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HomeMy WebLinkAbout0225 PATRIOT WAY - Health 225 PATRIOT WAY, CENTERv IL,L,E A= 193193 Sllln � �14 ocvwo�o�� llll UPC 12534 No.2'-153LO�R �srco %'� HASTINGS,MN TOWN OF BARNSTABLE LOCATION Q 0A L. ,.L, SEWAGE# Z011, - 019 VILLAGE I ,L-J ASSESSOR'S MAP&PARCEL 193) 193 INSTALLER'S NAME&PHONE NO. E Aeaya3l p.n (4;`)- OGS 3 SEPTIC TANK CAPACITY EX►s4: n a LEACHING FACILITY:(type) .SOO 9(3.) (size) 13 X 2S X Z NO.OF BEDROOMS 3 OWNER PERMIT DATE:�/ - Z rj - f�, COMPLIANCE DATE: 7 Iri 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) Fee('- Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Al 431 52• REAR • a g3- C3. 3a° ,y. aw5 Q C4• w4 L 9 j No. � _. __0 Fee far'-. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Npli cation for VopoSal 6pstem Construction J)Prmmit Application for a Permit to Construct( ) Repair(c),-6pgrade( ) Abandon( ) ❑Complete System [J>dividual Components Location Address or Lot No.M 5 /07' WA{ Own is Name Addr ssy,and Tel.No. Assessor's Map/Parcel 3- ,, M , 1q-Face,-' Iwo PA SOP-4129- -Z Z3 In ller's Name,Address,and Tel.No. es er' Name,Address,and Tel.No. �3 Exi4 voJcUn � 0 4,77.- V l sst�u e S 60k 43-3 Type of Building: Dwelling No.of Bedrooms �3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided gpd Plan Date r I Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) K ZO dbox, I,,j L e.q i OGJ cabambeo' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar of ealth. Signe Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 2 0/ /) J Date Issued No. 2016 v ' '7 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in compute PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplication for Disposal �&pstpm Construction 3permit ',Application for a Permit to Construct( ) Repair(0e,6pgrade( ) Abandon( ) ❑Complete System Ej>dividual Components Location Address or Lot No. 5 Q l,97- Ow is Name,Addrq/s ,and Tel.No. Assessor's Map/Parcel 1.3-I� P✓��iY1 .eboer tO U PP `50 ,P- y ze -,)_2 3 Installer's Name,Address,and Tel.No. Desi ner's Name,Address,and Tel.No. 646 Excnvah,1)n ,6ok-°477-c &6Z Vli.Asc-OU-04eS 50k433 �00 `/l Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other` Type of Building No.of Persons Showers( ) Cafeteria Other Fixh�`ires' - Design Flow(min.required) 330 gpd Design flow provided gpd Plan Date 1 1 1 4-1 1 to Number of sheets,_ Revision Date Title r Size of Septic Tank Type of S.A.S. ` Description of Soil 1 Nature of Repairs or Alterations(Answer when applicable) Zb &60X, 12) f I i/� �.e q e-A-) c�a c.ha m6p 6- Date last inspected: -- ,Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar of ealth. Signe ) Date Application Approved by ;n / Date Application Disapproved by U Date for the following reasons j Permit No. Z o 6-1 Date Issued / / THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERT,I.FY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by 6 t E at 2 T B n J i. �v J has been constructed in accordance with. the provisions of itle 5 and the for Disposal System Construction Permit No. ° 6"O I dated 1 1 Installer Designer #bedrooms Approved design flow gpd The issuance this permit shall not be construed as a guarantee that the system will n is o as designed. Date �-- 1 1 I Inspector �1 - - --_ - ---- - - -- -- - - - - - --- - -. _ .--------------- - -•-- No. U 1 i Fee Jou - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposar 6pstem Const rtion 3permit Permission is hereby granted to Construct( ) Repair(L,)-' Upgrade( ) 'Abandon( ) 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:C nstruct•on must be completed within three years of the date of this permit. Date 1 7�7 Approved by C/ 1 f Town of Barnstable Regulatory Services _ Thomas F.Geller,Director Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: t-i4- 16 Sewage Permit# 20 N - 01q Assessor's Map\Parcel - 3 Designer: 1///-/ SS OCfIlfl'S Installer: Address: ��� /� Address: On ^�1 4-� �XCq 1,, �ek*as issued a permit to install a (date) (installer) septic system at ZZ 5 A�J% /a-r> based on a design drawn by ✓,, (address) / A53 De'fq/� S dated (designer) ✓ I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. 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. ANATY er's Signature) a r mwwe � �'' •"'IIT7 �^.t?'v=�-'�i ( esigner's 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. L: NealtblSepticlDest'aner o Certification ation Form 3-26-04.doc P#Town of BAmstable. � 9 2� °+ Department of Re�( atory Services i Public Healfh Z Division Date 30 (9 M •sip• �� 200 Main Street.H ..nnis MA 02601 Date Scheduled 1 (� Time q Y"� Fee Poi. wv l�l m 1 Soil Suitability Assessment for Sewage Disposal '`T' Performed By: y// s'95,0y � ' Witnessed By i1 „I LOCA ON&GENERAL INFORMATION Location Address . Joelt® / Owner's Name En Assessor's Map/P4tcel: 9 �y gineees Name I hone# �� NEW CONSTRU0N REPARt Tel eP Land Use g A -�rw OL Slopes M_ �0 Surface Stones Distances from: Open Water Body Passible WeeAnea ft Drmidng Water Well — fk Drainage Way �`�y ft. Property Line �Z ft Other- SKETCH:(street name,dimensiods of lot,exact lo�ations of 1 4t holes&perk tests,locate rdan0s in.,prroxi�mitty�to holes) I = � / .��'��GO/ k Q1 N �_ x , d/ .) (geologic) Depth to gedfoek Parent material Depth to Groundwater: Standing Water in Aola • I Weeping tom Pit Patx . Estimated Scasonal high Groundwater Al eta � D TERIVIIN TI ON FOR SEASO"L HIGH WATER TALE Method Used: ! l'l- �- in. Depth to aoll Inottlea: Depth (Ibpaved standing in obs.hole ft. Depth tolweeping from side of obs.hole: in. Oro etor Adj.Clraundwater Lavt�l.,,._. er At�uAttttent Index Well#�� Reading Date: Index Well levtl -- Adj.fketor,,.,.