HomeMy WebLinkAbout0089 OLD FARM ROAD - Health 89 Old Farm. load,
Centerville
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No. �` Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in co puter.
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftphration for Nsposal *pstem Construction Vermit
Application for a Permit to Construct X Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. c9 9 d C-o f,'OJLA �� Owner's Name,Address,and Tel.No.
C d"rt-o v%#.a..�
Assessor's Map/Parcel Z — C)Zj
Installer's Name,Address,and Tel.No. 3 9 9-g 47 mot- Designer's Name,Address,and Tel.No. .42,0-O c,SJ
/�/OhTTf�w.� ��✓�.+4_ ylarFc.:E 4 -«'s
'lope of Building:
Dwelling No.of Bedrooms Lot Size ' 2- sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3 O gpd Design flow provided 3 3 gpd
Plan Date 7 Le, Z+i 1 Number of sheets 2-- Revision Date
Title
Size of Septic Tank / S-o o Doti Type of S.A.S. 2 S-� &
Description of Soil d ` — 4-" GGd 4 n- ?0 4 d'L
Nature of Repairs or Alterations(Answer when applicable)
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 b this Board of Health.
i e A Date 2 Z7 L12-
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
PjQ__� l 4i�"1
oll-
No. Fee
THE B ONWEALTH OFAAS..SAGHUSETTS Entered in pp-t"__�_k� pYes
PUBLIC HEALTH DIVI PION`=TOWt4, BARNSTABLE, MASSACHUSETTS
application for Disposal *P'stl tm Coftstrurtion permit
Application for a Permit to Construct X Repair( ) Upgrade,( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. cy�/ U e-`' t�'2``' ' Owner's Name,Address,and Tel.No.
e C: N T_C 1/I� t Z
Assessor's Map/Parcel Z _ U Z, i
J
Insttaller's Name,Address,and Tel.No. 3 9 fit- D'esigner's Name,Address,and Tel.No. -4
Type of Building:
Dwelling No.of Bedrooms. . .. Lot Size sq.ft. Garbage/Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) -3 O gpd Design flow provided 3 3 d gpd
Plan Date 7 �� /2 e r i Number of sheets Z- Revision Date
Title
Size of Septic Tank / S'u u Go��o Type of S.A.S. 2 SZc) G t) t.
Description of Soil U L u - /Z C. '' f
Nature of Repairs or Alterations(Answer when applicable)
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 b ithis Board of Health.
e (q Date Z /Z7/2-
Application Approved by V, Q Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
-------- --------- = v�o _l_ .11 THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(X Repaired( ) Upgraded( )
Abandoned( )by T 4- 1` .r c,/,A
at u O L '� �� '`''r �Z '� has been cons uuccteAin accordance
with the provisions of Title 5 and the for Disposal System Construction Permit Nod% �'"� dated
Installer /Va-�T-r ✓� t Designer � oia,v. < <� f �•�
#bedrooms 3 Approved-design esigned.
IN/flow ? U gpd
The issuance of this permit shal not be c nstrrueed as a guarantee that the s stem will futn�cas d
Date ( -' �"`� Inspec o-t__ , r`°� ✓
No. Fee �-
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction Vermit
Permission is hereby granted to Construct V) Repair( ) Upgrade( ) Abandon
^^ ( )
System located at % O e- �� /"` �� `� ( It, . K t I 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:Construc on t e co pleted within three years of the date of this permit.
Date Approved by
,
No. 1 Fee
THE COMMONWEALTH OF MASSACHOSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftplicatlon for Vsposd *pstpm Construction Permit
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) Complete System ❑Individual Components
Locat'on Add ess or Lot ` ''0�-3�:L-a7 l
Np gP'�Lj Qct Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel
Installer's ame,Address an Tel.No. Desi n r' Name Address,and Tel.No-po D./�a K �f loin^ =A tnl�Sorl !/9 Kau t,� l e`�
o[
Type of Building:
Dwelling No.of Bedrooms /�� Lot Sized- sq.ft. Garbage Grinder( ) st/®
Other Type of Building �/�Cf L'p•? _No.of Persons _-,4 Showers Cafeteria( )
Other Fixtures -T6 em e LOwc;�_-
Design Flow(min.required) 3M51 gpd Design flow provided gpd
Plan Date -1y/4, �' 7�l Number of sheets ;7- Revision Date
Title ,:�9l/Zg Age 7S
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)woe
Date last inspected: 6011 h!Vjf
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. - W_*
i ed Date
Application Approved by Y C Date
eel
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
- - -- - -------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO C Y,that the On-site S wa a Dis o al s e ons cted( Rep it` ( ) Upgraded( )
i
Abandoned( )by
at has en const uct d'n acc e
with the provisions of Title 5 and the for Disposal System Construction Permit No ted
Installer Designer
#bedrooms Approved design flow and
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposa[ 6pstem Construction Permit
Permission is hereby gr me to Construct(t Repair U grade ) Abandon( ) Q
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must brc /
toewhin three years of the date of this permit.
