M<GA, CEa• E9V L,l, Size of Septic Tank 0bc-a Type of S.A.S. 1 a. Z(0V(,FNJ 1 Iwc V., 3 Description of Soil S P44JU Nature of Repairs or Alterations(Answer when applicable) J r9_ 'Qd,, C- - I t=G Cry c� �4 96w,5 as 3 ar S° :t 3 Co vec.Ex,0 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 Health. Si Date a'aac) Application Approved by Date 2 q s Zvi Z Application Disapproved b Date for the following reasons Permit No. 2—o a — p 43 Date Issued Z l Z w 2.0 / Z T r �1�— �� ---------------------------------------Fee ---- ---------------------- - of No. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal *pstrm Construttion Permit Permission is hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon( ) System located at ,30 g No&aw o Y �, 1 iP G�►L� GbI.�T V/(,L 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:Prist tion must be completed within three years of the date of this permit� Date 2 Z`l O Approved b}? Oaf No 113 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF�BARNUABLE, MASSACHUSETTS Yes appYicatiolYjggr nt,spoSal *pstem Construction Permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3 Q g M ON olUo-) C.U6f,L.. Owner's Name,Address and Tel.No. . cw� ►1�c r- 3'ottN Z 1"ii�usisjJ DC-t=eZ Assessor's Map/Parcel IC(OLA111. 308 600 V 1LL_J--e Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. dAP6ax0i CRJ jL-T Lf-p U00kx5, A446019697 vissr C c 7 Type of Building: Dwelling No.of Bedrooms 3 Lot Size k sq.ft. Garbage Grinder( ) Other Type of Building egS;1b.t-M ", No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 Q gpd Design flow provided � gpd Plan Date I-DXk-o-LOl,.2 Number of sheets Revision Date Title Q 64 D 001440V C(AC LC C 4 1 A Size of Septic Tank (�(�[j Type of S.A.S. 1 Zl�t n t ) Z rn,17Jr lI� Description of Soil P-(.A&j S ""Nature of Repairs or Alterations(Answer when applicable) I/ d C—�� .� i yy b�r .rlL C`.CJ t� leis/. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in a accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si gnqd Datetj Application Approved by DateZ- Application Disapproved by Date for the following reasons Permit No. Zo 2 — O 43 Date Issued Z THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded( ) Abandoned( )by <�APEtc>Q h�)U 61; �.�.. at 3 o$ mawouov Ct.e[,E G�V I LL67fias been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 012'043 dated 2 6 2-W Zo 12_ Installer I�RPL LUJ QJJi-XPXJ, 15e, - Designer r=L)G Ili t-L_p1 L -- 4OM ICS #bedrooms 3 Approved desigaffow 3 gpd The issuance of this permit shall not be/construed as a guarantee that the system ill functionZ'-igned. Date Inspect Town of Barnstable Regulatory`Services Thomas F. Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 026.01 Office: 508-862-4644 Fax: 508-790-6304 Date: 2`l - IL Sewage Permit#Zo�a-�`13 Assessor's Ma 19 a 'Z I Installer&Designer Certification Form t�E.. Designer:... ,,�,: n ea+•',r, W c r 4 r, Inc . Installer: Address: 2 W. C.rb s s e lCA 4. Address: 1S3 6o&to-wer_,oJ ST M A- a 2,6 y On 2 -Z` ' �OIZ' Caevj_�elp `&3_er Uses was issued a permit to install a (date) (installer) septic system at 30 Grtle 6!nk,(vt1U based on a design drawn by n (address) YAW Me L,ke 14E dated ,Z)Z4 , 4 (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 OFM,gSd' PETER T. �N 1UcENTEE , nstaller s Sign re) CIVIL. No:35109 a hSTEgot F, (Designer's Signature) (Affix Design <s e) 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. gAoffice formsWesignercertification fonn.doc Town-.of Barnstable P# � (p Departinent of Regulatory Services NAM• n ! Public Health Division Date QED MKt�1 200 Main Street,Hyannis MA 02601 1Timehe Date Scheduled Fee Pd. Soil'Suitability Assessment for S e Disposar l Performcd By: ✓' �� �-ts_ P Witnessed By: LOCATION& GENERAL INFORMATION i<A't . Loc�aft��t�coOn Address �i� ciao ey 4��ui� Owner's Name Z4W N Y Address3D9 !G(GK��( Assessor's Map/Parcel: ICi0 l vZ Engineer's Name ' C4fQQrDQ t5W1W_KKGT NEW CONSTRUCTION REPAIR Telephone# jig-4'7 -.9g7 Land Use &S I dkyl f4_?,� Slopes(96) 1 ^�Z— Surface Stones Distances from: Open Water Body ?30 o ft possible Wet Area�"__,L�_ft Drinking Water WellZSo ft Drainage Way, �3� _ft property Line __( � ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands 1n proximity to holes) 3ct Mmo rno'l Ct riu Parent material(geologic) v ' °5 Depth to Bedrock Depth to Groundwater. Standing Water in Hole: DJ/� Weeping from Pit FAce /V!A- Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: In, Depth to soil tmottlew In. Depth to weeping from side of obs.hole: In, Groundwater Adjustment Index Well# Reading Date: Index Well level Adj,factor- -,:. Adj.Groundwater Level- e PERCOLATION TEST Date,. Time- Observation 2, Hole# Time it 9" Depth of Peru Itl� Time at 6" Start Pre-soak Time @ "gip „/ �� Time(9"-611) End Pre-soak UI M Rate MindInch I Site Suitability Assessment: Site Passed Sitc Failed: Additional Testing Needed(YM) 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:\SEPTICIPERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture .Sdil Color Soil. . Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stoned;Boulders. to w.%'Gravel) DEEP OBSERVATION HOLE LOG Hole# 2- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv. �— A Yd/Z-9)z y-3c yi_Q 3(o_l Z C /A-C SotVk&J -,71 s-y41 C ra,v-e.( DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. ' J DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Boll Other M Surface(in.) (USDA) (Munsell) Mottling (Structure,Stories',Boulders. Co s' t Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes 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 �y 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 t ' ing,expertise and experience described in�10 CMR 15.017. Signature Date Z 23�t Zi Q:\S.EPTICTERCFORM.DOC I '�­x 21 COMMON;N'EALT'xI OF YES ACMiSETTS fn EXECUTIVE OFFICE OF ENVIRONMENmu AFFAIRS t DEPARTMENT OF ENVIRONMENTAL PROTECTION V r _. 1913 -� ;RCE1 2`� TITLE 5 OT OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: C<<'C Le , j D j i Owner's Name- Owner's Address: - Date of Inspection- Name of Inspector: please print e7El� a `' Company Name: Z an m 2� -5 . Mailing Address: x ! "sP Telephone Number: —3 _ d 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 Approving Authority Fails Inspector's Signature: ^� Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.if the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address flow the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of i 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: JOS p� C Owner: Date of Inspection: 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 CNM 15303 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 P 'section need to be replaced or repaired.The system,upon completion of the replacement or repair,as proved by the Board of Health,writ Pam• Answer yes,no or not determined(Y,N,ND)in the for following statements.If`snot determined"please explain. The septic tank is metal and over 20 years oI or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfil on or tank failure is imminent,System will pass inspection if the existing tank is replaced with a complying tank as approved by the Board of Health. *A metal septic tank will pass inspection if it' structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 Id is available. ND explain: Observation of sewage ckup or break m or High static water level in the distribution box due to broken or obstructed pipe(s)or due to ken,settled or uneven distribution box.System will ass won if(with broken pipes)area obstnu�is removed distri1xiti(m boot is IeYeled nr replaced ND exp e system required pumping more than 4 times a year due to broken or obstructed pipe(s).The systern will pass spection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND-explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3o mn f gvl y i =,I Owner. y Date of Inspection: 1 _QS C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to dete a 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 31 MR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, ety 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 w and or a salt marsh 2. System will fail unless the Board of Health(an ublic Water Supplier,if any)determines that the system is functioning in a manner that protects public health,safety and environment: _ The system has a septic tank and soil sorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a