�..�. I PERCOLATION TESL' Dam . xim�.112:11�? YP Observation P I Time at V Hole# i Time at 6" ._......—.- • Depth of Pere Start Pre-soak Time-0iSL °= - End Pre-soak Rate MinJinch ! ed Site Suitability Assepsmenh Site Pass __ Site Failed; Additional Testing Needed(Y/N) Originnk.Public Hollh Division Obsematiol Dole Data To Be Completed on Back- - - first ***If percola i¢n test is to be conducted within 100'of wetlltnd,be must notify the Barnstable C t6]¢servation Division at least one(1)we&prior to g�nl g � Vs Yr4 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil , Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders,Consistency.%Gravel) Zia DEEP OBSERVATION HOLE LOG Hole# Z- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones,Boulders. sistency, '' • d LE LOG Hole# DEEP OBSERVATION HOLE Depth from' Soil Horizon Soil Texture Soil Color Soil ' Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. i DEEP OBSERVATION'HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color $oil Other Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones.Boulders. t Flood Insurance Rate Mau: / Above 500 year flood boundary No—/ Yes✓ Within 500 year boundary No✓ Yes Within 100 year flood boundary No_1Z Yes • Death of Naturally Occurring Pervious Material Does at least four feet of oatumHy occurring pervious-Material exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pe 'outs unaterial't Certincation / I certify that on )V� 1* ffdate)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with ' the required training.expe "so and experience described in 3.10 CN R 15.017. Date Signature G � � I ,1 of VE 0 BORTOLOTTI CONSTRUCTION, INC. e' �HEAL r'D��F 45 INDUSTRY ROAD, MARSTONS.MILLS, MA 02648 r�ie 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:,Vq,�7- Pa,&46� Ov-&Ih Date Of Inspection /9 Inspector^ ame: Owner's Name and Address. CERTIFICATION STATEMENT: I Certify that I have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate and complete as of the time of Inspection. The Inspection was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.T system: P Passes Conditionally)?a es Needs Further valu i y the Local Approving Authority Failure _..... Inspector's Signature Date: The System Inspector4lall submit a copy of this Inspection Report to the Approving Authority with Thirty (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 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., INSPE -Sum MARY: A) SYST PASSES: I have not found any Information which indicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated below. 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,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not determined",explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- tration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank is Replaced with a.conforming Septic Tank as Approved by the Board Of Health. Sewage Backup or Breakout or High Static Water Level observed in.the Distribution Box is clue to broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution Box. The System will pass Inspection if(With Approval of the Board Of Health): - 1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM .INSPECTION. FORM PART A CERTIFICATION (continued) Broken pipe(s)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 HELATH 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 FUNCTION- IN.G IN A MANNER THAT PROTECTS 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 Water Supply or Tributary to a Surface Water Supply. The System has a Septic Tank and Soil Absorption System'and is with a Zone 1 of a Public Water Supply 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 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 from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equallo or less than 5 ppm• D)SYSTEM FAILS: 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. t Backup of sewage into facility or system component due to an overload 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 o&Ik uivert due to an overloaded or clog-' • ged SAS or cessp1ool ' Liquid depth,in cesspool is less than ti"Below�nvert'or available volumes less than 1/2 3 day flow.` - ,.. Required.pumping more than 4 times in the last year NOT ilue'to`clogged or obstructed pipe(s). Number of times pumped - 2 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 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 106 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: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 ggd 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:. - The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet 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 1I 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 315 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: V Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast two weeks 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. As-built plans have been obtained and examined. Note if they are not available with N/A. � The facility or dwelling was inspected for signs of sewage back-up. _ALThe system does not receive non-sanitary or industrial waste flow. ✓ The site was inspected for signs of breakout. ✓ All system components,excluding the Soil'Absorption System,liave been located on site. ✓.t The septic tank manholes were uncovered,opened,and the interior,of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of.sludge,depth of scum. L/1-11'he'size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. - 3 - 'SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION - FLOW CONDITIONS RESIDENTIAL: Design Flow: gallons Number of Bedrooms:_Nut Aber of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use: NO Water Meter Readin ,if av ilable: Last Date of Occupancy: OM ER I L/IND T IAL;../)-6. Type ofEstablishment: Design.Flow: "' gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: - - Non-Sanitary Waste Discharged To The Title V System: - - Water Meter Readings,If Available: Last Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL INFORMATION O PUMPING RECORDS any source of"information: �9U System Pumped as part of inspection:,!W It yes,volume pumped: gallons Reason for Pumping: TYPE OF SYSTEM: —ZSeptic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any)' - Other(explain): APP OXIMATE AGE of all components,.dafe install'ed-(iUknown)and source,of information: _ Sew e`odors iletected when arriving at-the site:". -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART C GENERAL INFORMATION (continued) ,/ SEPTIC TANK:/ad&l31?// Depth below grade: �8 Material of Construction: ✓ concrete metal FRP Other (explain) Dimensions:R:,,�VX 4P' XS 1 Sludge Depth: [o " Scum Thickness: / Distance from top of sludge to bottom of outlet tee or baffle: a L Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,conditioin of inlet and outle ees or baffles,depth of liquid level in relation to o let invert,structural integrity,evidence of leakage,etc. ' v -A GREASE TRAP: /mod Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: 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) - TIGHT OR HOLDING TANK: /06 Depth Below Grade: Material of Construction: concrete metal FRP Other (explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments:(condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: - Depth of liquid level above outlet invert: Comments: (note if level a�nd�dis-triibution is a ual,evide ce of solids carryover,eve dce of leakage into or out of box,etc.) ' — 4.4'- 4 42z e� L� D� PUMP CH-AMBER:.-/l-)O- -_._......__..__'._ .... . __. Pump is.in working order Comments:(note`condition of pump chamber,condition of pump"nd'appurtenances;etc.) - 5 - " SUBSURFACE''SEWAGE DISPOSAL SYSTEM INSPECTION, FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): ✓ (Locate on site plan,if possible;excavation not required,but may be approximately by non-intrusive methods) If not determined to be present,explain: Type Leaching pits,number: - / Leaching chambers,number: Leaching galleries,number: Leacahing trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: omments: (note conidtion of soil,signs of hydraulic f ilure level of ponding,cond' 'on of vegetation etc.)_ Af ZY CESSPOOLS: _ Number and configuration: ryI Depth-top of Ji4pid.,to inlet invert: Depth of solids layer: Depth of scum layer: .-' Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) - Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments:(note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.) t 5 k' - 6 - SUBSURFACE SEWAGE.DISPOSAL*SYSTEM.INSPECTION FORM I'AlIT C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. Locate all wells within 100 Feet. �1 11-x .... _............ ... . _..,.. .,.____...._... «._-.....• 'Y j.�1�2?1?,p -1 A. _.__..«_. _ .«.. oaf.. • _"I� �Yll i� DEPTH TO GROUNDWATER: Depth to groundwater: 2.1 Feet Method of De ermination or A roxi ation: �Z"�i��' �-1 WB ✓r /75, - 7 - I 9 R�cc�ivEO 1 DEC 1 111. - a BORTOLOTTI CONSTRUCTION,INC. IMCF&W 765 WAKEBY ROAD,MARSTONS.MILLS,MA 02648 508-771-9399 508428-8926 FAX: 508428-9399. S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART A , CERTIFICATION , Property Address: e + � Date of Inspection: Inspector's Na e: Owner's Name and A ess: SSEBTIFICATION TAT ENT• I certify that I have personally inspected the sewage disposal system at this address and that the tnfonma= tion reported below is true,accurate and complete as of the time of inspection.The inspection was per formed based on my training and experience in the proper function and maintenance of on-site sewage ' disposal ystems. The System: ✓ Passes Conditionally Passes Needs Further uation B the oval Aproving Authority �,. Fails Inspector's Signature: Date: The System Inspecto hall submit of this ins PY inspection report to the Approv><ng atitho ity within thu ty(30)days of compl g this inspection. If the system is a shared system or has a design flow of 10 000 gpd or greater,the i or and the lm Pp P ' 8iFr nspect" system owner shall submit the report to the a ro nate,re onal 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 qil 1 X11 A)SYS PASSES:have not found any information which indicates that the system violates any of the failurex ;ra t t c A criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. t: 3rl{i 3a�� Lj7 Tyr . t tt B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The ste upon comple- 6 V"1; tion of the replacement or repair,passes inspection. m' Y • y�7 Indicate yes,nor,.