Date Approved by
No �*-• .�. t t * f a,Fee
� �m„�. -• r' �`� � Entered in computer:
THE COM O��W LTH OF.MA�SACH 'SETTS
PUBLIC HEALTH DIVISION -'TOWN OF-BARNSTABLE, MASSACHUSETTS Yes
F, kcy 0 U% posai -pstem Construction Permit
Application for a PeXmit to'Co s•�t Repair( ) Upgrade( ) Abandon(�*Ckplefe' System ❑Individual Components
Locaon Add'essfo'r�Lo 1I�T c �'�l�j pc� ,..,Owner_-'s Irlam'° rAddress,and Tel.No.
Assessor'sMap/Parcel 47 W , ffxMiA;n7-$ . D f
Installer's-.lame,Address,an Tel.,Nd. am s'gne' e;Address;and.Tel.No
l( Sj t 3 ff o n'1 .^a G
AA 44
c //
Type of Building: 5 al 3 .0j---5 qq 3 '
_. Dwelling No.of Bedrooms / Lot Size i e - sq.ft. Garbage Grinder( ) A&)
Other Type of Building !r/ iCf L'O% No.
/of,.,Peersons F Showers(3) Cafeteria( )
w0ther Fixtures �� /h� i fr /� e't
i Design Flow(min.required) - 3'-51 gpd Design flow provided gpd
'Plan Date J A, ;e> Number of sheets Revision Date
Title T I r�9�f //d? P t`8 r
Size of Septic Tank Type of S.A.S. rt 'tl
~ Description of Soil
s/ L — 3 3c>
o SL lab
i
g . Nattrre`of Repairs or Alterations(Answer when applicable)_//��
9 . r
-Date last inspected:
Aireement:
-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.
r' � signed °'.� � ,. � ;� tt�. _ Date
Application Approved by Date
l -Application Disapproved by r V• tt� �� 1 x / Date r
for the following reasons
Permit No. �- Date Issued-
Permit /
a
THE COMMONWEALTH OF MASSACHUSETTS
F
BARNSTABLE,MASSACHUSETTS
' Certificate of Compliance
t
THIS IS TO C Y,that the On-site S a e Disposal sy e onstc��d( Rep it d( ) Upgraded( )
Abandoned( )by V 1571
J
at has been construct d'n acco. a e
with the provisions of Title 5 and the for Disposal System Construction Permit N t dated
Installer Designer
#bedrooms Approved design flow gpd
The issuance of this permit shall not �cons4 ed as a guarantee that the system will function as designed.
Date Inspector
-------------------------------'---`--------------------------=----------------------------------------------------------------------------
No. � � Fee
- THE COMMONWEALTH OF MASSACHUSETTS '
PUBLIC-HEALTH'DIVISI&_BARNSTABLE',MASSACHUSETTS
Misposal *pstem Construction Permit
Permission is hereby grant to Construct( Repair( U grade ) Abandon( ) 4
System located at
' and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
r•
Title 5 and the following local provisions or special conditions.
� 4
Provided:Construction must co 1 e,wAhin hree years of the date of this permit.
/1 f
Date Approved by �)
TOWN OF BARNSTABLE
LOCATION
SEWAGE #VILLAGE (-/�
e"j' -^y,4-&,C ASSESSOR'S MAP & LOT Z31-0Z4
r. 3
INSTALLER'S NAME&PHONE N0. oi+Tr4c:n^ �A✓� Sy�9 r �- 3 ® 5'*7#
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) D'-yws#-K (size) ZS •�/ Z• 3
NO. OF BEDROOMS >
BUILDER OR OWNER `Q�yJ.g �y�`-'"•''` �'�.
PERMITDATE: �l Z�/�Z COMPLIANCE DATE: Z(Zs �t2—
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If"any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by ���'`� """ ��' ~ ~O
26
Z
1 3 37
44 4
�r s
Town of Barnstable
Regulatory Services
ti
Thomas F. Geit6r,Director
MASS. i Public Health Division
039.
3 9. �
0. Thomas McKean Director
FD p�pl
200 Main Street, Hyannis,MA 02601
Office: 508-a-44 Fax: 508-790-6304
Date: 3 Sewage Permit#2 d ' Assessor's Map/Parcel
Installer & Designer Certification Form
Designer: R C zon Installer.