s ce water supply. The system has a septic tank d SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a s c tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply w ]**.Method used to determine distance "This system p es if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and vo 'le organic compounds indicates that the well is free from pollution from that facility and the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure Grit a are triggered.A copy of the analysis must be attached to this form. 3. ther: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM--NOTFOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DIRP06AI,;SYSTEM INSPECTION FORM PART-k CERTMCAT R (continued) Property Address: 301hoAQV-A04 Owner: Date of Inspection: e�> D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections_ Yes No — Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or pending 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'%day flow V -3.r Required pumping more than 4 times m the Last year Nndue to clogged or obstructed pipe(s).Number of times pumped — Any portion of the SAS,cesspool or privy is below high ground water elevation. — Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. i Any portion of a cesspool or privy is within 50 feet of a— -� private water supply well. , Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis••(This system passes K the well water..analysis, performed at a DEP certified laboratory,for auflf rm 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 tier less than 5 pm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) (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 erve.a facility with a design flow of 10,000 gpd to 15,000 gpd' r You must indicate either"yes"or"no"to of the following: ('The following criteria apply to large s ems in addition to the criteria above) yes no — ` the system is wi 400 feet of a surface drinking water supply the system is thin 200 feet of a tributary to a surface drinking water supply — — the syste is located in a nitrogen sensitive area(Interim Wellhead protection Area—TWPA)or a mapped Zone of a public water supply well If you have wered"yes"to any question in Section E the system is considered a significant "yes"in 'on D above the large system has failed.The owner or o rgntfi or answered Aerator of any large system considered'a signifi t threat udder Section E or failed under Section D shall upgrade the system in accordance with 310 Cuk 15.3 .The system owner should contact the appropriate regional office of the Department. A Page 5 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 30 �A 1 e ►yi l� Owner: �✓a, Date of Inspection:_ t Check if the following have been done.You must indicate`yes"or"no"as to each of the following Yes No 4C — Pumping information was provided by the owner,occupant,or Board of Health _ Were any of the system components pumped out in the previous two weeks? K Has the system received normal flows in the previous two week period? q" Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available cote as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of a baffles or tees,material of construction,dimensions,depth of liquid,uid depth of sludge 4 ep and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yeas► no � _ Existing information.For example,a plan at the Board of Health. a _ 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)] c Page 6 of I I OFFICIAL FORM INSPECTION INSP _. E -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: O p Owner: �-{ Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual):_ DESIGN flow based on 310 CMR 15.203(for example: i 10 gpd x#of bedrooms): 33a Number of current residents: O Does residence have a garbage grinder(yes or no): Ab Is laundry on a separate sewage system(yes or no):TV f if yes separate inspection required) Laundry system inspected(yes or no): WO Seasonal use:(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): Sump Pump(yes or no): A20 Ll Last date of occupancy: COMMERCIAIANDUSTRIAL Type of establishment: Design flow(based 7C= 15 )Basis of design flow sgtetc.): Grease trap present( _Industrial waste holdsent(yes or no):Non-sanitary waste o the Title 