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,cracked,structurally unsound,shows substantial infiltration or ��;t exfiltration,or tank failure is imminent. The system will pass inspection>tfilte existing sep- tic tank is replaced with a conforming septic tank as approved by'The 13oard of Health.' Sewage backkup or breakout or high static water level observed in the distribution box is due ';, ,: 'ON to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The f �` system will pass inspection if(with approval of The Board of Health): 1 � J ' t _ ✓Utk"ad SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a^� � A F" PART A CERTIFICATION(continued) Broken pipe(s)replaced tk S n i l V Obstruction is removed k f " Distribution Box is levelled 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): ;µ E Broken pipe(s)are replaced r � z Obstruction-is-removed s �� hs C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: : ' " Conditions exist which require further evaluation b The Board., Health.to order to determine..if eq y J y x t rr t the.system is failing to protect the public health,safety and,the envtronment �. _ s t 1)SYSTEM,WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE., s SYSTEM IS�NOT,FUNCTIONING IN A MANNER WHICH WILL PROTECT THE.Q� F, ; rYJ fr 3a PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: t Cesspool or privy is within 50 Feet of a surface water .�y 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-P:UBLId.WATER` k {fiY SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH'AND SAFETY�AND ENVIRONMENT: The sy4em has a septic tank and soil absorption system,and is wtthin 100 Feet to asurfacewateply or tributary to a surface water supply. ; t� x sY The sy tem` as a septic tank and soil absorption system and is with a Zone I of a pub�tc water.supply well. f The system has a septic tank and soil absorption system and is within 50 Feet of a pnvate , : r water supply well. The system has aseptic tank and soil absorption system and is less than 100 Feet but SOSuYr 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 fromy� inlf # , ' — the facility and the presence of ammonia nitrogen and nitrate nitrogen,is equal to ores than 5 ppm. D)SYSTEM FAILS: I have.determined that the system violates one or more of the following failure cntena as defined Y u , ` in 310 CMR 15.303. The basis for this determination is identifted below: ,The,Board of Healthy should be contacted to determine what will be necessary to correct the failure Backup of sewage into facility or system component due to an overloaded or clogged or cesspool. Discharge or ponding of efluent to the surface of the ground or surface.,waters due to, overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to^an overloaded or clogs a *tea h ged.SAS..or cesspool. t Liquid depth,in cesspool is less than 6"below invert or available volume}s less than 1/2 .day flow. Required pumping more than 4 times in the last year NOT due to clogged or,obstrucied jT pipe(s). Number of times pumped 4 -2- �^ o X, �y tt # k s r Y t l.�: I l ll+•' t a,, , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A F 1; aX CERTIFICATION(continued) b An portion of the Soil Absorption System, "{� ;y po rp Sy t ,cesspool or privy is below the high groundwater elevation. A;� Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to :i a surface water supply.1 . s £ Any portion of a cesspool or privy is within a Zone L.of a public well: Any portion of a cesspool or privy is within 50 Feet of a private water supply well. II ., Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a pnvate b' w water supply well with no acceptable water quality analysis. If the well has been analyzed 1 to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic Yj aa' compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above. . f The design flow of a system is 10,000 gpd or greater(Large System]and the'system is'a'stgnificaht� x: threat to public health and safety and the environment because one or,more of the`followmgt � �ri` ;j} s conditions exist: u The system is within 400 Feet of a surface drinking water supplyU z" The system is within 200 Feet of a tributary to a surface drinking water supply ,':, t' The system is located in a nitrogen sensitive area Interim Wellhead Protection Area to 1 '•�; `. r..,,, or,a;mapped Zone II of a public water supply well bT Sn�'(s , z ry,� :.The owner or opera�to an .such stem shall bring the stem and facili .into full cote'fiance y system g system facility� p groundwater treatmentp gram requirements of 314 CMR 5.00 and 6.00. Please constiittlte`local° vwn°' Fy� a>' regional office of the Department for further information. Y r#K � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � ` PART Bt CHECKLIST ' p Check.if the,following havebbeen done: ss�n �A� to'*�Pumping.information was requested of the owner,occupant and Board ofHealth one of the system components have been pumped for atleast two weeks and the systemtha$ Large"volumes of water been receiving normal flow rates during that period. have not been ( f, s�tibi introduced into the system recently or as part of this inspection. As-built plans have been obtained and examined. Note if they are not available with N/A', The facility or dwelling was inspected for signs of sewage back-up: __�he system does not receive non-sanitary or industrial waste flow. The site,was.inspected for signs of breakout. _&ZAll.system components,excluding the Soil Absorption System,have been located on site, r s y The septic tank manholes were uncovered,opened,and the interior.of thb.:4gtrcttii