Y&VI lLGe C.C..n v -VCLI
Address: 1.11 Ro L,J( 14 9 Address: f,3 4-;,C_ 9 g
oz6a9
On 2-12-7 Z- ✓ /� -�`� ��''� ^'�- was issued a permit to install a
(date) g j (installer)
septic system at (rqry� aJ eeY1e0A based on a design drawn by
(address)
dated Z L
(design )
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 inspected and the soils
were found satisfactory.
vV '
(Installer's Signature)
(D i is Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
q:\office forms\designercertification form.doc.
i
Town of Barnstable P#
rt�
Department of Regulatory Services
anrwarnstu Public Health Division Date
rdees. I i
200 Main Street,Hyannis MA 02601
{
Date Scheduled �f Time Fee Pd. /06
Soil Suitability Assessment for Se age Disposal
Performed By: Witnessed By:
LOCATION& GENERAL INFORMATION
Location Address C L
U�G� l e,,V Y✓1 11C d` Owner s Name C,,.j Vt r�1 Cti
(,e k4 -ert,/ lC v3 i` -r—i-e i i
Address 00 /I..
Assessor's Map/Parcel: �j U Engineer's Name yVn K
NEW CONSTRUCTION � REPAIR Telephone#
� 7 r7�CJrr'�j
Land Use Slopes(%) Surface Stones
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft
Drainage Way ft Property Lane ft Other ft
SKETCH:(Street name,dimensions of tot,exact locations of test holes&perc tests,locate wetlands in proximity,to holes)
!
i
Parent material(geologic) o Depth to Bedrock l�
j
Depth to Groundwater. Standing Water in Hole: � Weeping from Pit Face TA '
Estimated Seasonal High Groundwater
DETERARNATION FOR SEASONAL HIGH WATER TABL,Ia
Method Used:
Depth Observed standing in obs.hole: in, Depth to loll mettles: in.
Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level. Adj,factor Adj.Groundwater Level
PERCOLATION TEST bate Time,______
Observation I
Hole#
Time at h"
, v—
Depth of Per Time at 6"
Start Pre-soak Time @ 01J, Time(9"-6")
End Pre-soak
Rate MinJlnch � /k✓
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN)
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:\SEPTICVERCFORM.DOC
i
DEEP-OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling
(structure,Stones;Boulders.
on i tenc:L--%Gravel)
1
0
i
DEEP OBSERVATION HOLE LOG Hole#
SDepth from Soil Horizon Soil Texture Soil Color Soil Other
urface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders,
onsi5tency,%Gmyel
t
i
I
i
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
I
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consistency, 1
l
1
Flood Insurance Rate Map:
Above 500 year flood boundary No- Yes
Within 500 year boundary No=' Yeses
Within 100 year flood boundary No. t Yes
I
Death of Naturally Occurrint:Pervious Material
Does at least four feet of naturally occurring pervio Taterial exist in all areas observed throughout the
area proposed for the soil absorption system? ~ 1` �r�
If not,what is the depth of naturally occurring per sous maCerial?
Certification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Enviromliental Protection and that the above analysis was performed by me consistent with
the required training,VXper
' e nd experience described in 310 CMR 15.01Signatur % Date ZC)
Q:ISEPTICVERCFORM.DOC
Town of.Barnstable Geographic Information System May 23;2011
f 251002 251001003
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#75 #86
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® #68 #62 #62
231 Parcel:025:DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map: Selected Parcel ��boundary determination or regulatory interpretation. Enlargements beyond a scale of Owner:PIKNICK,CYNTHIA O ESTATE OF Total Assessed Value:$657700
1"=100'may not meet established map accuracy standards. The parcel lines on this map
are only graphic representations of Assessor's tax parcels. They are not true property Co-Owner: Acreage:0.42 acres - Abutters w'� ' E
boundaries and do not represent accurate relationships to physical features on the map
Location:89 OLD FARM ROAD Buffer
such as building locations. -
w
Commonwealth of Massachusetts
L W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 89 Old Farm Rd.
Property Address
Estate of Cynthia Piknick
Owner Owner's Name
information is required for Centerville Ma. 02632 7/10/09
every 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: A. General Information
When filling out IDS
forms on the
computer,use 1. Inspector:
only the tab key
` to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
P.O.Box 763
Company Address
Centerville Ma. 02632
�rmn City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
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 ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
7/10/09
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authprity{hoard
of Health or DEP)within 30 days of completing this inspection. If the systeft1s a shar6d.Esyste.rh or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit tilb
report to the appropriate regional office of the DEP. The original should besent to the systerrtner
and copies sent to the buyer, if applicable, and the approving authority. ; Ina
****This report only describes conditions at the time of inspection and under the coridations;$f use
at that time.This inspection does not address how the system will perform in the fiuturonder
the same or different conditions of use. Naca
M
LboeA
t5ins•09108 Title 5 Official Inspection For .Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 89 Old Farm Rd.
Property Address
Estate of Cynthia Piknick
Owner Owner's Name
information is required for Centerville Ma. 02632 7/10/09
every 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:
The septic system is in proper working order at the present time.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I r,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Old Farm Rd.
