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HomeMy WebLinkAbout0212 PATRIOT WAY - Health 212 Patriot Wav Centerville P A 193 200 Coe MI�i=11�Nr M� I �\ COMMONIVEALTH OF MASSACHUSETTS (Zl, EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS i 1 �I DEPARTMENT OF ENVIRONMENTAL MAR 12 2004 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address- +vfAP � Owner's Name: PARCEL 2�® Owner's Address: LOT y �n Date of Inspection: Name of Inspector- please print) Company Name Mailing Address: Telephone Number: 0� y0 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below.is true, accurate and complete as of the time of the inspection. The inspection was performed based can 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: 1� Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 3 a/v- ' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ' Property Address: Owner: Date of Inspection: SG' Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15:303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments:, " B. System Conditionally Passes:. One or more system components as described in the"Conditional Pass"section need to be replaced or repaired..The system, upon completion of the replacement or repair, as approved by the Board of Health, tiyill pass. Answer yes, no or not determined(Y,N,ND) in the for,the following statements. If`'not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration.or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: -Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with. approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more.than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: 2 Paae 3 of ll OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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 aseptic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100,feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed.at a DEP certified laboratory, for coliform bacteria and volatile oraanic'compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to'or less than 5 ppm,provided that no other failure criteria are triggered. A-copy of the analysis must be attached to this form. 3. Other: 3 Paoe 4 of 1 I OFFICIAL.INSPEC.TION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: 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 ofthe ground or surface waters due to an overloaded or J 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 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 l 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes" or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. '4 _ Page 5 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: z0Q Aa 11Q101.4 Owner: 2 Date of Inspection: WgAAA 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 t,/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? _ V Have large.volumes of water been introduced to the system recently or as part of this inspection? c/ _ 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 T Was the site inspected for signs of break out? , Were all system components,excluding the SAS, located on site y _ 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: Ye/ no , 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(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARYASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: o y FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actuaI): DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):AD Is laundry on a separate sewage system (yes.or no).X;2,().[if yes separate inspection required]' " Laundry system inspected (y s or no): 0-6 Seasonal use: (yes or no): Water meter readings, if av�ilable (last 2 years usage (gpd)):01—5xpa 07i—Z10-O5 Sump pump(yes or no):` V Last date of occupancy: COMMERCIAL/INDUSTRIAL/M_ Type of establishment. Design flow(based on 310.CMR.15.203): gpd Basis of design flow('seats/persons/sgft,et'c.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records , Source of information: Was system pumped as part of t e inspect on(y r no If yes, volume.pumped: gallons--How was qt n_tity pumped determined? Reason for pumping; TYJ1 6F SYSTEM �( Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system.