rk*aa,ins su ° spected for:condition of baffles or tees material of conswctron dimensions de th of�rqutd; s� tde th of sludge,depth of scum. v p lfte size and location of the Soil Absorption System on the site has been detemuned based on j existing information or approximated by non-intrusive methods: n k{ x y , ati a a s v � � x SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART B CHECKLIST,(continued) ! The facility ,owner(and occupants;if different from owner)were provided with information on , .jY , Y the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM '*gs PART C SYSTEM INFORMATION FLOW CONDITIONS r ,v r RF.SIDENTLAi: V '•` : f 4 ''o "i�:i' r s Design Flow: lons Number of Bedrooms: Number of Current Residents. fi ks Garbage Grinder: Laundry Connected To System:_Y68 Seasonal Use: ![,•yf! �Water Meter Readings;if ilable: LastDate of Occupancy: COMMERCLALANDUSTRI_AL � Type of Establishment � Desi Flbw � i�rr lbns✓daGrease:Tra Present, es.or.no) p. (y Industrial Waste Holding Tank Present: 7 h y Non-Sanitary Waste, hanged.To The Title V System: }� 1 Water Readingp.711WAvailable: Last Date of Occupancy r R a Ax° a r OTHER: Describe) ' Last Date of Occupancy: GENERAL INFORMATION VNII! - � ' '' PUMPING RECORDS and source of information. ` �� CJrw L�C�• System Pumped as part of inspection: _ If yes volume pumped �` f aalloiis fv �* - 3s" Reason fot`pumping � z ._a - k �r�:• to ,�{* .s �X f�l�i �c gas TYPE :SYSTEM: k + f epticaTank/Distribution Box/Soil Absorption System j h ' Single Cesspool Ems"v Overflow Cesspool , Privy ` Shared System(If yes,attach previous inspection records,if any) ,' u, Other(explain): �,t� � kit ) - f. : ' n 5. ..w t•'a»ys;J �'�'� `��� E�' 'Na ti RO TE AGE of all compo en�p�t installed if known)and'source of inf k=, Sewage odors defected wh n arriving at the site: ! a�,41t r"M SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` {� r PART C GENERAL INFORMATION (continued) SEPTIC TANK:_ tiyYt Depth below grade: Material of Construction: concrete metal . FRP r (explain)_. ,5r�h!yr�j . / Dimisions:�_,SX���/�_Sludge Depth: Distance from top of sludge to bottom of outlet tee or baffle:, Distance from bottom of scum to bottom of outlet tee'or baffle: y � it' Comments'(recommendation for pumping,condition of inlet and outlet tees or baffles,depth`of�lfgwdJ { level in relation to outlet invert,structural integri evidence of 1 ge;etc) >< .n '51WOV, d case I `J'1Gi-j�e/JG . e'�O ��iji Ft,1 GREASE-,TRAP: Im Dept�i`Below Grade: Material of Construction:— metal h FltPk Other,v�h< z (explain) ,� > �. r n ' ' � Dimensions: Scum Thickness: �f x Distance baffle: from top of scum to top of outlet tee or bae: 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) {, y ¢5sr � ,ty3C, and + t L TIGHT OR HOLD ,n HOLDING TANK €F -e of 1t."z�a Depth Below Grade: Material of Construction:_concrete_metal_FRP Other(explain), y .fF.F y.R. 7 L'44 ri. Dimensions: Capacity: gallons Design Flow: pW, gy�°5 Alarm Level:Comments: (condition of inlet tee,condition of alarm and float switches etc.) z f.• e ... _ - r5 y� J'1 v JYai"a�'rAr',y a t c�y1 Y� "t DISTRIBUTION;BOX' Depth of liquid level above outlet invert: =a 7..L u , Comments: (note if level and distn u 'on is pMevidece of solids ov r i avd nce:of leaks o'e mto# or o t�box,etc. < < '7i (%% E, ., V. PUMP CHAMBER Pump is in working ord r: ' josi Comments:.(note condition of pump-chamber,condition of pumps and appurtenances;etc.) CsAf i. , Y Y n+ `11^S`�. Y ` Y' �5 (}fry,, �'• ,.y� N 1 _ '.. r.d-x7N' a �a�a na c Nil k UA SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART Ct� ^. SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS):_LZNi (Locate on site plan,if possible;excavation not required,but may be approximated by non-uttrusive t "� - ems{ ' x° methods) If not determined to be present,explain: Type: !!YY``'''Leaching pits,number: Leaching chambers, number: - Leaching gallenes,number: > z. } ` Leaching trenches,number,length: Leaching fields;number,dimensions: 1 ', Overflow cesspool;:number: j Comments:,(note condition of soil, signs o hydraulic failure level o po ng„con ; of getatioq r elic. r ' d ' y � ,• I �rc4 ep4{tsk� 'h�n7r 3 s kip " ji t, [d a. CESSPOOLS: z t Fr Numbers configuration: Depth-top of liquid to inlet invert: t " Depth of solids layer ;Depth of scum layer Dimensions:of Ce MateRRs�ls of construction: Indication of groundwater: Inflow(cesspool mushtipumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegeiatioq etc.) 4 r r r p PRIVY' ' Material4ofcong truction: Dimensions: { Depth of Solids: a �,�� $` Comments: (note condition of soil,signs of hydraulic failure,-level of ponding;condition 4 8A L etc.) 3 x ,f x '•.�'�' «;x;.. ;. -..H,r .PFs{g r to ,.� �:i ix� i , x kva i in t f'4<s�-n •' - - - { ,..a;� x 9a k q�+ try S ? - a�A ' 3 Y a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. °Y 4 �lr 7r t SYSTEM INFORMATION(continued) AD SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. °' ,yin' ' Locate all wells within 100 Feet. � ,a a 'fix { 1G rs•xx�tyy �' �A f ryR ,,iN( FRO , U �i I 15 Ai R• Mai 4 ff � 3 tI 4 F"N DEPTH TO GROUNDWATER: Depth to groundwater: _Feet Meth of Determination or Ap roxima 'on: /T /�© r�Il1 ?'