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HomeMy WebLinkAbout0498 NOTTINGHAM DRIVE - Health 498 Nottingham Drive Centerville P A = 147 016 oo I Commonwealth :of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form Not for Voluntary Assessments °p 498 Nottingham Drive .... y.. .. -.. .... Property Address: .... ... ...... Michael Valerio Jr. Trust -Owner: Owner's Name information is required for every MA 02632 3/29/13 page. City/Town State Zip Code.: Date of inspection - Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness.checklist at.the end.of the form. Important:When A. General Information - filling out forms on the computer; use only the tab: .... 1. Inspector: key to move your �j cursor-do not.. ` Use the return: Matthew Gilfoy --�. key. Name of Inspector B & B Excavation;Inc. Company Name 14 Teaberry Lane Company Address. ram Forestdale ........ MA::. 02644 City/Town State Zip Code 508-477-0653 S113640 Telephone Number License.Number B. Certification 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: 0 Passes. ❑ Conditionally Passes ❑ .Fails Needs Further Evaluation by the Local Approving:Authority 4/1/2013 Inspector's Signature V Date - .... The:system inspector shall submit:a.copy of this inspection report to the Approving Authority(Board of Health or:DEP)within 30 daySrof completing't is inspection. If the system is a shared system or has a design.flow of 10,000 gpd or greater,:thetiyspgytor 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, 7appilc915l`e, and the approving authority. ***.This report only.describes conditions at the time.of inspection and under the conditions of use at that time. This inspection dais.nit apgrtsts'[ wv.the systernmill perform in the future under the same or different conditions oP use. _. ... ... _. t� fare, .L,-D �s Zv t5ins•11/10 .: Title 5 Official Inspection For u urface Sewage Disposal System Page 1 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 498 Nottingham Drive Property Address Michael Valerio Jr. Trust Owner Owner's Name information is required for every Centerville MA 02632 3/29/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined"(Y, N, ND)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. ❑ Y ❑ N ❑ ND(Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 498 Nottingham Drive Property Address Michael Valerio Jr. Trust Owner Owner's Name information is required for every Centerville MA 02632 3/29/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 498 Nottingham Drive Property Address Michael Valerio Jr. Trust Owner Owner's Name information is required for every Centerville MA 02632 3/29/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 fecal coliform bacteria indicates absent 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: 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 ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert.or available volume is less than % day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 498 Nottingham Drive Property Address Michael Valerio Jr. Trust Owner Owner's Name information is required for every Centerville MA 02632 3/29/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 498 Nottingham Drive . Property Address .... .. .... .... ... .. Michael Valerio Jr. Trust Owner Owner's Name information is required for every Centerville MA 02632 3/29/13 page: Clty1rown State Zip Code - Date of Inspection C. Checklist .. .. .. Check if.the following.have been done..You must indicate".yes" or"no" as to each.of the following Yes:... . No El Pumping information was provided by the owner, occupant, or Board of Health ❑ Were:any of:the:system components pumped out in the previous two weeks? Has the system received normal flows:in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Z Were as built plans of the system:obtained and examined?(If they were not available note as N/A) Z El Was the facility or dwelling inspected for signs of sewage back up? .... M El Was the site inspected for signs of break out? ® ❑. . Were all system components, excluding the SAS, located on site?. . .... .... ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occu pants:if different from owner) provided with El . ® 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: ® ❑ Existing information. For example, a plan at the Board.of Health.. ® Determined in the field(if any of the failure criteria related to Part C is at issue :::approximation of distance is unacceptable [310 CMR 15.302(5)] D. System Information Residential.Flow Conditions: Number of bedrooms(design):._ 4 Number of bedrooms(actual):. 4 DESIGN flow based.on 310 GMR 15.203.(for example: 110 gpd x#of bedrooms): .. 