Property Address
Estate of Cynthia Piknick
Owner Owner's Name
information is required for Centerville Ma. 02632 7/10/09
every page. City/Town 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
I
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 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
° 89 Old Farm Rd.
M
Property Address
Estate of Cynthia Piknick
Owner Owner's Name
information is required for Centerville Ma. 02632 7/10/09
every 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 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 Old Farm Rd.
Property Address
Estate of Cynthia Piknick
Owner Owner's Name
information is required for Centerville Ma. 02632 7/10/09
every page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 89 Old Farm Rd.
Property Address
Estate of Cynthia Piknick
Owner Owner's Name
information is required for Centerville Ma. 02632 7/10/09
every page. City/Town 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
® ❑ 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?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note 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 the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge 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:
❑ ® 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): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 89 Old Farm Rd.
Property Address
Estate of Cynthia Piknick
Owner Owner's Name
information is required for Centerville Ma. 02632 7/10/09
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 1000 gallon septic tank,distribution box and leaching pit.
Number of current residents: 0
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 NA
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
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•09/08 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
wM 89 Old Farm Rd.
Property Address
Estate of Cynthia Piknick
Owner Owner's Name
information is required for Centerville Ma. 02632 7/10/09
every page. City/Town 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):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 Old Farm Rd.
Property Address
Estate of Cynthia Piknick
Owner Owner's Name
information is required for Centerville Ma. 02632 7/10/09
every 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:
1995
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10'+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
Depth below grade: 2'5'
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 gallon
Sludge depth:
5"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 89 Old Farm Rd.
Property Address
Estate of Cynthia Piknick
Owner Owner's Name
information is required for Centerville Ma. 02632 7/10/09
every 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
17"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle 1 2.,
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 89 Old Farm Rd.
Property Address
Estate of Cynthia Piknick
Owner Owner's Name
information is required for Centerville Ma. 02632 7/10/09
every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,0 89 Old Farm Rd.
Property Address
Estate of Cynthia Piknick
Owner Owner's Name
information is required for Centerville Ma. 02632 7/10/09
every 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 No
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.):
Bos is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or
out of box.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM ,•°''� 89 Old Farm Rd.
Property Address
Estate of Cynthia Piknick
Owner Owner's Name
information is required for Centerville Ma. 02632 7/10/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ 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.):
Sandy dry soil.No signs of hydraulic failure.Leaching pit was dry at time of inspection.Stain line
observed 52" below invert.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
ti
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 89 Old Farm Rd.
Property Address
Estate of Cynthia Piknick
Owner Owner's Name
information is required for Centerville Ma. 02632 7/10/09
every page. City/Town 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.):
f
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
0.
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Old Farm Rd.
Property Address
Estate of Cynthia Piknick
Owner Owner's Name
information is required for Centerville Ma. 02632 7/10/09
every page. City/Town 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:
❑ hand-sketch in the area below
❑ drawing attached separately
..
i
T .
t5ins•09108 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
M 89 Old Farm Rd.
Property Address
Estate of Cynthia Piknick
Owner Owner's Name
information is required for Centerville Ma. 02632 7/10/09
every page. City/Town 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: Bottom of LP 20'
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: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
As-Built
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
r +�
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 89 Old Farm Rd.
Property Address
Estate of Cynthia Piknick
Owner Owner's Name
information is required for Centerville Ma. 02632 7/10/09
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary:A, B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
E System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
f S /- 0os
r
V
Fmc.... ....30._Q.�..
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliratioat for M-1-ip oral Workii Toatotratrtioat runfit
Application is hereby made for a Permit to Construct ( ) or Repair )(XN an Individual Sewage Disposal
System at:
..M......i�1_a-lee ,r-... _kikrzi_ck..;era--------------------------- 1 f Va
Location-i\ddress or Lot No.
89 Old Farm Road Centerville
Owner Address
aS-..P..Macomber-..J=....................................................... ..................................................................................................
Installer Address
UType of Building Size Lot............................Sq. feet
Dwellin6X No. of Bedrooms-----------3...............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons________._-_-------____._. Showers ( ) — Cafeteria ( )
dOther fixtures --------------------------------------------------------------------------------------- ------------------------------------- .......................
Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter.--------------- Depth................
x Disposal Trench—No. .._____-___-_____- Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
►-, Percolation Test Results Performed by-------- ------------ -------------------------------------------------=- Date-----------.....-----------------------
a Test Pit No. 1________________minutes per inch Depth of Test Pit-------------------- Depth to ground water-..._...__.__-_______._.
LZ4 Test Pit No. 2................minutes per, inch Depth of Test Pit-------------------- Depth to ground water........................
0 ----------------------------------------------------------------------------•---•-------•--•--------------••-----•-----•----•.-----......-----.........-----
0 Description of.Soil........................................................................................................................................................................