(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP.approval _Other(describe): A roximate a e of all components, d to installed(if know )and source of information: Were sewage odors detected when arriving at the site(yes or no X- 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Add ress: h G� -V Owner: A 4Q Date of Inspection: BUILDING SEWER(locate on site plan) )Q)- Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water.supply,well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: —1Z r1ocate on site plan)[ 3QI r W/ Depth below grade:, Material of construction:�oncrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age: — Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: s"'X _ Sludge depth: Zy Distance from top of ijudge to bottom of outlet tee or baffle: Scum thickness:lam— Distance from top of scum to top of outlet tee or baffle:_3 Distance from bottom of scum to bottom f outlet tee or baffle: How were dimensions determined: /1�f/ Comments (on pumping recommendations, (nlet and outlet tee or baffle condition, structural integrity,liquid levels related to outlet invert, evidence of leakage etc.): nD, . d/J i GREASE TRAP J��,ocate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of I 1 OFFICIAL INSPECTIONS FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C aa- Owner: Date of Inspection: TIGHT or HOLDING TANK(tank must be pumped at time of inspectidn)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions'.. ---- — Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches,,etc.): DISTRIBUTION BOX: (/ (if present,must be opened)(locate on,site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to out ets equal, any'evidence of solids carryover,any evidence of aka ge into or Oil t of box, tc.): r Afo PUMP CHAMBER/ (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps-and appurtenances; 8 Page 9 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Y U__-(/ Owner: Date of Inspection: SOIL AIBSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type Ching pits;number:_ leaching chambers; number; leaching galleries,number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool; number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil; condition of vegetation. etch: � A44 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 laver: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no):.. Comments(note condition of soil, signs of hydraulic failure,_level of ponding,condition of vegetation, etc.): PRIVYV (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR, 1VI PART C SYSTEM INFORMATION(continued) Property Address: 2�1_/'a xav Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL.SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 45 4 l Q O 10 Page I 1 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �. Owner: g—W Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallop;-wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 5 /29W 9 t G ll'G/ r 11 Permit Number: Date: Completed by: � HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 7,// &e11*k1 f_ot No. Owner: ckade`z_�(°�!�'_i� Address: Contractor: ZJA��`D�, G���s�` . Address ���?� o��ry z/ ' Notes: ✓�'�(p�JX(�!�J STEP 1 Measure depth to water table /5-/,Oy tonearest 1/10 ft. ................................................................ ....... .Date ... month/day/Year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: 5de�JV �C—z OA Appropriate index well.................................................... © Water-level range zone ..................................................... STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to water level for index well ........................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) Z ,6 determine water-level adjustment ........................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water 6/• level at site (STEP 1) .................................... ....................................................... Figure 13.--Reproducible computation form. 15 i Ll L 14 TOWN OF BARNSTABLE p�� LOCATION SEWAGE # VILLAGE ��I �//L� ASSESSOR'S MAP & LOT 1=00 INSTALLER'S NAME&PHONE NO. vrA % SEPTIC TANK CAPACITY l.000 s LEACHING FACILITY: (type) !—w /.e( 44e4 (size) // ie VT f''s,�,2 NO. OF BEDROOMS S,J BUILDER O OWNE PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) - _ Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) LA Feet Furnished by p C L ���� r ��r .. � y�6 �� � /s' � _ _ -. b ��� O ~ No. i/ .' �t! g J Fee - ✓ v.� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYication for Migpozal *patent Construction Permit Application for a Permit to Construct( )Repair(/)Upgrade( )Abandon( ) ❑Complete System (dividual Components Location Address or Lot No. � 'z tvwf 9f we/ Owner's N e,Address and Tel.No. Assessor's Map/Parcel !