440 t5ins•11/10::: Title 5 Official Inspection Form:Subsurface Sewage:Disposal System-.Page 6 of 17 Commonwealth of Massachusetts ti w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 498 Nottingham Drive Property Address Michael Valerio Jr. Trust Owner Owner's Name information is required for every Centerville MA 02632 3/29/13 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 498 Nottingham Drive Property Address Michael Valerio Jr. Trust Owner Owner's Name information is required for every Centerville MA 02632 3/29/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): n -11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 t5 s P 9 P Y 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 498 Nottingham Drive Property Address Michael Valerio Jr. Trust Owner Owner's Name information is required for every Centerville MA 02632 3/29/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3'6" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: f 20 e0 Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in working order no sign of leakage or blockage. Septic Tank(locate on site plan): 3' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No Dimensions: 1000 gal Sludge depth: 6 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 498 Nottingham Drive Property Address Michael Valerio Jr. Trust Owner Owner's Name information is required for every Centerville MA 02632 3/29/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be structurally sound. No sign of back-up. Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 498 Nottingham Drive Property Address Michael Valerio Jr. Trust Owner Owner's Name information is required for every Centerville MA 02632 3/29/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 498 Nottingham Drive Property Address Michael Valerio Jr. Trust Owner Owner's Name information is required for every Centerville MA 02632 3/29/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(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.): At time of inspection d-box appears to be in good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 498 Nottingham Drive Property Address Michael Valerio Jr. Trust Owner Owner's Name information is required for every Centerville MA 02632 3/29/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (3) 500 gal ❑ 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.): At time of inspection leaching appears to be in working condition. No sign of hydraulic failure 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 groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 498 Nottingham Drive Property Address Michael Valerio Jr. Trust Owner Owner's Name information is required for every Centerville MA 02632 3/29/13 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(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.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 498 Nottingham Drive Property Address Michael Valerio Jr. Trust Owner Owner's Name information is required for every Centerville MA 02632 3/29/13 page. Cltyfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: 0 hand-sketch in the area below ❑ drawing attached separately Pt a y � �Cl szo•� " AZ= z8 A 3T6 A4 = 36 ,6 . B�- 52. -831 56 _B4= G9' i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 498 Nottingham Drive Property Address Michael Valerio Jr. Trust Owner Owner's Name information is required for every Centerville MA 02632 3/29/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >144" feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 4/8/02 Date ® 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 the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 498 Nottingham Drive Property Address Michael Valerio Jr. Trust Owner Owner's Name information is required for every Centerville MA 02632 3/29/13 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 C� -�2 No. o L 2 Jb Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1�/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Migogal *pztem Construction Vermtt Application for a Permit to Construct( )Repair(./I'Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. AM Owner's Name,A dress and el.No. kMv tJl�� Assessor's Map/Pazcel / / �� / �/e OCR( Installer's Name,AddrPLARelUNCO Designer's Name�ddress and Tel.No. / 350 Main Street Meyer W. Yarmouth, MA 02673 S . D t�3 Type of Building: Dwelling No.of Bedrooms�_ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets / Revision Date Title Size of Septic Tank /O t. I, Type of S.A.S. Description of Soil LAB Nature of Repairs or Alterations(Answer when applicable) d a,,, e r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of a FLah ental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. 