U ...............Sand... ::.:c V z---------------------------
w
UNature of Repairs or Alterations—Answer when applicable._.-_.__Omit--Cesspools_.-...Install 1---1 000.,
Im l.D.D.Q..-gallon..leaching_..pit._.........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has Wepir
is ed the bo d o health.
Signed ...- . - .. ......" -- - - 3.L.1 7./9.5.....
- � Dare
Application.Approved B _ D�e
------------- --- ------------------------- , 6
Application Disapproved for the following reasons:
................... ..... ......................... ........................ ................ ........................ ----------------. ................
• � Mro
Permit No. ---- ...... ... Y Issued ......... .......... .�j.... E�,t............
.. Dare
o 0�—
.�
P1.51
THE COMMONWEALTH OF MASSAG ` USETTS
_ BOARD OF HEALTH
i
TOWN OF BARNSTABLE
- � r
A liration for Dig nial U ark,i Tva� trnrtiuitef rrnttt
4Application is hereby made for a Permit to Construct ( ) or 'RcIktIr')(XX)`•an fndividual Sewage Disposal
System at:
Mr W7alter kn
Location-Address U or Lot No.
89 Old Farm Road Centerville__________________ " ' _
-- ---
Owner — »'�' Address )
aaT.P...!a. !C2P,1hF?3'..._Lr........................................................ ......_--------- 7 -7
Installer Address
Type of Building Size Lot............................Sq. feet
DwellingXX No. of Bedrooms-----
_--...--
-------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building _-------------------- .... No. of persons-_---....._.__-_-----.._. Showers ( ) — Cafeteria ( )
QOther fixtures ------------------------------------------------------------------------------- ------ -------------------;.........................................
W Design Flow--------------------------------------------gallons per person per day. Total daily flow........----_.;--_-_........_...............gallons.
WSeptic Tank—Liquid capacity.-..----....gallons Length---------------- Width..--_-...._._ Diameter---------------- Depth................
x Disposal Trench— No. ....-_-_.---.------- Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.............---.... Depth below inlet..................-- Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY.........-................................................................ Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water..............--...--...
44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-.---------.__-_.._----.
9 1 •---•--•------------------- .................................................................................................................................
0 Description of Soil------------------------ ----------------------------------•-•-------------------------.---•-•----------------•--••--------------------•--•••----•••-•-............,-..
xSand---..--•Gravel------------------------------------------------•----:---------------------.....--------•---•-•--•-----•----•--•-•--------------•..........---------•--
W
U Nature of Repairs or Alterations—Answer when applicable.-----.-Omit Cesspools. Install 1 -_1 0 0 0
,.gallon tank, l -distribution-•box and 1•-1 000--_gallon._Leachina..pitK --.-----.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has bee is ed y the boVhealth.
Signed ...... . f .... _.... . �.......l .....------
............. 3 1 7 9 5
Dace �---�
Application.Approved B ---- -- ------- --- --- --- - ---------------- -------------------......----------------------..... .'" i l3'` .%✓
Dare
Application Disapproved for the following reasonf: -----------------------------------------l---------------------------------------------------------------------------------
........... ...... .............. ...... ..._.........-------------------------_------------ --------------------------------------------------------------- -------------------------------------
Permit No. {'.. ` ........
. .......�.... ....._.. ... Issued ------- `--- -------"'
Dace
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
QLIErttftcaxte of (1umplia ace t
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired 9XV0
J.P.Macomber R.r. - ------------------ ------------------- ---------------- ....... -------------------------------
Installer
at .. 89 Ol.d_Farmhil.l.-Road-------------C.ent.er.vil-le-.-------------------------------------.---------------------------------------------------------------
has been installed in accordance with the provisions of TITI_ 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ._......... ... _.. dated
THE ISSUANCE OF THIS CERTIFICATE SHALL N �E CO TRUED-AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
�� [�
DATE..�..:...../�--.--... ....._`..G.'�........ -..._..... _ -- Inspect . .-
—---_---------------- ------------_•-- __—— ——— ---- .. ------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.11_....t � FEE-.--......0 0
Riipniitt1 Vorkii Tunutrurtilan "rrntit
Permission is hereby granted----J.P.Macomber.... r-......................................
to Con t uct ;( ) or Repair(XX) an Individual Sewage Disposal System
atNo........•�-•-d---Farm Road Centerville...M�SS----------- -------------------------------------------------------- -----•---•-•--
street r''T '
as shown on the application for Disposal Works Construction Permit' �Date4K'.'....... ,5
................ r'' rr-�'? -.. ....c_'s'L... . ...----•-
� we q Board of Health `I
DATE �,_--------------••-----••-•---------------------------•-••-----------------
FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS
TOWN OF BARNSTABLE N
LOCATION 9 QL A) Ed SEWAGE# 7.�
VILLAGE-C9 yl,4e d'✓P I i ASSESSOR'S MAP&LOT ---e )
INSTALLER'S NAME&PHONE NO. __ -� VVl w C ®l�Vl�I�/' 50" t ri c.