�i611! / •� fiYt . Y T -7— 4 d a r e �2 c TOWN OF BARNSTABLE Pa7�LOCATION 5 �'�� SEWAGE# VILLAGE /`U. le ASSESSQWS MAP &LOT Q—q. Ag2 AMT0��7�J� NAME&PHONE NO. b �D I-V//I 6�aT_l 651 SEPTIC TANK CAPACrTY a/d0 /(i01 4ir/✓"l t . -A s-/ LEACHING FACILITY: (type) '? C/J (size) NO.OF BE:=tE�A_ BUILDER � P/ PERMTTDATE: 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 1paching facili Feet Furnished by 1` �O b�/er (YY)S (-LbY�. /��• n ':l0 CAT ION _AGE PERMIT NO. L.z VILLAGE INSTALLER'S NAME ADDRESS S U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 0000000f `IZ 2-t Z� Z9 �Y o � s =♦ THE COMMONWEALTH OF MASSACHUSETTS \00 BOAR® OF HEALTH 1..0 .. OF.... 3..................................... , pVfira iou for Uiipniia1 Workfi Tomtrurtion ramit ? Application is hereby made for a Permit to Construct ( �or Repair ( } an Individual Sewage Disposal System at: C - - - ............. .�_.....�.c. ---------ess - ---------------------- ---------•----••-•......---•••----••-----------�. Z Location-Address or Lot No. ..............` s - - ......�.ik•----- . ..�.L ...................................c�,^�-......................................... Owner Address ----------------- —=�-...�. . .........----------------------------- ...................................... -----------------------.......------------.... Installer Address Type of Building Size Lot... -1A...3Z...7......Sq. feet U Dwelling—No. of Bedrooms-------3............. .....Expansion Attic WL) Garbage Grinder (41q Other—Type of Building �6oC� 1 No. of ersons....... Q, YP g -•----------•---•-••---- P -••----------•--•--• Showers (2-) — Cafeteria (W) a' Other fixtures .......kJ..M-- C..................................................................... w Design Flow.................S._......................gallons per person per day. Total daily flow..........3.D........................gallons. WSeptic Tank—Liquid capacity.0-300--gallons Length....l_P....--- Width----4-........ Diameter___-......... Depth....£f._..... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...,t.4-� .....sq. ft. Seepage Pit No.__Pl4.Wt Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (✓f Dosing tank ( ) N Percolation Test Results Performed by-_ t4-lk,'T :.(Z..... .................... Date.... .�l.z.�. �!_.......... ,aa Test Pit No. 1__�.=. ._minutes per inch Depth of Test Pit___ .�.._...._ Depth to ground water-----)Q_ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ........................................ --• -,.. ............................-......................................................... ODescription of Soil...... •-�--5-•---- `? !�- G... J b -•-•-----•-•----•--------•----•---•-----•-----••----•------•--•---•-------•-•------------------ w UNature of Repairs or Alterations—Answer when applicable---------------------_----------_.............................................................. ---------------------------•---•-......---.................---•--..............--•-----•--•---•---•--------•-•-----------------...-----....................... ................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal SystAn in accordancp with the provisions of iITL U 5 of the State Sanitary Code— The undersigned f ler agree n t place t stem in operation until a Certificate of Compliance has be n issued by the board of h It . Signed --------- ------- -•------ Application Approved By XW A ' PP PP .....-••••--••--------•-•-••----------------••••-•-------------••---•--......__.... -----......__ ,Z to Date Application Disapproved for the following reasons:-----•--------------------------------------------------------------------------•--------------•----......----•- ------------------------------------•-----------......-•-•-•-----•-------•---............---------•--••--•------•----•-------•----•---••-•------•-•-----•---•-------------------...- -•--••------. Date �� Permit No...........----------------------------------------- Issued........................ Date 1 a• �j i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH =.Gzr... "`..................OF... .Gt,y Appliration fur Disposal Works Tonstrurtiun Vantit Application is hereby made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal System at: ............ �A --- -! S L� - `•"`` - ...............'---------•-----....._�:�.........----------•---•----•--.................. Location-Address or Lot No. J ................. '��� .!. _---•- i . ...-�k.G ........................................ -' -.....=-................................... OwnerA •ress a ---- `.r... ..... .!:� ............................................ ........................................... Installer PQ Address UType of Building Size Lot...�.. .......Sq. feet Dwelling—No. of Bedrooms.......?3..................... .....Expansion Attic (JO) Garbage Grinder (jO) aOther—Type of Building s? r�-I!tn......... No. of persons___.`�.................... Showers (2--) Cafeteria VD) dOther factures ......-�JJKVI.C...---•------•-'•--------•--------------•-------------•---------------------- S w Design Flow_______________........_ .._______..___.gallons per person per day. Total daily flow........ .........................gallons. WSeptic Tank—Liquid capacity!- ...gallons Length...)_?_....... Width__6..___..... Diameter__Ce__-___•-_- Depth... `......... x Disposal Trench—No................... Width.................... Total Length.................... Total leaching area.. ` ......sq. ft. Seepage Pit No...NO ______. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (✓) Dosing tank ( ) f Percolation Test Pit No. Results Perfor7- m nutesmedr inch X`c -r•-------••---•----..._. p Depth of Test Pit__.1_ ____________ Depth to ground water..