2wo 2 Date Issued 0 iZ s "d THE COMMONWEALTH OF'MASSACHUSETTS Entered in computer: r '.4 PUBLIC' N HEALTH DIVISION-TOWeO -"' ARNSTABLE., MASSACHUSETTS Yes „2pprication for Oiopo�aYem Conotruction Permit Application for a Permit to Construct( )Repair --'Np�/ de( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. A U, Owner's Name,A dress and Tel.No. Odle. 4=26 -Assessor's Map/Parcel, QO�rI` le oc1� Installer's Name,Address,AAANCANCO Designer's Name,,Address and Tel.No. 350'Main Street W. Yarmou.. , MA 02673 1 Vf - O 3 Type of Building: Dwelling No.of Bedrooms ! Lot Size , sq.ft.. Garbage Grinder( ) Other Type of Building No.of Persons r Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets / Revision Date .-✓"� Title T' Si - Se .c it s Size of Septic Tank /O UQU Xt S�� n Type of S.A.S. Description of Soil �C V IA-A Nature of Repairs or Alterations(Answer when applicable) P ! I C"71d Cao 1�,,., �a �J�/ r 1. i Date last inspected: Agreement: The undersigned agrees to ensure the cons trpct„;on-and-maintenatree ol"Ihe of re described on-site sewage disposal system A in accordance with-the provisions of Title 5 of e,,En, '�© enta'l•C==o'de an'"�nn-31 toitflce the system in operation until a Certifi- cate of Compliarice as been issued by this B6 o Health. ` Signed Date f'o / Application Approved by 1 �'�/ Date 6 i Application Disapproved for the following reasons - l 'I Permit No. Date Issued /V 0 X ————————————— ——— ------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance / THIS IS TO CERTIFY, that the On-site;Sewage Disposal System Constructed( )Repaired( t.•_Upgraded( ) Abandoned( )by �'.-I"i at 9 D i t vI C� has been constructed in accordance with the provisions of Title 5 nd the for Disposal System Construction Permit No. :?ova—?U dated ��l! 12 Installer Designer I The issuance of this ermit shall not be construed as a guarantee that the systefii ill f ction as designed. Date f) Inspector N. ZZZ --------------------------------------- No. oC W Fee s 1 a36 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mfo o�aY � gtem �ongtruction Permit � p f Permission is hereby ranted to Con truct y g ( ) epair( 'p rade( )A a don System located at �'� l A A vA C ��.. 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�enmnitj Date: //((NN 0 2 Approved by � L t S. ,�J-TO,W�N/OF BARNSTABLE LOCATION S- 0 r11V 44M L2M OF ' SEWAGE # _2a)A—e13C VILLAGE K;N7L�✓rCL tE ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. � (01YAC6 SEPTIC TANK CAPACITY C=erd-rlQer k2z 4u�! LEACHING FAC!LrTY: (type)<�6a 2ul/ D"), (size) �'��• rX 1 ��� NO.OF BEDROOMS BUILDER OR OWNS PERMITDATE: q d Z COMPLIANCE DATE: " a Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 i i 19 >W-V Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection ad One winter Street,Boston,Ma. 02103 •lithe eptiepti D.E.P. Title V Septic ItLspector kip P.O. Box 2119 Teati�cket,MA 02536 WILLIAM F.WELD '564-68 L3 Governor r� T ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR ' RJF �� PART A �' CERTIFICATION �t �p 22 1997 498 Nottingham Dr.Centerville Address of Owner: HEAL HD PSr Property Address: 9 Date of Inspection:9/17197 (If different) 4 Name of inspector:John Graci Wendell Rocky I am a DEP approved system inspector pursuant to Section 15.340 of Title%.(310 CMR 15.000) Company Name,Address and Telephone Number: CERTIFICATION STATEMENT i certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This inspection is based on criteria defined in Title V CondFbmita ses code 310 CMR 15.303.My findings are of how the system is Needaluation B the Local Approving Authority performinq at the time of the inspection.My inspection does Y PP 9 ty not Imply am warranty or quarantee or the longevity or the Fails septic system and any of its components useful life. Inspector's Signature: Date: 9117197 The System Inspector shall sy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C, or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/27197) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 0 Telephone(617)292-5500 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 499 Nottingham Dr.Centerville Owner: Wendell Rocky Date of Inspection:9117/97 _ 5ewaae backup or,breakout.or hiah.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for colrform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 498 Nottingham Dr.Centerville Owner: Wendell Rocky Date of Inspection:9/17/97 D] SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 498 Nottingham Dr.Centerville Owner: Wendell Rocky Date of Inspection:9l17/97 . Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: — Pumping information was requested of the owner,occupant, and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x _ The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _X_ — The site was inspected for signs of breakout. x _ All system components,excluding the Soil Absorption System,have been located on the site. x The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge, depth of scum. X _ The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)(15.302(3)(b)] (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 498 Nottingham Dr.Centerville Owner: Wendell Rocky Date of Inspection:9/17/97 FLOW CONDITIONS RESIDENTIAL: Design flow: 440 g.p.d./bedroom for S.A.S. Number of bedrooms: 4 Number of current residents: 2 Garbage grinder(yes or no): Yes Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year 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:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title S system: (yes or no) No Water meter readings, if available: n/a Last date of occupancy: n/a OTHER: (Describe) NO Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System was last pumped three years ego when new pit was installed. System pumped as part of inspection: (yes or no)No If yes,volume pumped: 0 gallons Reason for pumping: n/a TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records,if any) I/A Technology etc. Copy of up to date contract? Other: APPROXIMATE AGE of all components,date installed(if known)and source information: Original 22 years with new Pit installed 3 years ado. Sewage odors detected when arriving at the site: (yes or no) No (revised 04/27197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 498 Nottingham Dr.Centerville Owner: Wendell Rocky Date of Inspection:9/17197 SEPTIC TANK: X (locate on site plan) Depth below grade:4' Material of construction:X concreate metal FRP Polyethylene_other(explain) If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L B'6'H 5'7'W 4'10' Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle: 24" Scum thickness:5" Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle: 13" How dimensions were determined: Measured Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance. GREASE TRAP:_ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_metal_FRP_Polyethylene—other(explain) 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,/, Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) rJa BUILDING SEWER: (Locate on site plan) Depth below grade: 4'6' Material of construction:_cast iron X 40 PVC_other(explain) Distance from private water supply well or suction Iine:t— Diameter: 4• i;vemments: (conditions of joints,venting, evidence of leakage,etc.) (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 498 Nottingham Dr.Centerville Owner: Wendell Rocky Date of Inspection:9/17/97 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n/a Material of construction: concrete metal FRP Polyethylene_other(explain) Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day Alarm level:_n/a Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) n/a DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n/a Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) n!a PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no)No Alarms in working order(yes or no)_yes Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n/a (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 498 Nottingham Dr.Centerville Owner: Wendell Rocky Date of Inspection:9/17/97 SOIL ABSORPTION SYSTEM (SAS):X (locate on site plan,if possible; excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: n/a Type: leaching pits,number: 21,000 gallon leach pits leaching chambers,number:n/a leaching galleries, number: n/a leaching trenches,number, length: n/a leaching fields,number, dimensions:n1a overflow cesspool, number:n/a Alternate system: n1a Name of Technology:_n/a Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) The overflows are structurally sound and functioning propedy.The new pit C had t'of leaching left and the Old pit B was empty. CESSPOOLS:_ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n1a 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: n1a inflow(cesspool must be pumped as part of inspection) n/a 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 (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 498 Nottingham Dr.Centerville Wendell Rocky 9/17/97 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) r) A Cl) lYe� VA VIM ��G g7 �c �(�( (revised 04/27/97) page 0 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 498 Nottingham Dr.Centerville Wendell Rocky 9117/97 Depth of groundwater 12, Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (MUST be completed) USGS Maps and Charts (revised 04/27/97) page 10 of 10 i, r . e/ 9� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH ...OF.................. ...... ..��cJ�!. - ?.