HomeMy WebLinkAbout0535 PHINNEY'S LANE - Health 5 Phinney's Lane (Centerville)
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Town of Barnstable P#
Department of Health,Safety,and Environmental Services
tH Public Health Division Date (— 4-7
367 Main Street,Hyannis MA 02601 f
BARNSTABLE,
MASS.
9 i639 � PITime
Date Scheduled Fee Pd.
Soil Su ability Assessment for Sewage Disposal
Performed By: Witnessed By: 6'
LOCA0I0N &GENEAAL INFORMATION :
Location Address S3s P1f �,c3JviGy'$ LX, Owner's Name los-iatahi�
c L�F' Address 3 4- e E
Assessor's Map/Parcel: Z3,d>/ /&-7/alZ Engineer's Name r*—V-,4-5
NEW CONSTRUCTION REPAIR Telephone# sofl 3C 2 a/3 Z
Land Use Slopes(%) G Z Surface Stones 4J`-'
Distances from: Open Water Body ft Possible Wet Area PA ft Drinking Water Well ft
Drainage Way It Property Line ft Other ft
SKETCH: (Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
t �
Parent material(geologic) C,-ZiTtu � 1{ Depth to Bedrock s Ch co >
x�
Depth to Groundwater: Standing Water in Hole: VI/f H Weeping from Pit Face A tr?
1 stimaied Seasonal nigh Groundwater 1•� W
Q r*Y
DETERMINATION F+(JR SEASONAYI HIGH WATER TABLI+i
.... . .. .......... .
Method Used: cs-&
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well#_ . . _ Reading Date:.__.__ Index Well level._ Adj.factor Adj.Groundwater Level C'=
PERCOLATION TEST:
Date. ::13 �' Ttme Y
Observation
Hole# Time at 9" in Depth of Perc Sq Time at 6"
Start Pre-soak Time @ Time(9"-6")
End Pre-soak
Rate Min./inch �
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back j
Copy: Applicant
4
1
DEEP O$aERVTONI�?LE EQC Hole:#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,° Gravel)—
i2 (LS dn°Ca 3f
iL
DEEP OB.00ATION HOLE LfQG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency.%Gravel)
A, L.S 10 ex It,
DEEP Q$SERVATIQN DOLE LQO dole
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,%Gravel
DEEP OBSERVTIQN HOLE LC)G . Hole
D h from �.-.- ..zan> Sail T, S r ,1 C a Irv-- i1 Ct«.
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,%Gravel
r'
I
Flood Insurance Rate Maw
Above 500 year flood boundary No— Yes
Within 500 year boundary No Yes
Within 100 year flood boundary No �� Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
0 area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?
Certification
Ir1^'1i1 ^I
tJ-t I certify that on 61 ) q`� (date)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 trainin pertise and experience,described in 310 CMR 15.017.
Signature ___ Date
.P \ TOWN OF BARRNSTABLE ^fir
LOCATION Sa SEWAGE#
VILLAGE C.y(\SQ
ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO. M�-- 77� 9 I
SEPTIC TANK CAPACITY eSc(S� C CEO 6Z1X
LEACHING FACILITY:(type)—" �r(��p_ (size) _Id (,t9 X ®?7 /1 � �U f
NO.OF BEDROOMS
OWNER r
PERMIT DATE: �! 1 O COMPLIANCE DATE:
Separation Distance Between the:
- Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility I-GL f`fn^Feet
Private Water Supply Well and Leaching Facility(If any wells exist'on site or within 200 feet of leaching facility) c c A P Feet
Edge of Wetland and Leaching Facility'(If any wetlands exist
within 300 feet of leaching facility') �Peet
FURNISHED BY ^ .
Q
hoc
A�v s'r a3
No. 360� � � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
RpItCatton for Digogal *pgtem Con.Otructton Vertu
Application for a Permit to Construct( ) Repair(y' Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel No
C.v'N��.t. ��� Cc3v�rfi.r`CJ
Assessor's Map/Parcel -7:1 _` 7 mkt C.S
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
c.�4
Type of Building: "M u Old
Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(nun required 3 rz� gpd Design flow provided d gpd
Plan Date Number of sheets l Revision Date
Title
Size of Septic Tank Type of S.A.S. JOS6 rem U
Description of Soil Mf_dva� sc,. j k r t l tom.. \ ,,l �t, Y �q i X u�, ,J
Nature of Repairs or Alterations(Answer when applicable) 1p C G.L AL Le r~c...I,,
� . 3 .3 0 S� ���-��rz•�y.rS
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 Board of Health.
Signed Date �d a 10 7
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. 9 Au7— 366 Date Issued ��"�y d
t r
mo2t�,, y,`��� .•�,yt � � �' '
No. . yv�� _ 300 _.t`, _rim.•: Fee /6TI)
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Ytcatior -fo�»�ig ogaY �pgtem �tCougtruction permit
s �
Application for a Permit to Construct( ) Repair pgrade( ) Abandon( ) ❑Complete,System D Individual Components J
Location Address-or'Lot No.- !