� G edf er ViMe Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �D�taf 11`1 4o,1 5T &Hems 1- -�� 9' 3 77/0 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(1-60 Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow J�✓� gallons. Plan Date Number of sheets / Revision Date Title /�CQr1 Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) y`/TZ�'.C C��9 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued,by this Board f Health. Signed Date Application Approved b & 99=6ZLfl Date 9,-�Ozb Application Disapproved for the following reasons Permit No. Date Issued TOWN OF BARNSTABLE LOCATION Z l Z- l�4'7`-�fOy WQ' SEWAGE # —' G _T ASSESSOR'S MAP & LOT , VILLAGE ���� INSTALLER'S NAME&PHONE NO. p/�]`-A SEPTIC TANK CAPACITY LEACHING FACILITY: (type) fog, 1.( Crocti �`i��6��-s (size) // �C s , NO. OF BEDROOMS S` BUILDER O O--W-NE Oa PERMITDATE: �"� � � ..COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) . ✓f Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of.leaching facility) Feet Furnished by p 6 L The I i i 2 TOWN OF BARNSTABLE i z r� ,,o y LOCATION 4 /'Dy WCi' SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. Aal^ GA 40 SEPTIC TANK CAPACITY 1400.0 G�9L s LEACHING FACILITY: (type) Q (size) // >e-2 NO. OF BEDROOMS S BUILDER 0 OWNE PERMITDATE: RNO COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �� Feet Private Water Supply Well and Leaching Facility (If any wells exist. on site or within 200 feet of leaching facility) T Feet Edge of Wetland and Leaching Facility(If any wetlands exist / within 300 feet of leaching facility) Feet Furnished by 4 C L d i I i _ Sh SS L z ,;Fowa& w7 f atcu ,,:, ti ; Fee r.✓ ti"� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION TOWN OF(BARNSTABLE., MASSACHUSETTS _.. ZippYication for Migpozal 6potem Construction Permit Application for a Permit to Construct( . )Repair(Upgrade( )Abandon( ) ❑Complete System "In vidual Components o. Location Address or Lot No. 7,I Z A?;"4,`" j ,71 Owner's ame,A dress and Tel.No. 7 Assessor's Map/Parcel e6� V/,4v;l/e Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 80 �aLof/I'C�'�sr �€'r s - f'elc/mil/h aWv 3 S- 7710 Type of Building: Dwelling No.of Bedrooms L57 f Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /O gallons per day. Calculated daily flow .5—50 gallons. Plan Date I I L/ qo Number of sheets Revision Date Title S f�' .5el�C67e /J/gw Size of Septic Tank Type of S.A.S. Description of Soil 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 Certifi- cate of Compliance has been issue -y this oard :f Health. Signed Date 4-f 14qn Application Approved b Date Application Disapproved for the following reasons Permit No. Date Issued "'" --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS ` a BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (Upgraded( ) Abandoned( )by �� �`D / C'oyl5 J`; at R6//Ile has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction P ��Y jdated �, Installer Designer m The issuance of this permit shad t b _cdnstrue as a guarantee that the s, ste. .wi 1 fu ct' n designed: Date Inspector i ' 111 ^� ——————————————————————————————————————— ' s � Fee 4 ,4- No. THE COMMONWEALTH OF MASSACHUSETTS `ys PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS y ` Miopooaf 6potem Construction Permit Permission is hereby granted to Co truct( )Rep )(✓/)Upgrade( )Abandon( ) System located at 41V Get,Ye-rr-'sl�e and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to i. r� comply with Title 5 and the following local provisions or special conditions. t Provided:Construction must be completed within three years of the date of thispel t. �j �< Date: " C Approved % / :rT 0111 Town of Barnstable Health Inspector Office Hours 'THE r° Regulatory Services 8:30-9:30 *` Thomas F.Geiler,Director 1:00—2:00 • BARNSTABLE, • 9� MASS. ,0� Public Health.Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT— SEPTIC QUESTIONNAIRE 1. General Information: Size of Property: Address: Z / 02 �����d T �� Map Parcel Name: 01144e']F- Phone#: -7 7 a-X - 12.5 2a. How many bedrooms exist at your property now? 3 2b. Are you planning to add any bedrooms? X eS If yes, how many? l 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 2d. Please include a copy of the floor plans for the entire property- showing the existing rooms in the home plus the proposed amnesty apartment and/or addition. Please label each room clearly on the plans. 