� 4 Apphratann -for Biiivuiitti Works C owitrurtion. Puntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Lpeatig�.Address o or Lot No. ..-_1�0�/1�4/.......................... ......11�_N�._a.t....®..�4............................................................ Owner Address --------------- -- .. � Installer Address Type of Building Size Lot....____.,t__________-------Sq. feet aDwelling=No. of Bedrooms__._._.�7...............................Expansion Attic ( ) Garbage Grinder ( ) Q, Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures _______________________________ _ _ W Design Flow------------------------_-------------------gallons per person per day. Total daily flow-------------------------------------------.gallons . 9 Septic Tank—Liquid capacityjV0—gallons Length-_______.__-_- Width------.--------- Diameter................ Depth_.____--._....- xDisposal Trench—No. ..................... Widtl ---•---------------- Total Length----- �__,r achi area.. -._--_ sq. ft. Seepage Pit No.. Diameter.... .......... De th below inlet.�� to im are 1 P__...sc t. _.._ P - a t z Other Distribution box ( ) Dosing tank ( ) end " /�� 7 7 Ste" .9_ '-, Percolation Test Results Performed by.......................................................................... Date------------------------------------- W W Test Pit No. I................mmutes per inch Depth of Tes-t-Pit.................... Depth to ground water-.._-_-__----.-__-_ f� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.--.-----.-_------.... lL---... i------- 0 Description of Soil--- .-- - A1 `�t --------------------------------- - x2. - — ��-� --------------- -------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- ------ 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 be is d y the oard of heal igned -- -------------- --------- `' '6�!..---------•----------------- / Date �� Application Approved BY ...._.. --- = ...- 0...� Date Application Disapproved for the following reasons------------------------------------- - -------------------- ----------------------------- •••-••••--•-••---•----•-•--------•-----•-•-•-•--•-•-••----•--------------••--••--••••-••------•••-•••••••------------------......------.---------------------.'-.....------------------.....---------•--. �KPermit No. Issued. or.N------------ ----oft a. Date NSo ..Ul THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH ...... ... .... Gr ........OF................. t. ..... - -' ...:.. - A.VVIiration -for BioVvsal Works C ontitrurtion Vrrmft Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: •-------------------------------•-------------------------------•----------------------------_..._ .................---------•--------•-•-----•---------••---•----•-•---•......................... Location.Address or Lot No. r .... •_r...a, _..._It a Owner ------••--••-----------•----••..............Address - - -------- Installer Address UType of Building Size Lot.... 1- 0........Sq. feet Dwelling—No. of Bedrooms..----- -----------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building _________________•---..--_.- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures --•---------------•-----------------------•---------- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity/'�0..gallons Length................ Width................ Diameter_----...-__._--- Depth-----____..._.. x Disposal Trench—No. .................... Widtl -------------------- Total Length---------- ___ �V72M.Ieachigp area- ____.sq. ft. See a e Pit No._--^--_ ' ', , g p g Dr____________________ Depth below Inlet ._._.........___ tal I"e iiii irea.._.:._ _'..._.sc. ft. Z Other Distribution box ( ) Dosing tank �.{l Percolation Test Results Performed bY-------------------------------------------------------------------------- Date------_----------------- ------------ Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water-..----____.---------... f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground-------...i----------±------------- - water------------------------ p t -- ---------------- °r---•----••---•--- ---------------------•-------•--------------------------.. D Description of Soil----- ....... fJ'"�'. 1_ r , l _ G _ 1 ---------------------------------- r -- 'l {._ c w . ----------- � - . ------------------------------------- x ------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------- 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 issuedTby the bo"aarrd of health. lgned /"lei 8 ` w l• s✓u rn + Date � Date Application Approved B / /' - " Application Disapproved for the following,':reasons:-------------------------------------7 .._.......---------•------•-------•-•--•......----•-•---••.... .............................................................................................................