5 system(yes or no):Water meter readingle: East date of occupicy/use: OTHER(d be): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): b If yes,volume pumped:__gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy —Shared system(yes or no)(if yes,attach previous inspection records,if any) - _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of qlI c0mponenL54ate installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): Na / 6 I ' Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 30,e W' C%ftkrQ Owner: Date of Inspection: BUILDING SEWER(locate on site plan) . Depth below Bade: Materials of construction: kcast 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: a( (locate on site plan) Depth below grade: le Material of construction:4concrete metal—fiberglass___polyethylene _other(explain) If tank is metal list age:____ Is age confirmed by a Certificate of Compliance certificate) P (yes or no): (attach a copy of Dimensions: Sludge depth: 4/ Distance from top o sludge to bottom of outlet tee or baffler_ Scum thickness: d " Distance from top of scum to top of outlet tee or baffle:----�-T- Distance from bottom of scum to bottom of outlet tee or ffle: !Y How were dimensions determined: M er—C,I Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to et invert,evidk a of leakage,etc.}: � GREASE TRAP:—(locate on site plan) Depth below grade: Material of construction: concrete 1 fiberglass_polyethylene other (explain): — — Dimensions: Scum thickness: Distance from top of scum to of outlet tee or baffle: Distance from bottom of scu to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping commendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet in evidence of leakage,etc.): i 7 Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: JOR o.&o...l Ci Tc� Owner. ✓ ,� �— Date of Inspection: C TIGHT or HOLDING TANK: (tank must be ped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass poIyethylene other(expIain): Dimensions: Capacity:Z(yess ons Design Fonsfday Alarm prAlarm lem in working order(yes or no): Date of lCommenrm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of bo etc.): PUMP CHAMBER: (locate on site plan Pumps in working order>F(yes no):. Alarms in working ordeComments(note conditimp chamber,condition of pumps and appurtenances,etc.): 8 -i Page 9 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3b VLO Wt,p� ,�-,,e Owner: �tict ,c Date of Inspection: ( 5 16g SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: TOL ype leaching pits,number. leaching chambers,number. 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.): .� b r e p (c Sim i 6 makes a.�oo v e. CESSPOOLS: (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 groundw r inflow(yes or no): Comments(note co ttion of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site pl Materials of constructio Dimensions: Depth of solids: Comments(not condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: MOine-AAApc.� etv�lQ Owner: J'a.to -45 Date of Inspection: a 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 ebters the building. lea Page 1 l of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: j oL LL PC oL -� 2 &*&s�/c Owner: ycc N�j Date of Inspection: t�04 SITE EXA��'I Slope O Surface water Check cellar Vie> Shallow wells Estimated depth to ground water-.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) Accessed USGS database-explain: You must describe how you established thhigh round water levatiof: I1 L O CATION SEWAGE PERMIT NO. Lot 67 MONOMOY CIRCLE 74-102 VILLAGE CENTERVILLE INSTALLER'S NAME It ADDRESS Delta Crane BUILDER OR OWNER Alan Small DA T E PERMIT ISSUED 3-20-74 DATE COMPLIANCE ISSUED 4/8/74 ��- ` • . !. G �� , C-� .. u. �°� ��' �5 a-° � �._ � D f,Po�r• �a � �,,�� s�a FE �/:Q................ THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH V_4�A,_L....------.OF....... L GIN ....................... Apphrtation -fur l fipoii al Workii C owitrurtion Vrrmft Application is hereby made for a Permit to Construct (4-11"or Repair ( ) an Individual Sewage Disposal Syst aE P� N f -•---- = -`-------------- ----------•••• - ........................ L ion-Addre or Lot o. Tier Address Lk to ell r Address UType of Building— Size Lot............................Sq. feet Dwelling No. of Bedrooms..._____.......................Expansion Attic ( ) Garbage Grinder ( ) PL, Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 0.' Other fixtures __-----_ -------------- W Design Flow.. ....................... .... ........"gall per person per day. Total daily flow-________ _ gallons: ---------- --•-------------- WSeptic Tank Liquid capacity/ -..__. allons Length--------_------ Width_._ __........._ Diameter........._...... Depth...-----_.-.... x Disposal Trench—No. .................... N��id h,�.t_�:..�__.._ ._ _ _ tal RE , . __ ___--- _ Total leaching area..._.._......_._....sq. ft. i. Seepage Pit No•------_/---------- Diameter.' " We b�lA . •-------•-•----- Total leaching area------------------sq. ft. Z Other Distribution box ( ) [[[Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.._.---..-.-..-.--.___.. L14 Test Pit No. 2----------------minutes per inch Depth of Test Pit____________________ Depth to ground water-.._---____--__-_--_.--- 1:4 --------------------------------------------- . . • . •--- 0 Description of Soil---------------------------------------------------- fr : a. ' ------ .................. x U ------------------------------ ----------------•---•-----------------------•-•-----•-•----•-----------•-------•---•••---•-------•-••---•••••-••---•-...............--------------•----------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boa. of alth. gned = •. ••....... --• --•--•-•-•-•••= ' Date Application Approved By-------------- -­ • --•----....... -----• -• • ----- , � to Application Disapproved for the following reasons:------------------•--------------------.....----...._..•t-•-••••••-••--••--•--•---•--------••......-----•..... ---------------------------------------------------------------------------------------••-------------•--•---••......--••••......•--••---•------•-----------....._..•--.............-----------•---••-•- Date PermitNo......................................................... Issued......................................................... Date THE COMMONWEALTH OFiMASSACHUSETTS BOARD ; O HEALTH .. .... ........... .. .............. Fs E ...-o---w--..r i Itstt�'� CIT sfrurtioll tirrutit 22fo -� Permission eby granted .- --- -•--.._..•--•--......---•-----•----------------•------------------•------•-•----- to Construct or e air ( an Individual Sewage Dis o Sy m i street as shown on the application for Disposal Works Con ruction,P it No Dated_____ _d._: .��.... ...... Board o- ea DATE-=--- y................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Fics...... Q.:............. THE COMMONWEALTH OF MASSACHUSETTS •f BOARD F' HEA TH ..........O F........ . ... . ........ . .......................... ,� firtt i -for Ii.4 niittl Workii C otuitrurtion Pauli# Application is hereby made for a Permit to Construct ( 4Kor Repair ( ) an Individual Sewage Disposal Syst t ..... ............ ....... .........A.Al 4�m_A-� ---- • L ion-Addre or Lot No. VVV !, -caner Address a ...........- :_. . .'.'_. `-- cif*'r----�',"------••-•--•---•---•---•- n taller Address UType of Buildir Size Lot----------------------------Sq. feet Dwelling No. of Bedrooms................ Expansion Attic ( ) Garbage Grinder ( ) 'p Other—,Type of Building ----_--_.--_.............. No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .:__ .__ W Design Flow-- -.---:_.-'............. ............ 1llons per person per day. Total daily flow--_--_ .............................gallons. WSeptic.Tank Liquid capacity/ llons Length................ Width_.._..... _.. Diameter---------------- Depth._..----__-_-- : x Disposal Trench—N . .................... Wipd -..__ 4L _- Total leaching area_-_-_-_----_.____-_sq. ft. Seepage Pit No......_..----_--__-_ Diameter.. P- t in et.................... Total leaching area. le ft. z Other Distribution box ( } Dosing tank Percolation Test Results Performed by Datek--------------------------------------- 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 round water.-_----_-__--_-----__. - O Description of Soil---------------------------------------------------------- ._ = : ----------- ----------------------------------------------------------------------------------!