3. Is the dwelling connected to public sewer? or ' ENO) If the dwelling is connected to public.sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? \j(?r 6. Is a disposal works construction permit on file? YES or NO 6a. If yes,how many bedrooms were approved according to this permit? Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms? YES or NO 8. Is there an engineered septic system plan on file at the Health Division? YES or NO 9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO -------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this property. Special Conditions: I Signed: Date: Q;/health/wpftles/amnestyapp e ��n � r� A vz- LOCATION SEWAGE PERMIT NO. Ld r- 4 aj`,Zgj a7- w kY �e l VILLAGE CcN�i�u r L�� INSTA LLER'S NAME i ADDRESS Ic�-u1 I fit is I ZZ Q-A rL2 1�c7 Lt�/ � i✓ B U It D•E R OR OWNER SLF-ip-oi-\c .y- .p,��i' c ctivTL-2v ILLL— DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � _� �_ ��. ,� ®' �-� � - . y y � � -� J A a� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH �.O.laf6l�.............oF.../` � f�' .�L' ................................... Appliration for Dispoii al Workfi Tonstxnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �a t .�� � �as ( 1 ..---...... ....................... ......_.... --•-•-••• ... •......... ----•-----....... Location- ddees SGf /C�...................... :at.1�� . '_ G .... �/'. 2�.p.... -- ........... ...... -- Owner A dress ------------------------•----------•-- ----•----••- ..R... - Installer Address Type of Building Size Lot&:2o5_R........Sq. feet V Dwelling—No. of Bedrooms............. ................. .Expansion Attic (/� Garbage Grinder W65 pa, Other—Type of Building ..Ad CA' .......... No. of persons........................... Showers (,Q) Cafeteria W# a Other fixtures ---------------------------••••. - w Design Flow....../!9-_•-_---.--.._-_-_-.----__gallons per person per day. Total daily flow......... 3 d.........................gallons. � s WSeptic Tank—Liquid capacity/94Q-.gallons Length•__ .�.��. Width..,S'-........ Diameter________________ Depth...SZ`Y..... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----------/....... Diameter----6,4'_4_..... Depth below inlet....C.i......... Total leaching area. .0.6.—.6....sq. ft. Z Other Distribution box X) Dosing tank ( ) Percolation Test Results Performed by........ Q1Cl.. Date........................................ e-a �� Test Pit No. 1__________a______minutes per inch Depth of Test Pit----1_.`&.__.. Depth to ground water...... Lff--- f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water—..................... -----------------------------••------------....----•-•............. •-----------•--•----•------.------ .------- .------------------------------------------ o Description of Soil....... .. ��------'LgA1V---mjl�,5G.sl---------- ------------------------------------------------------s'== W � y� s'� �4/�' ---------------------------------------------------------------------------------------- UNature 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 Sanitary Code- The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been.issued by the board of�ealtlr. Signed--- --- "=r = � ..---- 7 Application Approved By--••-------------��-------• :/_..-------------- ........................Date-------------- Date Application Disapproved for the following reasons:-----•-----------------•--------------------------------------•---......-----------------------•-------•----.... --•------------•--......•------••-•••--•...............•_._.....-•-••••---•-----••...........-----••---•-••--------------••---••------------•--••-•------------•••• •••...... Permit No........�' Issued...--.- ------ `�� .................. Date Date AL. No.--------------------it, Fizz.... ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD- OF HEALTH ............. ....................................... Appliration for Disposal Works Tons' trurtion Vrrmff,,,,j 'Application is hereby made for a Permit to Construct or Repair an Individual Sewiage Disposal System at: .......................7...................... ....................................................................... . .. .. ...... .... ............... ....... .....Z.. Location-Address Lot No. ZIrz,�ii..................... ..............................................r- //.,f ......................................... ......... Owner Address ........ .......... .................................... ............... ........................................... Installer Address *_1 19 0 Q feet Type of Building Size Lot.......:....................Sq.-L' Dwelling—No. of Bedrooms...........................................Expansion Attic (414�) Garbage Grinder (Vel) A4 Other—Type of Building _16AArA.......... No. of persons......._Z............... Showers Cafeteria (41e) 04 Other fixtures ----------------_------ ...................................................................................................................... ­11 ...... . ,7 W Design Flow....../.!AG..............................gallons per person per day. Total daily flow----------17 2�.......6 .... .....................gallons. 9 Septic Tank—Liquid capacity/,,,-6.C..gallons Length-_ Width.. ------- Diameter................. Depth... ...... Disposal Trench—No..................... Width................ Total Length.................... Total leaching area....................sq. f t. Seepage Pit No.........../....... Diameter...(.a. ...... Depth below inlet... ............. Total leaching area./ ........sq. f t. Z Other Distribution box (X ) Dosing tank Percolation Test Results Performed by....... --- ....... 2CL /f fC If 10............. Date........................................ ......Test Pit'No. I.....!�R.......minutesperinch Depth of Test Pit._ Depth to ground water-___ Test Pit No. 2................minutes per inch Depth of Test Pit.__................. Depth to ground water._...._.___........____. ............................................................................................................................................................ 0 Description of Soil......67........0 ................. ........................................................................................ ,/ -D4-- U ..................................................................... ................................................................................. .......................................... --- ......... ................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable.____________________ ---------------------------_- ................................ ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI'ILE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board ofZ1l ealth. Signed ............ ........ ... ................................ e—- Date Application Approved By.......... . Date Application Disapproved for the following reasons:----........................................................................................................... ....................................................................................................................................................................................... ................. ......... . Permit No....... ... Issued......... Date ................................... ............................ Date THE,'COMMONWEALTH OF MASSACHUSETTS BOARD OF' HEALTH ................ ..................................... Trrtifiratr of Toutpliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (k) or Repaired ................................................................................................................................................. In taller at.../-0/ //J/f V r :, /V/ -- .... �:...... ............................................................... ...................................*.......*--------------------;,....................... ........ has been installed in accordance with tl I ie provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-------AT-J14- ----------------­--- dated_......ftll g ................ THE ISSUANCE OF THIS CERT�IFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....... .... ........................................ Inspector---.-.fill, 0......Q�.. ............................... . ... .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF %, f:XLTH ..................... . ...7owly No....... .................. FEE........................ Disposal Works -Talinstrudion "Prrutit Permission is hereby granted.......A: =/slr 1-_4e-A4�Y ........../ ...........?.................1.......................................................................... to Construct or Repair an Individual Sewage Disposal System at No...,.U .......................................................................... Street as shown on the application for Disposal Works Construction Permit No----,---&/J4-........... Dated............7 el...... .............................................. ----41✓ .111' rd of Health DATE....... ------- ..................................... .V FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 474 1 i A 'qty tt} _ .xm..awsmsa.