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HomeMy WebLinkAbout1041 OLD STAGE ROAD - Health 1041 Old Stage Road, Centerville III__�_ _ /J J�Q.ECVClppco I/N o tim 3 UPC 12543 o- No. 5_3LOR ot°pSl•CON'JY� HASTINGS, MN a ( v j 79:�� TOWN OF BARNSTABLE r or LOCATION ,a s e 16 SEWAGE# l �a VILLA E C �t �' / P �� ASSESSOR'S MAP&LOT E INSTALLER'S NAM &PHONE NO. �I/f r4 eeS C#a C ' SEPTIC TANK CAPACITY 15�� C7a—( LEACHING FACILITY: (type) .1/V �7,^`�Tb /rPr' (size) -s- I S NO.OF BEDROOMS ITW o S BUILDER OR OWNER PERMITDATE:` — MPLIANCE DATE: A?- Separation Distance Between the: �-- Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �1 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 Q � �3 .may, -7 3a" s , A 3 S3© � � S3,, ,�- 1 � ��1, 5� 8q) cza ,�' 'IPi,h PIXE,tnr /e� KIEIt ENiILNW/.NIGINhELD\ ^ Taor9a m/� ' 2 ' TSQEN:A15i5 / T ' IT vv SnvErwuzr,ronu;>rnl,me ---' ' A`DCELK'.S RRCa2 5'9/T' I� RKi YEIf F_-�'1 LU- lrJMl , NfEEO T.4 SNTSa CTx 4tAn GPC1.i I^'.11.j•: Sfj{ tAriLo!ARX �'1 S /2" 2J' �i 1.• F' 26 P.fX.CVI/. 54 YN y.• �iIIPISIIfE T. TYPICAL 5eCfION(NEW CON5.) NG'fE: vN�I�ELIrLNI:.iM,;.iIOhN;r�l: r�GNR., A5 6ELL,A5 POOR5 ANG MNG0✓v5 THAT All ALREADY EX15TIN6. fIf 5ECOND FLOOR DORMER ON MAIN HOUSE /(��, 15 EXISTING,A5 WELL A5 ROUQ1 PLUM131N6i. T ®� "A"VORMMS ON iNE FRONT WiLL PE APPEL? SECOND FLOORPLAN NL O�MfEafN.,NAfE MD LQ"X Ca.ES. ��•': L9FNVTSND�AlA11Cw'b.EiC.9Wa.OE 7j'.�'' - carcEgv Na/�ioa v�Eu�NE nEVY�w vNwcE vnm ms n,w.ce LeEl+s:v L:'. CQYIPICiGP ND/LE N7f.YQMER W1i. AYAAY NL IEYONSDLIry f LR 1�' C4At°LWI2 YJINNL Cll$Nf•EOEPIL,NA2 IW laa CRE£ fEIAfECIPEQD,DflNa 1fEW/A Ck PMICPARW DESYAERb AYAY.ES NfV H EPQYAf Nry O.ER MH Iwz a cousresra+aw.u4.Ertv uvt� NYf m c,ff LOE H`10, ro VEREYNl ELEAYAIS a mEY PJNSfQi ,(.. WCOAC.A4CR V:/lL -� ''1" 1'4OI/2' DEWN,KCIPXYMID A7E PRCYroKnYC �. i �cr ccu ?-� a.HmE EYlSttG vpoe Drawn fay: rAvacv.,e _Aa.Efra�ME,nRr; �' �� "'P''>'•. drian f.Ferrari .-^LIffPCIAK.WitPW-1 WAY VENT N!018V/CRJ/A`.PA2 CAPE CAP `• '.1:1" '-T' EO/bB T.'B.. wuwE�Nrww�pY` (CanputerAided Praftiivi&Des ) 4'W. 1----{a.0.a W L b' EEFl NE TOOT M EO Drawn For: I .�T.a. -Na &LEANPER 5COVILL �-i I041 a[?5TAGE WOA19 1YA"R rIDA4ZAYl.Ta �, raorau rmXwLu I PETER fHRKt ON S:CaD I W'6'rAPRIERSPGB]I ' nCCR Mph fHRKE $ W fRb fLGbEw/curtu 11�� � CENiEK'VILLE nl xmww.e ou4tr. Ir-�-� r�1 r0-1 —IrjE � 'L GRWNG6NT fp XIiE ru roAtrorENnarartrQ wa � a.oa nEz I� y SCOVLL- -2 rPae Y acNaP FIR5T FLOORPLAN °7/10/99 FOUNDATION PLAN 7/9"-I'O" Public Health Division Town of Barnstable �G��AW PO Box 534 Hyannis;Massachusetts 02601 Fax(508)775-3344 Phone(508)790-6265 CAPE & ISLANDS ENGINEERING SHELLBACK PLACE• BUILDING 2, SUITE E 133 FALMOUTH ROAD(RTE 28)• MASHPEE, MA 02649 (508)477-7272• FAX(508)477-9072 December 27, 1995 Mr. Ed Barry Barnstable Board of Health 367 Main Street Hya ukis, '.VIA 02601 RE: Lot 2 Old Stage Road, Barnstable, MA — Dear Mr. Barry: The septic system has been installed in accordance with the plan on file.. The site inspection was made on December 22, 1995. Sincerely, David Sanicki DS/cma " 1G , j � �T Commonwealth of Massachusetts r Executive Office of Environmental Affairs Dept. of Environmental Protection ad One winter Street, Boston,Ma. 02108 .John eptiepti D.E.P. Title V Septic Itispector P.O. Box 2119 �., Teaticl 536 WILLIAM F.WELD Governor ARGEO PAUL CELLUCCIVEG Lt.Governor RECIE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A O OCT ��, 1997 CERTIFICATION TOWN OF BARNSTABIE Property Address: 1041 Old Stage Rd.Centerville Lot 69 Address of Owner: t1 HEALTHDEPT. Date of Inspection:9125197 (If different) Name of Inspector:John Graci MrA Mrs.Unda:Box 718 Booth Bay Ha rb in 4538 9 1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) L 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 Condit(n/sses code 310 CMR 15.303.My findings are of how the system is Needsvaluation By the Local Approving Authority