__...__.....'._. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------/------_._-_---. 9 ..............�- ------------•-- --------- ---Soil..... - U '--•-•'----•-•-•'------------------- ---- -- ......-- ....... --jtl` ,........------------------ w UNature of Repairs or Alterations—Answer when applicable............................................................................................... ..--'----------------------------'•--•-------'-----•-----•-•------------.._..-'----.....""-.......----•'---------•-----------•'---•-'••-'-'••-----'-•••••-'---•-----•------'••'-•'-----"••'-.......-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sys am in accordange with the provisions of TITLL 5 of the State Sanitary Code— The undersigned f ier agre t place t stem in operation until a Certificate of Compliance has been issued byfte board of h It % -� Signed I . . f�� ter^,• py �J .......-•-----•- «�r~` C_ -!lei.. 6)k-. to Application Approved BY �S "" ....------"'--•--------•---•--'.''''" Date Application Disapproved for the following reasons:................................................................................................................ ..........-•-----•--•-•---....-'------•---•----------------•--•-•---•-•-•-------------...._..'--....------'-'•-•-•'-•....-'•----•"••-----'•'---•••---•-'--•---•---•-'--'-----•--•-----•---••-----'•--•- PermitNo. .........................................Z Date '-� Issued.----•"...............•'-'-" - - _ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1- ..................OF....U.. J` ?°7. ..... C�rr#ifirtt#r of tl�nnt�rfi�nr�e • __� �.,,,,. T4W I �CERTIFY, Than the Individual Sewage Disposal System constructed (�' ) or Repaired ( ) at......... Cy' ------ 1.......--PTT.A-1.�..l_-5 t-J"'F taller has bee-trinstalled in accordance with the provisions of ILE 5 of The State Sanitary Code as described-in,the application for Disposal Works Construction Permit No..__.._____� �.^: dated_...-_..........................................K "7 " THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE C NSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. ............. -� --- Inspector..... THE COMMONWEALTH OF MASSACHUSETTS �- BOARD OF OF HEALTH L...v��f�.✓t.......OF........�?G"`-' y'�....................•-- ..... ................:......... No......................... FEE........................ Disp apal rk Pf ltr iorn° ermi Permission is hereby granted -V......� �'c --- -•---------••-•-----•--------------•'--------•'-----....----.................... 1 to Construct (�/}or Repai-r-{� ) an Individual Sewage Disposal ystem atNo. c' y -k F�'� r • .­-----•--.-.� -- -----------------•--------•--------------------------------•---.._- Street - as shown on the application for Disposal Works Construction Permit No— .................. Dated.......................................... �7 '--------------•--- ------------•----- DATE. g o r �� Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON - t + i S/NGLE F.�I�y/G Y --- 3 BEO�eaoivt 41 SEF�T/G' T,4N/L = 33�X/Soo =`�`9�G.P.o. �• r1� 1:� alll 1P 50lI Ae�Q X , J\ 4 sW-- -AV iC FU i SULLIVAN „ No. 29733 74 104 /A4 :,•'� 79 a 3 /.V✓. 6 AL... 7�v`'aG /�Yi✓ BOX 78,E w-3'•�/S/` ,o TAA//< y 2z, ' :. i�✓,atHEO ' 7B•Z. 78.E �L=7Z r Z G8 ! �� � q �r�T / G°E.er��y TN,QTTyE• �o S� S�/ow�r/ �� C •C, 38�7 .r/E.�E'O.c/ GOMp�Ys Gd/Tf/TiyE S�CJE�/�t/E B,d xTE,e ,t/yE /,VC. Ati�.fETI�/1G` ,e4V/2E�l�NTS O.` THE .2�Gisr�ec� .vo.SU,2�Eyo,P� Toxiv aF I4/2.1I6TA,349A,vP 5 �°,t�fi c / �'� '� ..t✓— T//!t PL.QN /.S iVoT aAsE�Di✓,4 AI S�yOl�Yif/,yE,�E4N.S.�v'l�UG I�yaT LSE U.SEl7 Ta EST�l�G/.Sy Lar ,G/NE,S erne LOCATION dU P-3 1 DATE VILLAGE APPLICANT FEE O� ADDRESS�/ �` TELEPHONE N0. (Non-refundable ,.ENGINEER _ TELEPHONE NO. DATE SCHEDULED �" (Applicant ' s signature . . . . . . . . . . . . . ' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \, SOIL -LOG .. SUB-DIVISION NAME �' ODDS VL DATE__ � TIME SUB DIV •`• gXPANSION ARE ': YES NO �l�Vc.uJ ENGINEER '?v TQWN WATER " PRIVATE WELL ® �1 � BOARD OF HEALTH EXCAVATOR SKETCH: (Street name , etc. ,dimensions of lot, exact location of test holes and percolation tests , locate we'tlands . in proximity to test holes )' , NOTES : ,o — ' o PERCOLATIO N RATE : N TEST HOLE NO: ELEVATION : TEST HOLE NO : ELEVATION: 1 1 3 3 4 4 5 5 6 6 7 7 8 W o 8 9 9 ° 1 10 0 11 12 12 13 13 . 14 14 15 15 16 16 /�r - SUITABLE FOR SUB-SURFACE SEWAGE : LEACHING FIELD LEAC G PITS__ LEACHING TRENCHES__ UNSUITABLE FOR SUBSURFACE SEWAGE. REASONS :. NOTE : ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED N ENT P AN URNED TO BOARD OF HEALTH COPY: RETAINED' BY APPLICANT GENERAL NOTES: C1' 1. VERTICAL DATUM: ___Assumed_________ 2. MUNICIPAL WATER lS AVAILABLE. 23. SCHEDULE 40 PVC PIPE TO BE USED THROUGHOUT P��O 50 C� ��, SYSTEM UNLESS OTHERWISE NOTED. �' 4. ALL PRECAST UNITS TO CONFORM TO S AASH T0: H_10 & H_20 �^ Q° z ��� S`To 5• PIPE PITCH-1/4" PER FOOT UNLESS OTHERWISE NOTED. J z �" — , _ v� 1b �� 6• ALL CONSTRUCTION DETAILS TO BE IN CONFORMANCE O o / / — — — ��. O WITH MA ENVIR. CODE (TITLE 5) AND LOCAL / q°` Lot 29 REGULATIONS. / � --O — \ F CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES 6;3_07t S.F. ,9 PRIOR TO CONSTRUCTION. Q ��� ,► , � / 000 0.4tAc.- - (b� LEGEND: Map 193 C) �6 �o Parcel 193 1-1 1 AQ PROPOSED CONTOUR 1 + \ rL2 °) 12 A -1 �Q ss PROPOSED SPOT GRADE .b' b� �� \ �� `96✓ — 40 EXISTING CONTOUR MA S X 30.23 EXISTING SPOT GRADE 00 TEST PIT � a: '.:: ;::: ti Benchmark et: �2 / /: �� °���. � �o�' \ ��F���2 Left corner Pad ® EXISTING WATER SERVICE 2' ti� / / :.,...Q . �` ti: : :. �\ 2 �, EL.