1 Lam-"— O ner's Name,Address,and Tel.No. r
Assessor's Map!Parcel �,,k 7 1 V V
s
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
sC��C=�,,...•�.. �c ('��.s'� c •i;��. ', 1 vim. `�c.r,�S �t � Sbk 3�a 4��
Type of Building: TO 1� aA us UU l�S
Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder
Other Type of Building j No.of Persons Showers( ) Cafeteria( )
Other Fixtures 1 d
Design Flow( 'n.required) .�3 gpd Design flow provided �� 3 gpd
Plan Date (, V Number of sheets - Revision Date
Title
Size of Septic Tank 'e-7<� l V Type of S.A.S. _� 3 6 S� 11Ct\ «r.- U 4
Description of Soil Me d w x -.)q X
1
Nature of Repairs or Alterations(Answer when applicable)
1
Date last inspected:
i
Agreement:
iThe undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Y�a1 10 7
F Application Approved by Date �j 7
Application Disapproved by: Date {
for the following reasons
3
Permit No. 0 ou 7 3 66 Date Issued o
--------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS j
BARNSTABLE, MASSACHUSETTS
I
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( � Upgraded ( )
Abandoned( )by
at t C' ��►ut�V C Lc&LA t j�-`\W has been constructed in accordance
with the provisions of Title 5 and the for r Disposal System Construction Permit No. �� ^36U dated -a �'a
rI�lle Designer &4\10 &a,)
#bedrooms Approved design flow gpd
The issuance of this permi all not e_cor�strued as a guarantee that the system 5N- notion as designee ' G fir��J
Date (J Inspector J 1l
V I V'l v 1
i —-------- 2-----;-----------------�--------ll--
No. 2,0 .. j 6 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
D l gpool 6pgtem (fon5truction Permit
Permission is hereby granted to Construct ( ) Repair (V) Upgrade ( ) Abandon ( )
System'located at ,C 7,� (��n k/\P-2 N,/J l..-c-� V )�-k
' and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this ermit. (}
Date E.0 ,Approved by A4
Town of Barnstable
Regulatory Services
P
Thomas F. Geiler, Director
► BABNSfABLE,
9qp MASS. � Public Health Division
lFD 1"°r p Thomas McKean,Director
200.Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: !' Z z -1 Sewage Permit# Z06-2- 3&0 Assessor's Map\Parcel
Designer: 5 t-Z--P F+to— Installer:
L c L 5 v
Address: 8��3 . � E Address: Z-tq P-,
'S ®'l✓77-f��YV'r F./c .�'{- CT��v"Z3� �L��i2��-ld c �.,.r�,
On S Z l 6? c'� was issued a permit to install a
(date (installer)
septic system at a.3� '`S i_, 3 C based on a design drawn by
(address) k
dated �3
(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 stem referenced above p Y was installed with mayor 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.
A.
i� Sl'EPHEN � .
8
(Installer's Signature) CML
No.354i;1
(Designer's Signature) (Aff Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\Septic\Designer Certification Form Revised.doc f
.,' COMMONWEALTH OF A ASSACHUSETTS
EXECUTIVE.OFFICE.OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF.ENVIRONMENTAL PROTECTION
A
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TITLE 5
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE°DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: � `
Owner's Name: ��_�-� i�� RECEIVED
da4&
Owner's Address:
Aa
CQ of
Date of Inspection: �/y/v i MAR 3 0 2001
Name of Inspector:(please print) + ��� TOWN OF BARNSTABLE
Company Name , HEALTH DEPT.
Mailing Address.: .6 r 0
Telephone Number '7 9 R
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 on my
,training and experience in the proper function and maintenance of on site sewage disposal systems. I.am a DEP
approved system inspector pursuant to ection 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditions y Passes
1d' ds Fu er Evaluation by the Local Approving Authority
ails /
Inspector's Signature: Date:. �at
Z I
The system inspector slia 1 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 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION (continued)
. 1
Property Address-
0
wner:
Date of Inspection: 3 Q
Inspection"Summary:"Check A,B;C;D or E Y 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.
Comihetits:
4
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to'be replaced or.
repaired.The system, upon completion of the replacement or repair;as approved by the Board of Health,will pass.
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 exfiltrationor.tank failure is imminent:`Systernuill"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 bo-. 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
Page 3.of 11.
OFFICIAL_INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE.DISPOSAL SYSTEM.INSPECTION FORM
PART`A
CERTIFI.CAJTION(continued)
Property Address:
Owner:�/�P�i
Date of Inspection: / /U6
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 a septic:tank and soil.absorption system(SAS)and the.SAS is within 100 feet of a
surface water supply or tributary to a surface water supply::
_ The system has.a septic tank and SAS and the SAS is within a Zone I 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 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.
.3. Other:
,i
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Page 4 of 11
OFFICIAL:'INSPECTION:FORM!—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE>DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
c
Property Address: <J
Owner:
Date of Inspection: 3 /y/pl
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
1 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
— . Discharge orponding of effluent to th`e si�rfaee of the ground or surface waters`due to an overloaded or
7 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 Tess than 6"below invert or available volume is less than'/2Y
da 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
water supply.