--------------------------------- ---- -----------------------------------------------------------------------------------------------------------------------------------------•------------------------4--- -------------------------- VNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------................-------------- F + ___________________ -.f __________________________________________________________________________________________________t-per._____.....__.__._.____..._.___ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued-by the boa of lipRlth. ned. .--.-•... ••------- -• -----••----•_.-• •-------------- ---- Date ,�/ Application Approved BY f'-.. �- - ` to -------- Application Disapproved for the following reasons:-------"•------------------------------------------------------------•---•-•--"-••-•------.....--------•-------- ..-•--•-•----•--•-•------•-----•"---"-•-----------------------"--•--.....--""---•-------••-----•----••--•...---•----•----------------"-•--.......--•-"•---••------------------•----.........------._--•-- Date Z. Permit No......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H ALTH OF..................... ►................................ Al 01rdifira#r of Tomplianre 400,0' THI IS T —TIE, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by....... .... ---------------------------------------------------- �tair ------ at. ----- .. R `.._ has een installed in accordance with the pro ons of Article XI of The State Sanitary Cod as d cribed in the application for Disposal Works Construction Permit No.-_-_--__1_ . ------------------------ dated._. Z J THE,ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE© AS A G ARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. `. DATE............................. Inspector------- r N a ® GENERAL NOTES: 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE y LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. a a 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE , ` LOCAL RULES AND REGULATIONS.° ° 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR BENCHMARK SET m` o' TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE O OUTSIDE COR./BULKHEAD zv DESIGN ENGINEER. 4 ti N EL.=102.66 (Assumed Datum) 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING �a ° EXISTING LEACH PIT FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ko ENGINEER BEFORE CONSTRUCTION CONTINUES. co TO BE PUMPED, FILLED WITH �c m' F a SAND AND ABANDONED. Ch 5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM. 01 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF o O HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. EXISTING SEPTIC TANK y Stoney W00611 fie TOP OF TANK, EL.=100.28 O 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. \.n INV.(OUT), EL.=98.95 / �_�\ 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. � � R LOCUS 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS i AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE LOCUS MAP .101`0 i DIRECTED BY THE APPROVING AUTHORITIES. NOT TO SCALE 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION, 2 18 j �'10 101,5 6�45 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS 6� +• 101,59IN THE AREA= 7798 ?3�. REPLACE WITHBCLEANHSAND AS SPECIFIED SIDES OF MR THE S. AND 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE �� +•162.26 1, INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. PORCH 10 .06 x 3 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND 101.76 IS NOT CONSIDERED TO BE A PROPERTY LINE SURVEY. 11 103.12 ,� :\ /EXISTING 1�. +. ` TP-2 X G HOUSE(#308) 20 W. -1 0.86-:. T.0.F.=102.65 k -�.H.. H•-W v���' 7 �V 1(S 100.05 v10 �0. GARAGE �\ v62 \Nr / 11• . 102,37 103/19 x 101.32 Doti .\ \\ �x � ,✓/ � 0 -�� �-- �o �Q� s9cy 101,84 �� �-0 .'