SEPTIC TANK CAPACITY I o a U
LEACHING FACILITY: (type) ?I f" (size) (o O U
NO.OF BEDROOMS 3
BUILDER OR OWNERi
PERMTr DATE: . COMPLIANCE DATE:
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
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TT" ....................... ..I................................ ��' V;
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DEEP EARLY ENTRY SAWCUT1 I A.5 a
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CH IOhQO•STRIP FOOTING. I CONTRACTION JOINT6 I _
PROVIDE DI.S NORIZ.BARB CONTINUOUS 1 STRIP FOOTING w I
KEYWAY.PROVIDE i5 VCRT.DOWELS S 2Ny O.G.=IORIZ.EXTENDED I �__}____________________
W-6'MIN,ABOVE TOP Or FOOTING.PRO✓ID!5/� ANCHOR I r_________________ I I
DOLTL S Li O.G.MAX.MIN 7•EMBEDMENT.v .Sk1/4'PLAT!WASHER I I 4''CONC. SLAB
Z.ALL STRUCTURAL STEEL COLUMNS TO BE 5 1/2'CONCRETE FILLED LALLY I I ON VAPOR BARRIER I $ _1pjla fg=13
COLUMNS To DCTOND TO FOOTING BELOW.PROVIDE ik6kD/L•CAP PLATE I I GARAGE SLAB I I , 1,� "R/iRl�l LAP 01.1
6 7`xI2W4•MBE PLATE w Z 83/4• DIA.BOLTS.WELD ALL CONNECTIONS EE C
FOOTINGS TO DE a6k56kT2'SQUARE CONCRETE w 5•5 BARS EACH WAY. I { I ~TOOWACH R•a�DOORF, I I i pppp�l
CONTRACT SMALL I g
5. DOUBLE FLOOR JOL7'9 UNDER ALL PARALLEL PARTITIONS, 1 ANCAVIRAGI UM 1 I g5 gi
CUT ALONG WALLS AND 4.CONCRETE IN TO BE 4'BEEAMM COLUMN LINES.ON COMPACTED raL. - I 1FOOTING,
5. CONTRACTOR TO PROVIDE BASEMENT VENTILATION A9 I 1 I G dd�g3E E
REQUIRED DY COD!(WINDOWS OR MECHANICAL) I G i A.6
61 CONTRACTOR SHALL INSURE THAT ALL FOUNDATION WALLS MAINTAINpig
m
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DS OF
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q CONTRACTOR SHALL NOT SCALE DRAWINGS FOR DIMENSIONS. ANY MISSING, ..
INCORRECT oR GiUISTIONABLCC DIMENSIONS NOT DRO/GNT TO THE ATTENTION /
Q THE DE�IGNLR BlCOT1E TM!RESPONS181LYTY 0I TN!CONTRACTOR. ______AFR—'ON
10.
2@i"PAGE OAND
$BOTTOM BA�RS.FQD
ftE9TATouNSDATION gN�ZO'fO TTit�FOOTING. MCKPILL W CLEF.4 TYPICAL NOTES: X
PROVIDE'11 a5 CONTINUOUS HORIZONTAL BARS AND KEYWAY IN STRIP FOOTING. COMPACTED FILL N =
LAP TOP MRS TO MAIN WALL BARB. PROVIDE TR/WBI'�ICH REINFORCING w N.5 y.
BARS SPACED•IZ'O.C.VER7ICALLY. PROMO°5/5'XI� 4NCHOR 1�-q• '-b' '-6' -6' p_q• STRUCTURAL EMINEER/DEBIGNER TO Pl"To0rg FRAMING INSFSELC
BOLTS
•96'O.C.MAX.MIN 7'O"IBEWICNT.r/51B'al/4 PLAT!WASHER WHEN FRAMING IS CAMPLETE AND PRIOR TO ENCW911R!DY INTERIOR •"
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A ....................................................... .. A b eTORAGE so FT. e
•• ••••• FORCN AREAS NO FT. e y
A.5 A 5 TOTAL UNDER Moor
w ' NOTEI 9 ga R9�
ALL WINDOWS ARE TO BE
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i fi'O.C.UNLEEe OTNEIWISL NOTED. C1
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EXISTING STRUCTURES
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MASON m g QSTEPHEN �N a
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16 ® `
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PROPOSED DECK
®♦ 00 Feet v,
pct` PROPOSED HOU C',
u
LOCUS MAP
PLAN REF 36-69, 105-107
� PROPOSED RET. WALL & STAIRS
1 .8ft DEED REF.- 1128-78
O ASSESSOR'S MAR- 231-025
'EXISTING CONCRETE OR O '% %= ZONING: RD-1
STONE ONE WALKWAYS & STEPS / " ' '%"" �'
,j � - �-l-; ;;,, �-�� SETBACKS.- 30'-10'-10'
FLOOD ZONE.• C
PANEL NUMBER- 250001 0005 C
DATED.- 0 81-1 911 9 8 5
LOT 5
OVERLAY DIST GP, RPOD, ZONE II,
MASS ESTUARIES
SITE & SEPTIC
PROPOSED RET. WALL
f. 4
1 1 .2f �2�� o A 9 _ _ PLAN OF LAND
PROPOSED SEPTIC TANK
r P LOCATED AT
TO WETLAND = 105.3' 6' / 89 OLD FARM ROAD
PROPOSED S.A.S. PROPOSED BRICK WALK �-
TO WETLAND = 120.9' 2 CENTER WLLE, MA
-13
PROPOSED 1500 GAL. TANK � �� #1P 3r PREPARED FOR.-
-- PROPOSED S BOX 4
QD� LOT CAPE COMMERCE NOMINEE
� PROPOSO S.A.S. CHAMBER TRENCH /Gc�� �j���Q $ REALTY TRUST
_—_� � �� �
< JUL Y 6, 2011
LOT 3
REV
I
GRAPHIC SCALE �P #86;;� • $ � REV
�o�30 0 15 30 60 REV
YANKEE LAND SURVEY
1 inch = 30 ft. LO CO., INC.'