__..___........_._..______._________.........._.___'.Mx-�..----------------------------------- Date PermitNo........................................ ..: %Issued---------------------- ................-......---------- n r� Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1... .. . .................OF.........! :. Trrtifirate of .Tim;i.0aurr TH115 IS 0 CE That the Individual Sewage Disposal System constructed ( or Repairedby 61Y, ----•---•- ! �-------- Installer at - '`, `,fit--- - --- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------------------....................... dated_---;�'Xt9X7- --- ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............ .............................................................. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1.4 C?-!i ............. FEE./ ............ k n`ntrrtiatrrutit Permission is ieb ranted......_`U-4_ 4 � . . Y g ,�!.- td` -----•--------••------------•----------------------------------•--•---..-•_----........ to ConjWct ( ' ) or Repair ( (4 I izlval,.Sewage Disposal System at No. - �-> ,� a ---- ---`----•-------•- � Lls v f c Street , as shown on the application for Disposal Works Construction ermit N ::. ..._ . Dated.... _ ..:✓''_ ••- .�fC...t .................... Board of Health DATE.... *,2-7�---;7J-----------1-....................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS A TOWN OF BARNSTABLE �n C"p1' LOCATION � ��d C l(�/`� -�rzt tXr SEWAGE # VILLAGE C� A}'��i21�rLC�T �AS"SESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. t C) 64MC® `7 7 S_".18 6 D SEPTIC TANK CAPACITY C(Si&2c! i� LEACHING FACII.ITY: (type� 'AT&ZD!i4 1 w• (size) NO.OF BEDROOMS ,,�BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leachi g a ' WA C Feet Edge of Wetland and Leaching Faciyy w9�anq exist within 300,feet of leaching f ' i 5 Bin rt Feet Furnished by �►• armouth, MA 02673 i i t �TOW`N/OF BARNSTABLE LOCATION � O rm)6, 1M 1291 tk SEWAGE # VILLAGE �f-N��Z 1l�CL.�� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type)��� �� �` � (size) S& �r 13 `*0. OF BEDROOMS BUILDER OR OWNSP 1-4 cemr PERMITDATE: blqFO21 COMPLIANCE DATE: a r Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 A 19 i �.�.. R c r - ,. TOWN OF BARNSTABLE LOCATION -1 /" V�- rf,,e SEWAGE # VILLAGE O gWW✓L4y ASSESSOR'S MAP 6z LOT INSTALLER'S NAME Sz PHONE NO. rEPTIC TANK CAPACITY /000 544t 6yJ - (f-cCIyT i , LEACHING FACILITYAtype) pf�--�V� ► (size) u/ NO. OF BEDROOMS PRIVATE WELL O BLIC WA ER� BUILDER OR OWNER 'e- DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: Zz� VARIANCE GRANTED: Yes No V `vew� P�r a LOCATION : �O �9 SEW&CIE PERMIT UO. VILLAGE - - - - - - - - rO.0014 7Z /less, - - IWSTQLLER 5 U&NIE 4,-' ADDRESS BUILDER'S VJ�& .AE ADDRE.SS L D�►TE PERKA T 155UED d 7� DATE COMPI I WacE ISSUED ; �'-� _ -�}- :. i �O V YI� � .F' I, s ASSESSORS MAP : NOTES:�4'7 _ TEST HOLE LOGS F' PARCEL : Ifp { t ,-� 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH SOIL EVALUAT R : IJR� ge�1 M. M• trig.p-'5, GSE THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF FLOOD ZONE: C WITNESS : IgJA f I IS�`YBL BOARD OF HEALTH REGULATIONS. REFERENCE: 0JA DATE: Pt2tL, � Z - � --- 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES PERCOLATION RATE: 4 2 m'"//n/G14 SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO �, INSTALLATION. Sri CLf�ss S SotL. L =O,'?�f ��� TH- l ei„. 42M TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE 1 A " 'O�i�R � DETERMINATION. +�t �3ry �d 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS G SPECIFIED OTHERWISE) .� LOCATION MAP(N T-< iV q 5)�jy THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A J6 4'3 GARBAGE DISPOSAL.(DrS PoS+4_ TO /SC 9.EM OV" .1) 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) �cr 7,- MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON 4 A BASE OF 6"OF CRUSHED STONE. 4�g�p Lay t "/ . 1 �0 ' 10 SEPTIC SYSTEM DESIGN l , A,/0 9A),Ow,�.�_POerUst; WELLSw�t� FLOW E:ST I MATE BEDROOMS AT I GAL/DAY/BEDROOM - 440 GAL/DAY ' /U). SEPTIC TANK GAL/DAY x 2 DAYS - 910 GAL USE �L GALLON SEPTIC TANK— XfSTx ' —Rep"('tCe iiSoo E;Ar4c It'N Ipwe IF F"m ifao o4mAt�" 04 el 1�i • � SOIL t BSORPT I ON SYSTEM 3) sco P17- L6 -t k1 331511-x t3'wK2'b) ti . SIDE AREA: Z Z x X �Y7 � 3 ? e ,�,�� �° 7Jo � i��"lt i► 'BOTTOM AREA• 31 15 x 13 x G.74 _ 32 Z.'Z-7 tr L .�, .- 440 3 SEPTIC; SYSTEM SECTION y , enr' G ` �E�tIGF(ktRl� / .o 'ro F" EL J / �, e Qv II � � o�eox ��ZV-2 � � �/ GAL Z`/, ,rt�%5f =�i/�d = = �7 SEPTIC TANK � lss .J= � � r SITE AND SEWAGE PL AN LOCATION : E . Starr tr�����,�? j—?ue I 1140 , PR EPARED FOR :Ds - o M 0 z SCALE :r►, DARREN M. MEYER, R.S. --= - W µ� � DATE 43 VINE STREET Z DUXBURY, MA 02332 3 DATE HEALTH AGENT 781 585-0293 Z I,