performing at the time of the inspection.My inspection does not Imply any warranty or guarantee of the longevity of the Faitsseptic system and any of ds components useful life. Inspector's Signature' Date: 1017/97 The System inspector shall submit a copy 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 CoThpliance(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 04127197) One Winter Street 9 Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1041 Old Stage Rd.Centerville Lot 69 Owner: MrA Mrs.Undo:Box 718 Booth Bay Harbor Maine 04538 Date of Inspection:9/25/97 _ Sewaae backuo or.breakout.or hiah.static water level observed.in.the distrihution 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 coliform 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 used to 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) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1041 Old Stage Rd.Centerville Lot 69 Owner: MrA Mrs.Undo:Box 718 Booth Bay Harbor Maine 04538 Date of Inspection:9/25/97 DI 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. h , (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 1041 Old Stage Rd.Centerville Lot 69 Owner: MrA Mrs.Undo:Box 718 Booth Bay Harbor Maine 04538 Date of Inspection:9)25/97 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-Lip. x — The system does not receive non-sanitary or industrial waste flow. — 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)115.302(3)(b)) (revised 04127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1041 Old Stage Rd.Centerville Lot 69 Owner: Mr.&Mrs.Unda:Box 718 Booth Bay Harbor Maine 04538 Date of Inspection:9/25/97 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g.p.d./bedroom for S.A.S. Number of bedrooms: 2 Number of current residents: 0 Garbage grinder(yes or no): No 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: 3 weeks ago. COMMERCIAL/INDUSTRIAL: Type of establishment: rda Design flow:o 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: n1a Last date of occupancy: n/a OTHER: (Describe) n/a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last year. 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: B-28.95 Sewage odors detected when arriving at the site: (yes or no) No (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1041 Old Stage Rd.Centerville Lot 69 Owner: MrA Mrs.Unda:Box 718 Booth Bay Harbor Maine 04538 Date of Inspection:WSW SEPTIC TANK: X (locate on site plan) Depth below grade: 2' 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 10'6"H 5'7"W 5'a' Sludge depth:1" Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness:0 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: 0 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: We Material of construction: concrete metal FRP Polyethylene_other(explain) Dimensions: We 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 pumpingn/a 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.) n/a BUILDING SEWER: (Locate on site plan) Depth below grade: 2'6• Material of construction:_cast iron X 40 PVC_other(explain) Distance from private water supply well or suction linellown Diameter: 4" t;vamments:(conditions of joints,venting, evidence of leakage,etc.) (revised 04/27197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1D41 Old Stage Rd.Centerville Lot 69 Owner: MrA Mrs.Unda:Box 718 Booth Bay Harbor Maine 04538 Date of Inspection:9/25/97 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n/a Material of construction:_concrete_metai_FRP_Polyethylene_other(explaln) 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: X (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottom ofpipe Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) Distribution box is structurally sound. 