119 ROUTE 149
BENCHMARK: GAS SHUT OFF MARSTONS MILLS, MA 02648
ELEVATION: 54,13' TEL• 508-428-0055 FAX 508-420-5553
YAMM SURVEYOCOMCAST.NET A'{>PTY.YAAQEFASURVEY.COM
DATUM: TOWN GIS±
r SHEET 2 OF 3 JOB 09 54723 SH
F
SEWAGE SYSTEM PROFILE VIEW N . T . S .
T.O.F. EL. 52.5'
FIN GRADE = 52't 1 '
RISERS FIN ADE = 52.3't
1/8" TO 1/2" DOUBLE WASHED STONE 0 3" THICK OR GEOTEXTILE FABRIC
INV EL. nIA. D A, tN-
FIN GRADE = 52.5't
49.92' S1.06' . i / i . i i . . . . / i. . .
8" MIN
DIA. �- 8.5'
INSPECTION
INV EL. 10" MIN. 14' MIN. INV EL. PORT ONE) L. 49.74'
49.62' �- 49.37 INV EV EL.BELOW FLOW LINE 49.309.10' EL. 48.91LIQUID LEVEL 48" GAS BAFFLE D STONE °a a ° EL. 46.91'
>7:a:<cz:c:�;> :;`-:6 STON a;.�:xc �-:�>c-_ PROPOSED • ° ° - --- - - --- - e •°, • e
PROPOSED 15ST GALLON TANK DISTRIBUTION BOX 4,8" ° 3/4" - 1 1/2" 48"
PRECAST REINFORCED CONCRETE DISTRIBUTION ,BOX DOUBLE WASHED STONE
TEES SHALL BE CONSTRUCTED OF SCHEDULE 40 PVC AND SHALL EXTEND A DISTRIBUTION BOX SHALL HAVE WATERTIGHT COVER 25' o
MINIMUM OF 6" ABOVE THE FLOW LINE OF THE SEPTIC TANK AND BE ON MINIMUM WALL THICKNESS = 2" PROPOSED CHAMBER TRENCH
THE CENTERLINE OF THE SEPTIC TANK LOCATED DIRECTLEY UNDER THE MINIMUM INSIDE DIMENSION = 12"
CLEAN-OUT MANHOLE. OUTLET INVERTS SHALL BE EQUAL TO EACH OTHER AND AT
THE INLET PIPE ELEVATION SHALL BE NO LESS THAN 2" NOR MORE THAN 3" 2" MINIMUM BELOW INLET INVERT.
ABOVE THE INVERT ELEVATION OF THE OUTLET PIPE. THE DISTRIBUTION LINES FROM THE DISTRIBUTION BOX SHALL ALL HAVE
EQUAL INVERTS AS DETERMINED B FLOODING OODING THE DISTRIBUTION BOX TO
- L
=
SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9" THE HEIGHT OF THE DISTRIBUTION LINE INVERT AFTER ALL LINES HAVE BOTTOM O 0F SOIL PIT EL. 42.9'
TWO 20" MANHOLES WITH READILY REMOVABLE IMPERMEABLE COVERS BEEN SEALED IN PLACE. NO GROUND WATER OR
OF DURABLE MATERIAL SHALL BE PROVIDED WITH ACCESS PORTS. INVERT ADJUSTMENTS SHALL BE MADE BY FILLING WITH DURABLE AND REDOXIMORPHIC FEATURES OBSERVED
MIDDLE ACCESS PORT SHALL BE 8" DIA. MINIMUM. NONDEFORMABLE MATERIAL PERMANENTLY FASTENED TO THE LINE OR
THE OUTLET TEE SHALL BE EQUIPPED WITH GAS BAFFLE. RECONSTRUCTING THE LINES UNTIL ALL INVERTS ARE OF EQUAL ELEVATION. OBSERVED TOP OF POND WATER
SEPTIC TANK SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL, DISTRIBUTION BOX SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL. ELEVATION = 31.7'
STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON WHICH STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON WHICH
6" OF CRUSHED STONE HAS BEEN PLACED TO ENSURE STABILITY AND 6" OF CRUSHED STONE HAS BEEN PLACED TO ENSURE STABILITY AND
TO PREVENT SETTLING. TO PREVENT SETTLING.