= 95.76 As umed S a 225 GB g ( ) TOF UPPER= 101.19' — a TOF LOWER 96.84 O p rxo 25 \ � (Assumed) \��� �� �����, OF Mgff9� � OF Mgffq� \ AMY L. y� TERRY y� 0 4 Sewer Line exits :'� r' o ,r %�t Below Slab ANN Floor :''G �O� \� �\ Cm VON HONE ti o WARNER ti No. 1068 J No. 38721 / qb',' \ \ O ,4hr.....o Exist. f \ u �� / o qbo°�..: . fi000g Tank ASSESSORS MAP: 193 / °) PARCEL: 193 'L �S `— �' i NOTE: This plan is to be used for septic L.C.C. 38507B \� �`�� �' �'� � � 44 4' 3' �� +� Y purposes Y system ur oses only and is not to be REFERENCE: 3• ti� considered a property line survey. \ S ,, C \ T 1 0-TH�� � q,�. : + P P Y FLOOD ZONE: X Town of Barnstable �� Q h°� , 25001 C0561 J/07 16 14 + + 94 �`� Lawn—''4- ,O°' oaf 225 PATRIOT WAY �°o� 2�� �s. +Pump and Backfill V CEN TER VI LLE, MA e' °�\ Fail ed Leach P associates PREPARED C °s ( 4 FOR:5 n 22 Herbert K a U P P 320 Cotuit Road + �2' Sandwich, 225 Patriot Way 508 833.Z� /Q / �_+ 3.0041 02563 'S or � Centerville, MA 02632 ee � jh` o g 1-LOCUS �/ Terry A. laSurveying e P.L.S. Oa `� +� / Harwich,"MA 2645 DATE REVISED SCALE SHEET No. LOCUS MAP N.T.S. Al /—/90 — oG' (5W) 432-8W9 01/14/2016 1 = 20, 1 of 2 » / (+ i T.O.F. (Full/Walkout in Rear) Provide Riser over-D-box NOTE: All components to be marked with NOTE: To prevent breakout, final Upper EL. 101.19 to within 6" of final grade magnetic tape or similar prior to final cover. grade of EL. 91.5 to be carried Lower EL. 96.84 (Cover to be watertight) out a minimum 15' beyond edge F.G. EL: 94.5-100.7f F.G. EL: 95.4 F.G. EL: 93.5 Maintain Min. 2% slope over leach facility to of leach facility. Existin �- reventBondingF.G. EL: 92.5-93.5 Install risers w/covers over inlet and Min. 2" of 1/8" - 3/4" Washed Stone or Ins ection Port within 6" to grade outlet to L=20f'(Access Covers min: of final 20" diamr per Code)ade Geotextile Fabric ; :p �S= " SCH 40 P . 30 3/4" - 1 1/2 Double Washed Stone • 4" SCH 40 PVC L=10 Top of Peastone or Geotextile Fabric EL. 91.5 (1%TAIN 4' SCH 40 PVC Exist. Invert10' ®5=1.8% 1 r-- .�14" 6 �� CDS=1 0.5�.MIN a®a 24 Eff. Depth (Below Slab Floor) EL. 91.32t �12 83Install Gas Baffle EL. 90.77 - EL. 90.6 BBa8 TRe%++nrn 88 5 NOTE: Leach EL. 91.57t PROPOSED DB-3 EL. 90.5 Use 2 - 500 Gallon Precast Chambers Trench can be H-20 DISTRIBUTION BOX (H-10) with Double Washed Stone 4 08' lowered an Am aoft Watertest for levelness 4 Ends, 4' Sides additional 1' as Install PVC Inlet & Outlet Tees needed to ( EXISTING 1000 GALLON ) if more than one SEPTIC SYSTEM PROFILE (25 x 12.83 x 2 ) H-10 SEPTIC TANK outlet EL. 84.42 remain in C1 N.T.S. Bottom of TH-1 horizon upon confirmation of SOIL LOG ADDITIONAL NOTES DESIGN CRITERIA constrructomn. of 1 Contractor to confim soil suitability prior to installation. Contact Number of Bedrooms: SOIL EVALUATOR: AMY VON HONE, R.S. S.E. #2517 BOH and Design Sanitarian in the event of varying soils from original Existing 3 Bedrooms INSPECTOR: DAVID STANTON, R.S., BOH soil test. DATE: JANUARY 13, 2016 10:00 AM Soil Type: Class I PERCOLATION RATE:<2 MIN/INCH IN C1 2. Failed Leach Pit to be pumped and backfilled. Any contaminated Percolation Rate: <2 min/Inch PERMIT NUMBER: #14928materials within 5' of proposed Leach Facility to be removed. Daily Flow: 110 G.P.D./Bedrm x 3 =330G.P.D. Design Flow: 330 G.P.D. Min. Required) TH - 1 TH - 2 3. Water line to be sleeved at any sewerline crossings and within 10' ( q ) EL. 94.75 EL. 95.0 of any septic components, as needed, per Water Department Garbage Grinder: requirements. Contractor to verify location of water line prior to Not Allowed A/Fill A/Fill construction. Sandy Loam Sandy Loam Leaching Area Required: = 445.9 S.F. 10YR4/1 i 0YR4/1 Required: 16" 93.42 18" 93.5 4. Distribution Box to be placed on 6 crushed stone or compacted, level base. Septic Tank Required: 330 G.P.D. x 200� = 660 G.P.D d dy Loam Minimum 1000 Gallon (Existing) Sandy Loam Sandy 10YR5/8 10YR5/8 5. Contractor to confirm elevation of existing septic tank inverts prior Use 2 - 500 Gallon Precast Chambers H-10 with 33" 92.0 31" 92.42 to construction. Water level in tank above inverts and unable to , C1 C1 confirm during field work. Double Washed Stone: 25 x 12.83 x 2 Fine Sand Fine Sand Perc 2.5Y7/4 2.5Y7/4 2(25' + 12.83')2= 151.32 S.F. 50" Bed Bed Bottom Area: 25' x 12.83'= 321.25 S.F. Living Total Area: 472.57 S.F. Room 11 2 Desi n Flow Provided: 0.74 472.57 S.F.)= 349.7 G.P.D. Garage Kitchen 225 PATRIOT WAY pining o ALaud.Bed vCENTERVILLE, MA m 3 associates PREPARED sEPnC SYSnW DESIGNS FOR: 124" 84.42 124" 84.67 Family Sun Herbert Kaupp No Groundwater Observed No Groundwater Observed Room Room 320 Cotuit Road 225 Patriot Way Sandwich. MA 02563 PERC RATE: <9" 0 14: 13 minutes <2 MIN INCH C1 Horizon 5o6.e33.00a� MA 02632 '/ Centerville, I, Amy L. von Hone, R.S., hereby certify that I am currently approved by- Surveying by. the DEP pursuant to 310 CMR 15.017 to conduct soil evaluations and FLOOR PLAN Terry A. Warner.P.L.S. that the above analysis has been performed by me consistent with the Harwich,Long Road 02845 DATE REVISED SCALE SHEET N0. requirements of 310 CMR 15.017. 1 further certify that I have N.T.S. (508) 432_8mg successfully passed the Soil Evaluator's Exam on November, 1994. *Floor Plan provided by Owner 01/14/2016 1 = 20 2 of 2