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 04127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1041 Old Stage Rd.Centerville Lot 69 Owner: MrA Mrs.Unda:Box 718 Booth Bay Harbor Maine 04539 Date of Inspection:9/25/97 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: We Type: leaching pits, number: n/a leaching chambers,number:Total 6 infiftrators 5'x15'2 infiltrators per trench leaching galleries,number: n/a leaching trenches,number, length: n/a leaching fields, number, dimensions:n/a overflow cesspool, number:n/a Alternate system: n/a Name of Technology:_n/a Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Sas is functioning properly. CESSPOOLS:_ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a Inflow(cesspool must be pumped as part of inspection) nra Comments:(note condition of soil, signs of hydraulic failure level of ponding, n/a Y p ng, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: We Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) n/a (revised 04/27197) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 1041 Old Stage Rd.Centerville Lot 69 Mr.&Mrs.Unda:Box 718 Booth Bay Harbor Maine 04538 9/25197 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) (� C B v A oR M L 5 y �q 33 � VY b3 L�f (revised 0427/97) page ! of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 1041 Old Stage Rd.Centerville Lot 69 MrA Mrs.Unda:Box 718 Booth Bay Harbor Maine 04638 9125/97 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 FIRMA 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 Chart (revised 04/27/97) Page to of to 'n No......... .... Fxa......./vv.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � rri S fd..................OF.... 0 .....................- -- Appliratiou for Uiipooal Works Tonstrur#ion run fit Application is hereby made for a Permit to Construct (X or Repai ( ) an Individual Sewage Disposal System at: i to ----__......_................................... ... •-•• _.....--j •-_._... _.._... - / Loca'on-Add ss ( or Lot No. ��9`�✓ f.G 4............................................... ............ ...................................................... caner d ess a �o fob` C.t14 ------..... x__--•- .-�------------------------------- •�------------------......__.._.....-- Address Type of Building InstallerSize �___._...... U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) 'Garbage Grinder ( ) a`4 Other—T e of Building No. of persons............................ Showers Other—Type g ---------------------------- P ( ) — Cafeteria ( ) QOther fixtures ----------------------------------------•-------------••-------•--•••••------•-•--•-•---••-•••--•--•---•-•-•---••-•-••._...-•--•..._.............---• W Design Flow.......... ...................................gallons per person per dam. Total daily flow._._.____ � ................gallons. WSeptic Tank—Liquid capacit-/ gallons L e n g thy __�____ Width ___1._ Diameter................ Depth.,4"7' x Disposal Trench—No. _.a?__.....__.. Width___.. ._._.._.__ Total Length._. Total leaching area....................sq. ft. 3 Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ) Dosing tank ( Percolation Test Results Performed by._C__R :_. .___., 1t�f-._._ ��� Datedi .__.f as Test Pit No. 1....�.......minutes per inch Depth of Test Pit.................... Depth to ground water'. at r_..____�l_*__. Test Pit No. 2....;?:-......minutes per inch Depth of Test Pit__ a_"__. Depth to ground water........................ O Description of Soil...&.......... ......:�5 ^ -------------- 0 �1 ................................--�,Z-•- '-CQ t° /� 'v.._ ..... . __•___.��-..> �.._..-- . - .. :fie-•-�rsaa�w.jl�`__'_s�ner�a-�.p� -------- -- 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 TITLE 5 of the State Environmental Code—The undersigned further agrees.not to.place the system in operation until a Certificate of Complianc as been issued by the bo f health. f as igned ........ ............... ..... D-a�ce � APPlication Approved By .. J ... S Application Disapproved for the following reasons• ..............................................................