SEPTIC TANK CAPATICY:
REQUIRED - 330 GALLONS AT 200% DESIGN DATA:
PROVIDED - 1500 GALLONS THREE BEDROOM = 3 X 110 = 330 GPD REQUIRED FLOW FIN GRADE = 52.5't
NO GARBAGE DISPOSAL ALLOWED 12.83' ' '' ' '
USE: CHAMBER TRENCH 251 X 12.83'W X 2' EFF/DEPTH 34'v °°"I° °° °° °
°ae •o - 24,>
GENERAL NOTES: (25' + 25' + 12.83 + 12.83) X 2.0 = 151 S.F. • -;58
1 . ALL THE WORKMANSHIP AND MATERIALS SHALL CONFORM TO DEP 25' X 12.83 = 320 S:1 . 48" ° 48"
TITLE V AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS 471 X 0.74 = 348 GPD TOTAL DESIGN FLOW
FOR THE SUBSURFACE DISPOSAL OF SEWAGE. NUMBER of TRENCHES = ONE
NUMBER OF UNITS = TWO
2. ACCESS PORTS OVER TANK TEES SHALL BE ACCESSIBLE WITHIN 6"
OF FINISHED GRADE PROPOSED LEACH TRENCH - END VIEW
3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF INSTALL Two 500 GALLON UNITS
WITH FOUR FEET OF DOUBLE WASHED STONE
WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10' AT SIDES AND ENDS
OF DRIVES OR PARKING. �2-0_ LOADING SHALL BE USED UNDER OR WITHIN T.P. #1 PERC <2 M/INCH T.P. #2 PERC <2 M/INCH
10' OF DRIVES OR PARKING, UNLESS NOTED.
4. THE EXCAVATOR/CONTRACTOR SHALL CALL "DIG SAFE" AND VERIFY THE LOCATION EL. 53.4' O" EL. 53.4' 0"
OF SITE UTILITIES PRIOR TO ANY EXCAVATION, AND SHALL BE RESPONSIBLE FOR
ALL MATTERS RELATING TO ELECTRIC AND/OR GAS EASEMENTS. "A" "L'" 4„ "A" "LS" 4"
5. SEWER PIPES SHALL BE SCHEDULE 40 PVC. (4" DIA. UNLESS UTHERWISE NOTED) I
6. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL BE "B" "S 10 YR 6/8 "B" "SL" 10 YR 6/8 SOIL DATA:
MORTARED IN PLACE AND SECURED TO UNAUTHORIZED ACCESS. 30"(EL. 50.9') 3o"'EL. 50.9') TEST DATE: 04/27/2011
7. FINISH GRADE SHALL HAVE A MINIMUM SLOPE OF 0.02 FT. PER FOOT. PERC EL=50.0' PERC EL=50.0' SOIL EVALUATOR: DAVID B MASON
8. EXISTING SYSTEM COMPONENTS - IF ANY - SHALL BE ABANDONED PER APPROVAL DATE: 10/94
TITLE 5 REQUIREMENTS. "C" "MS" 10 YR 7/6 "�" "MS" 10 YR 7/6 HEALTH AGENT: DESMARAIS
9. THE EXCAVATOR/CONTRACTOR SHALL BE RESPONSIBLE TO CONTACT YANKEE EL. 42.9' 126• EL. 42.9' 126" P# 13266
SURVEY 24 HOURS PRIOR TO ANY REQUIRED INSPECTIONS.
10. ALL COMPONENTS SHALL BE MARKED WITH MAGNETIC TAPE OR NO G\WATER OR NO G\WATER OR
COMPARABLE MEANS IN ORDER TO LOCATE THEM ONCE BURIED. REDOXIMORPHIC FEATURES REDOXIMORPHIC FEATURES
SHEET 3 OF 3 JOB NUMBER-_ 54 723
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JOB: 1125
DRAWN BY: KW
DATE: I I/15/11
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SCALE: 1/4' - I'-0"
JOB: 25
DRAWN BY: Kw
DATE: 1,/I5/11
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DRAWN BY: KW
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DATE: 11/15Y11