� �'�LOT 67 o PETER T. 101.78 = 5-----J� M CIVILEE ' OvM No.190-212 PA VED o. 35109 DRIVEWAY•• ��' 16,353±S.F. 100,21 ,off RfG/SZE��� `Q 100,08 0 LEGEND ,,,J .: . ` x 100,39 9.87 101.25 ---__ , �q EXISTING CONTOUR 0,02 cachbasin - 98 -- t_=229.88 99,61 x 100.98 EXISTING SPOT GRADE 100.58 100• R_119.g1' PROPOSED SEPTIC SYSTEM UPGRADE PLAN W EXISTING WATER SERVICE �On A 308 MONOMOY CIRCLE CENTERVILLE, MA EXISTING GAS SERVICE ' V O� G 'v/ O Y Prepared for: Capewide Enterprises, 153 Commercial St., Mashpee, MA 02649 --0.H. W- OVERHEAD WIRES • 101.58 CIRCLE PK SET Engineering b : SCALE DRAWN JOB. NO. U UNDERGROUND WIRES OWNER OF RECORD 9 g y TEST PIT DEFEO, JOHN & KATHLEEN Engineering Works, Inc. 1"=20' P.T.M. 1 24-12 308 MONOMY CIRCLE 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. BENCHMARK CENTERVILLE, MA 02632 (508) 477-5313 2/24/12 1 P.T.M. 1 of 2 iA NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL.98.33 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 RISER & WATERTIGHT INSTALL 1 INSPECTION PORT AT OUTLET AND SET TO 6" OF FINISH GRADE COVER SET TO 6" OF GRADE EACH END OF S.A.S. T.O.F. F.G. EL.=102.1 t F.G. EL.=101.6f F.G. EL: 101.3t F.G. EL: 101.33(MAX.) MAINTAIN 2% GRADE (MIN.) OVER S.A.S. _ INSPECTION PORT O S=1%5(MIN.) O S=1%((MIN.) (1 MINIMUM) 6„ w 4"SCH40 PVC 4"SCH40 PVC 17.46° 10"I 6izl �INLENC�TH 1 a" F0.75" TOEXISTING48" LIQUID INVERT 1 I 9.45LEVELGASADD LE INV.=98.17 PROPO .00 (4 ROWS OF 4 UNITS AT 5.0'/UNIT) + 3.5' (3 COUPLERS) = 23.5' 16" 12.37"INV.=98.95 SOIL ABSORPTION SYSTEM (PROFILE) 11, •• INV.=97.90 J% 91o.3a" EXISTING SEPTIC TANK NVERT DOME END ESTABLISH VEGETATIVE COVER HEIGHT BACKFILL WITH CLEAN NATIVE OR POST END PERC SAND TO TOP OF CHAMBERS C33.75" BREAKOUT=TOP TOP ELEV.=98.33 INV. ELEV.=97.90 NOTES: BOTTOM ELEV.=97.00—� 1) CONTRACTOR SHALL.VERIFY ALL EXISTING PIPE 2,83' NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT INVERTS, PRIOR TO INSTALLATION. 4' OF NATURALLY OCCURRING TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY 2) D-BOX SHALL BE SET LEVEL AND TRUE TO 5' MIN. MATERIAL EFFECTIVE WIDTH=11.3' DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE.. SEPARATION TO G.W. GRADE ON A MECHANICALLY COMPACTED SIX E 4640 TRUEMAN BLVD XISTING SUITABLE INCH CRUSHED STONE BASE, AS SPECIFIED NO GROUNDWATER, EL.=91.2 — MATERIAL ® HILLIARD, OHIO 43026 Arc 36HC SIDE PORT COUPLER IN 310 CMR 15.221(2). - ADVANCED DFWNAGE SYSTEMS.INC. UNITS MUST BE STAMPED H-20 3) INSTALL INLET & OUTLET TEES AS REQUIRED. 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE USE 4 ROWS OF 4-ADS Arc36HC UNITS + 3 COUPLERS PER 63,25" AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. ROW WITH NO SEPARATION BETWEEN EACH ROW & NO STONE SEPTIC SYSTEM PROFILE TYPICAL SECTION 18" �-1 N.T.S. 34.5" DESIGN CRITERIA SOIL LOG DATE: FEBRUARY 23, 2012 (REF#P-13,556) TOP VIEW NUMBER OF BEDROOMS: 3 BEDROOMS SOIL EVALUATOR: PETER MCENTEE (SE#1542) SOIL TEXTURAL CLASS: CLASS I WITNESS: DON DESMARAIS—HEALTH AGENT 60" END CAP END CAP --u tt-111 DESIGN PERCOLATION RATE: <2MIN/IN Elev. TP- 1 Depth Elegy. TP-2 Depth FRONT VIEW SIDE VIEW END CAP DAILY FLOW: 330 GPD 101.2 A 0" 101.3 A 0" REAR/TOP VIEW DESIGN FLOW: 330 GPD SANDY LOAM SANDY LOAM GARBAGE GRINDER: NO 10YR 4 /2 NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT SIDE VIEW / TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY LEACHING AREA REQUIRED: (330) = 445.9 SF 100.9 B 4" 101.0 B 4" DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. SANDY LOAM SANDY LOAM 4640 TRUEMAN BLVD .74 97 7 10YR 5/8 42" 98 3 10YR 5/8 36„ • HILLIARD, OHIO 43026 Are 36HC DETAIL ak EXISTING SEPTIC TANK: 1000 GALLON CAPACITY C C PERC ADVANCED DUNAGE SYSTEMS, INC. UNITS MUST BE STAMPED H-20 PROPOSED D-BOX: 1 INLET, 3 OUTLET (MINIMUM H-10 RATED 42'/54" PROPOSED SEPTIC SYSTEM UPGRADE PLAN USE 4 ROWS OF 4—ADS Arc36HC UNITS + 3 COUPLERS PER M-C SAND M-C SAND ROW WITH NO SEPARATION BETWEEN EACH ROW & NO STONE 2.5Y 5%GRAVEL 2.5YL 5%GRAVEL 6/4 308 MONOMOY CIRCLE, CENTERVILLE, MA BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.80 SF/LF OF UNIT) Prepared for: Copewide Enterprises, 153 Commercial St., Mashpee, MA 02649 (Arc36HC Units) 16 UNITS x 5.0 LF x 4.80 SF/LF = 384.0 SF Engineering by: SCALE DRAWN JOB. NO. (COUPLERS) 12 COUPLERS x 1.17' x 4.80 SF LF = 67.4 SF 91.2 120" 91.3 120" P.T.M. / N.T.S. 124-12 TOTAL AREA = 451.4 SF PERC RATE: <2 MIN/IN. ("C" HORIZON) Engineering WoYh.S', Inc. O. DESIGN FLOW PROVIDED: 0.74GPD/SF(451.4 SF) = 334.0 GPD NO GROUNDWATER OBSERVED 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET(508) 477-5313 2/24/12 P.T.M. 2 of 2 2