-a. _.aw>n'^'v..;�...+.. .+m�.�..,.... s� ' .�.....w..n..o-o.+..� «aw>4+�auisaan � •�r r 1. 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Li kc Ilk I a i `j SF 4 i & i � r i � 0.1 # ` 00 All s ! f Q� � :� e. @� c � U � _ ',ems�• � � � '�"''` -.... ..... .._a.—�r,...r._ : _.r-_._ _ _ _ ... ..,,ac---•'!: ��F� t - c, p ,n- �,�,a - 3 sl N ASSESSORS MAP. 193 TEST HOLE LOGS NOTES: e PARCEL: 200 +f-) CURRENT ZONING: RC ENGINEER: THOMAS McLELLAN, P.E. 1. VERTICAL DATUM: ASSUMED FROM QUAD (NCVD2. MUNICAPAL WATER IS AVAILABLE. BUILDING SETBACKS: WITNESS: DONNA MIRRANDI R.S. 3. SCHEDULE 40 - 4" PVC PIPE TO BE USED THROUGHOUT SEPTIC SYSTEM. F: 20' S: 10' R: 10' DATE: 9-23-99 4. ALL PRECAST UNITS TO CONFORM WITH AASHTO H-10 PERCOLATION RATE: < 2 MINE IN o►� y�� LOADING. SPECIFICATIONS. FLOOD ZONE: C 5. PIPE PITCH = 1 f 4" PER FOOT, (UNLESS NOTED OTHERWISE). TH-1 73�5 TH-2 6. FIRST 2' OF PIPE OUT OF D-BOX TO BE SET LEVEL. o LOCUS 0 A ELEV. 7. THE SEPTIC SYSTEM HAS NOT BEEN DESIGNED TO ACCOMODATE THE l0 / W/ HORIZON LOAL�Y SAND USE OF A GARBAGE DISPOSAL. 7" fOYR 212 72.9 8. ALL CONSTRUCTION DETAILS ARE TO BE IN CONFORMANCE WITH THE B HORIZO.Y STATE OF MASS. ENVIRONMENTAL CODE (TITLE FIVE) AND LOCAL LOCATION MAP LOAMY SAND So" 10YR 518 71.0 HEALTH REGULATIONS. LOT 74 C HORIzow 9. CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR 30,713 ± S.F. FINE SAND TO CONSTRUCTION. (0.71 + AC.) z.SY 7/4 10. GROUND COVER OVER ALL SEPTIC SYSTEM COMPONENTS NOT TO EXCEED 3.0'. 11. D-BOX TO BE WATER TESTED TO ENSURE LEVELNESS AND EQUAL FLOW. b 1sz" 625 12. EXISTING LEACH PIT TO BE PUMPED AND FILLED WITH SAND PROPOSED LEACH AREA o OR REMOVED. V(5-500 GALLON CHAMBERS NO GROUND WATER ENCOUNTERED TH 9' OF STONE ALL AROUND) { er, o 76 v 77 / ' y tz y PROPOSED 75 no BED ADDITION D RM. & BATH) EXISTING LEACH PIT g�" , SEPTIC SYSTEM DESIGN " ROOM � (SEE NOTE 12) / , r 25'4 STEP EXISTING 1000 GALLON 74 BTH DECK ►r ' FLOW ESTIMATE:. / ' SEPTIC TANK 78 , r ' 5 BEDROOMS AT 110 GAL/DAY/BEDROOM = 550 GAL/DAY k--PROPOSED 73 WET BAR 72 goy SEPTIC TANK: PROPOSED SITTING ROOM GAL/DAY x 1.5 DAYS = 825 GAL PROPOSED ADDITION ' r ' ` ' USE 1000 GALLON SEPTIC TANK (EXISTING) (CRAWL SPACE) LEACHING AREA: PROPOSED ADDITION 71 �• i , � , BENCHMARK AT USE-5- 500 GALLON CHAMBERS WITH 3' OF STONE PrOOD STAKE ALL AROUND (48.5 x 10.8 x.2 DEEP) _ DECK •lP: •:' � / / � ELEVATION 73.3 - , , ' 7o SIDE AREA: (48.5 + 10.8)2 x 2 = 237(.74} = 175 CAL/DAY KIT. BED DIN. RM. BT. RM. ram, Of ' , ' BOTTOM AREA: 48.5' x 10.8' = 524 SF (.74) = 388 GAL/DAY FAM. A r TH�f TREE LINE LIV. RM. CAPACITY = 563 GAL/DAY BED BED RM. b 69 RM. RM. 76 77 78 r J j�$�" '- ' C - SEPTIC SYSTEM SECTION 7475 ;. _ _ _ , ��� ', ' , ' EXISTING 1st FLOOR 72.7 Y OF COVERS WITHIN� ` � - ` �� G'`��'�G►� /� � � ', � ' , ' 68 $0.1 FINISHED GRADE 2" _ PEASTONE 72 i % , ��,� , ' 1 FIRST FLOOR 3 f 4" - 1 112- T=r WASHED $TONE .� 71 ELEV.= 72.6 72.85 68 71�°: . �. ELEV. o 0 �'ro 73.1 f000 GAL ID-BOX 7 469.8 ELEV. SEPTIC TANK 72.57 " OF ELEV. /� r e 3 ELEV. /75.0 (EXIST) (EXISTING) ELEV. STONE 485' 69 ELEV. UNDER) 0 GALLON CHAMBERS WITH 3' OF `�,rL. 70. i (EXIST) GAS BAFFLE 71'$ TOE ALL AROUND (48.5' x f0.8' x 2' DEEP) ' TEE SIZES: (TO BE CONFIRMED) AT OUTLET TEE ELEV. ' - - INLET: 6" UP, 13" DOWN EDGE OF PAYE J 69. OUTLET: 6" UP, 14" DOWN BENCHMARK AT PK NAIL SITE AND SEWAGE PLAN KEY: ELEVATION a 70.0 EXISTING CONTOUR: - APPROVED BY: DATE: PROPOSED CONTOUR: LOCATION.' EXISTING SPOT ELEVATION: 25.5 R 212 PATRIOT WAY PROPOSED SPOT ELEVATION: 25 , .� CF s " TEST HOLE: s �. �` r �,i.j ,. yG CENTERVILLE, MA UTILITY POLE: -o- '` ';I FENCE LINE: ' Z a� .�r,�i � � o�a�s.t�. PREPARED FOR HYDRANT: F e RETAINING WALL: - ,i �' ;.'10 CHARLES BENNETT TREE; 0 - DEMAREST-McLELLAN ENGI NEERI Nt; _ a SCALE: 1"= 39 DATE. 11104199 24 SCHOOL STREET P.O. BOX 463 WEST DENNIS, MASSACHUSETTS 02670 REFERENCE: PLAN BOOK 312 PAGE 14 _ DM # -,S -101 PHONE & FAX : (508) S98-7710 THOMAS McL LAN, P.E. JOHN D MAREST JR., P.L S. REVISED: 3-20-00 NEW ADDITION LAYOUT i /dam,0 0 L oR.f SvBSo��- ' 7 S 30" GAT `fir 9 /' } Zo'+ /01 0 s.4.vo (b 0q q 702 9 •� o.�. I : L p f � � FivE 97.4 /oaf iXf'AN. � _ - --------�--.-..___,,. •_-__.._. 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