•----------------...---....................------......--............. ------------------------------------------------------------ ......-----...----....----.................---------...............---------------................----- ........................................ Dale Permit No. '...-..I........ 3.......... Issued Date No......C.s-•��3 Ficz ..1...�C-) THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 77;�r e>.................OF....... .��-- r�S: I - .: Appliration for Disposal Works Tanstrurtion rrrmit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: Locat�jon-AdXs or Lot No. /faC'r�e'o✓ „F /! /ear? e J ✓� 0 4_1 ....---•---- _.... ................. .•-•--.....__..... ---------........................... ........................................................ slx Ail ess yy� M Installer Address e. Q7i Type of Building Size Lot___ ......... U Dwelling—No. of Bedrooms_______________3__________________-____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..__._._..___-�- .... WSeptic Tank—Liquid'capacity/-- � gallons Length/4_._ __._ Width--�'.'.�._.-F."'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 (X) Dosing ank ( ) �- ''" Percolation Test Results Performed by__ �J .. - ✓�a �?�'.......... '•_•• Date_���r.:.. a M Test Pit No. I....._�'4—__......minutes per inch Depth of Test Pit._. '`? ... Depth to ground water........ 44 Test Pit No. 2....An_____.minutes per inch Depth of Test Pit... Q_"___ Depth to ground water_-_____....v........................ �+ D_ . ��... '�-ark�" 5i' `"..��... O Description of Soil...'`�-............3.._, 6 o-.R h.z S� ......................... •--- ------------- ° w ......••--•------•-----•-----•-•- q.�--•-•.Go ......... ..--•�s sue, ------= .. f•............. e. -.. _.._...._.... x �l ii,cW°wYr y....A.rc� 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliances as been issued by the boardhealth. lgned --. !ma y/ ......- r°..L r-c~ .. ....... ..----.._-...-- ........-...--.....-....-- .-.........-----�i-------..-.._...... Application Approved By ------ < --.../�! --5":��' Dace Application Disapproved for the following reasons: .......................................................................................................................•--...-..---.... ---------------------------------------------------------------------- ----------------------------------- -- ---------------------------------------------------------•-----..-.-.-.-.-..--..-.--..--.. ........................................ Dare Permit No. --..-- .-.`-l.S ......-.-- Igsued .............7-.5R2 -.- .-5�-.. Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........%a.w .......... OF ......... -s .............................................. (9ertiftrate of Cfompltanre THIS IS- - CERTIFY, .ThatN�q ndividual Sewage:Disposal System constructed ( ) or Repaired ( ) r by ..-... - .d''': .. --c.-�----------------�.....--..r:- .. .. - -ra...-.-..c:.� uc� 7 ..------0 �.. Ihsc < at .-...../.!--�1 ................... ...---`.............� f......... ...-.-....------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..415-.-.�53' -....... dated .. —..-. ..->�_ ..... . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFAC DATE-...--..-�-..-`....--...� Ins ect P Gi g -.. ...... ..- . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............� .......OF....... r4__ .................................. / No......... l s3S F> .....f...d.......... Disposal Works Tonstrudion rrrmit Permissionis ereby granted........................................................................................................................................_.... to Construct or Repair, ( ) an_Individual Sewage-Disposal System atNo..•-.�Ci Yl•-•-••--------. ............ .fu F......................n.L�.................................................................... - ..................... Street as shown on the application for Disposal;Works Construction Per - No..................... Dated_.......... _ �,�.. ........ .......... Board of Health Form 1255 H&W HOBBS&WARREN Publishers C NOT TO SCALE TOP FNON. FINISH GRADE OVER FINISH SPADE OVER EL FINISH GRADE" �a , c FINISH G�ADZE- OVER DIS T. Box 72. � INFIL,RA TORS r4. SEPTIC TANK ,/, �E MAX. � 4A.®•,a` '�'." ;O'.�'•4A.A�,•e9.:. ,off,.•��,• .QP:�b•{l,p,�••w• '?`.•4''b•'C7•.,a«(3 o`'o'Ye OUTLET PIPE" LEVEL ,...::4�:r . 3 S Q: % 4•;c., ° t;' S OF DOUBLE M ,f FOR P FT. MIN. MASHED 0 S p'•p:dpn6p r:.l•°°.,. •3 Ft "d•Y. a' S'4°.a„t; •l3•�.°,p Y.•°: '•;:.•~+�1 r. ' ^*',+• ''� . p,p.,.p. �� �®• .� C. I. OR P VC TEES .�" .. k ,• b.,y .ram r� -,-- -_'+.. •�"M" 'PR."".9 .�5�:C O /➢• A.. 115, Q �1, ),t),,.•fry C).. i J,.�li+t.. ,/+ v o6a © �: *b �- .Y/4" _ 1°-�°✓.�" D�JCI,( LE MASHED `v,l' i 7cj' UHU5HED STONE' ;� a ro GALL. Del by ��' � BSMT FL . ;p':o.;o :v EL . G, INSTALL CAN LEVEL BASE TR ENCH L'v •a EN°"'TH .. v PRECAST CGNC RE T'E dy•y •y•�0 0..o;oe �-- RE.INF�1RCED n INF.IL. TRA TOR TPLEWCH SECTION +0 4iP'c el v 'ta•,q gyp t �.:O d.: A" a"g i �9:P1' er D A. a ppp pi.®A.O,.q o�D•V .p,0 .�'.•O..• ° f°•P.O L1, •� a .7lAIsr; C \ ^d.^ t'Y3� ` '°�•^»+ems.ar• " OF Pff-A a.! V6Yi1.:' si,•g',•'p•••�.'.:'�' C3�✓ •^'w~\a .? ..:::A.a,•.cy• Y:.•i •ot°.i.�.;yw.4a.`•ti.:♦ 1 SEP TIC TANS INSTALL ON LEVEL BASE `� o - NOTE:' EXCA VA TE" TO ELEV. ��.8=" OR T � h " X ,3" MIN. `: ,<• \ LOSER Tlr� REMOVE ALL IMPERVIOUS f .' DIAM. � .` _ \ , MATERIAL BENEATH THE LEACHING AREA Y`�,(3� � n REPLACE EXCA VA TED MA TERIAL #I TH CL EAN, CL A Y FREE SA NO Y.-f•�;..�Q �, . 1.�" TC� - / "DOUBLE i b "V CRUSHED�STG7NE ----•- ,.„,•",.. "ram � i �� ( (' •' t `;_ ' N " �L 7R NCH IW,IDTH /o f 1. ALL EL EVA TIONS SHOWN ARE BASED' ON ASSUMED P. ALL PIPES IN T-HE SYSTEM MUST BE CAST IRON {� Off' SCHEDULE 40 PVC. � � V r �-� , b r ; N �. T-dE" BOA O OT" ,VEAL Tf MCS T E' NOTIFIED ---F ., -7r) r' r'VEN CONSTRUCTION IS COMPLETE PRIOR p �9pwy� y r��q y ,. w F'Eo�''r CCr,�.,.A d.d i✓N k°"�A 7 e, ��c I^A✓ra rr�Lvm l"'e^ r' �' f 7 } ! ; / l TO BA C 'FIL L INS P e � 4. .ANY CHANGES IN T7-17S PLAN MtI,.�T BE APPROVED r BY THE BOARD OF- HEAL TH AND CAPE G ,ISLANDS ,P/ITNESSED 8Y* 2 „ c :S"UPf VE WING CO.. INC. ED BA PP�' p / 5 'A TERIAL S AND INS i�ALLA TION SHALL BE IN COMPL.,I"ANCE All TH 71H " S TA TE SA NI TAR�' E'RL?. OF HE AL Tip DESIGN D,41 TA CODE' -- TITLE V •- AND LOCAL APPL.I'CABL E LATE: LAY _----'". // �� RO'L E.S AND REGUL A TION, / C/�1 ' / r NORTH A Rc 'E' FRC i RECORD PLANS AND O " NUMBER OF BEDROOMS ' N so4 �,� X U / IS NOT TO E G�SEf� FOR 'SOLAR PURPOSES _ CAR ' GE DI POSA,L. .r LOAMY SAND GAL . (o " �, .7'. FL OOO HAZARD ZONE � �` � B D .�L �' FL C o / , . .- B. WA TE'R SUPPLY TOYN PIA TEP SE „ � ��" SEPTIC i`�IC `AAA�°`ti K PEG 'D. ..1ffDs'� GAG L . L SEPTIC �'ANh' PRt�V.�L�ED ...1�D GAL . 4 �° ,. ° �� ' L EA C�-.�.I'NG F�Ec'�dJIR D 330 GPD. GRA VELL Y SAND / /o_7` 10 ' COa I3'LES11 SIDE ALL AREA -�O S.F. k MEDIUM' So S.F.X - 74�G/S.F. G°PD. �41 �D' �4 341 f` BOTTOM AREA i, S.F. LEGENDG° SANG Cz Z ' S. F.X-- 4- G/S.F. .® .�a._ GPD 1' L EA CHING PRO VIDE'D - .114•14 GPD o T 6 9 /` PROPOSED EL EVA TION 144,, NO G'ROUr'UDwA TER 12 114 X .3 — 342 GPO No —— r —— EXI S T.I'NG CONTOUR SI GL E FA MIL RESIDENCE OB SERVA TION PIT �11 A , ,� [� DISTRIBUTION BOX � >; L. S TE �. FLO, DIFFUSOPS ��� B$2RKe k 2vd9 PREPARED FOP c �AiFSF�117r4to .` ;' TEP EL SON SEPTIC TANudI' �s�� HOUSE ND. . D STAGE ROAD RESERVE AREA CENTER L L.E -- A NS "A L.E -- MA SS. PIPE .INVERT ELEVATION ��' ��m4r4C? .. CHARLES �4 SANICKt I : a ATE' /1�Qy. /9. /9 CAPE ISLANDS ENGINEERING 2£3Q85 l .., ... , - -- —_._ — / PLOT PLAN ry CA L E AS NO TED 133 FA L MOU TH ROAD — S UI TE 2E SCALE,' .0 N. TV `� ✓C7i`� \ �Crl'�E a .' �.r .. SO NA SHPEE, MA SS. 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