V 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.
Any portion of a cesspool or privy is less than 100 feet butgreaterthan 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 facilityand 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—IW— ( PA)or a mapped
Zone II of 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
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Page 5 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM
PART B
CHECKLIST
Property Address: 5
Owner: 7,_
Date of Inspection:
Check if the following have been done You must indicate"yes"or"no"as to each of the following:
Ye —o
Pumping.information.was.prov.ided bythe owner,occupant,.or Board of Health.
Were.any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period
Have large.volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A).
_ Was the facility or dwelling inspected for signs of sewage back up.?
Was the site inspected for signs of break out?
_ Were all system components,excluding the SAS, located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth.of liquid,depth,of sludge.and depth of scum?
Was.the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been'etermined based on:
Yes no
(-1 — 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
i nacceptable)[310 CMR 15.302(3)(b)]
5
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Page'.6 of 11
OFFICIAL INSPECTION'FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE'DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM 4NFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL � r
Number of bedrooms.(design):,3. Number of bedrooms(actual):.'
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):/')4&— '
Is laundry on a separate sewage system(yes or`noif yes separate inspection required]
Laundry system inspected(yes or no)/. Z:7—
Seasonal use:(yes or no):
Water meter readings, if available(last 2 years usage(gpd)):
Sump.pump(yes or no
Last date of occupancy: - C��
COMMERCIAL/INDUSTRIAL.//
Type of establishment: .
Design flow.(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgff;etc.):
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 the inspectr n(yes or no)
If yes,volume pumped:. gallons--How was quantity pumped determined?
Reason for pumping:
LYPOF 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):
proximate age of all co pone ts,date installed(if known)and source of information':
Were:sewage odors detected when arriving at the site(yes or no):_
6
r` Page 7 of 11
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.S.YSTEM INSPECTION FORM
PART C
SYSTEM.-INFORMATION(continued}
Property Address:
Owner:)
Date of Inspection: 2/Z!2 zo
BUILDING SEWER(locate,on site plan)`-Q;W, .
Depth below grade:
Materials of construction: cast iron 40 PVC_other(explain):
Distance from private water supply well.:or suction lire:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓(locate on site plan)
I/
Depth below grade:
Material of construction: ..�ncrete_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: �•�. X(�' /
Sludge depth:
Distance from top of sludge to bottom.of.outlet tee.or baffle:
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: _
How were dimensions determined: s�C,r�i►�(' /gy�e
Comments(on pumping recommen tidd ons, fillet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,.evidence of leakage,etc.):
GREASE TRAP,�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 11
OFFICIAL.INSPECTION FORM—NOT FOR,VOLUNTARY ASSESSMENTS
SUBSURFACE�SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM'INFORMATION(continued)
Property Address: \
Owner•
I
Date of Inspection:
TIGHT or HOLDING TANK: ank must`be pumped at time of ins ection)(toca'te on sita pla
n)
)
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:v(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 outlets equal, any evidence of solids carryover,any evidence of
akage into or�out of box,etc. :
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,etc.):
8
r Page 9 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR:VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM,INFORMATION(continued)
Property Address: 02
Owner:
Date.of Inspection:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation riot required)
If SAS not located explain why:
Type
leashing pits,number: 1
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology.
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
zz
e J
CESSPOO—(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of.groundwater inflow(yes or.no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY,�tj9---(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 SYSTEMJNSPECTION FORM
PART.C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection: �t/fp/
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.
o
to
,ED
10
Page I 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: _ S
Owner:
Date of Inspection: ��
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water `7 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:
'Necked with.local.excavators, installers-(attach documentation)
i✓Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
62&WZ101dY
It
L O CAT ION S E W A G E PERMIT NO.
VILLAGE
etil rer rl / lam
INSTA LLER'S NAME i ADDRESS
P
f
B U I L D E R OR OWNER
DATE PERMIT ISSUED 'A1 17
DATE COMPLIANCE ISSUED 7/���
,: --
zz � r� � � . ���
e
-,� � .
'� ��� ,
. t-s
__
No..... �9_' L��. �f� Fxs...... ...............
THE COMMONWEALTH OF MASSACHUSETTS
, ,POARD OF HEALTH
�
..._..°B./.. .........OF........ S:7� 9d >�.fE.....
Applirttttlan for R.5pogal larks C�nnitrnr�tnn ami#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: _
..................... ..... ...... -----•-••--------...----......---------.....------•----------------------------------.......----•-
L c to -Address or Lot No.
--------.�-�...nt�x...!e s b -------------------
Owner Address
a � . ...................................... ................................................ ...............................................
Installer Address ®
Type of Building Size Lot....Z_..._.........7.....------Sq. feet
U Dwelling—No. of Bedrooms.................. .._..Expansion Attic ( ) Garbage Grinder ( )
a
Other—T ype of Building . .52A ............... No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ------------_-----------------------------------------•-------------------•-----------------._.....------------•---------•-•................--•---
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.................... ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
. Percolation Test Results Performed by.......................................................................... Date........................................
1.4
Test Pit No. 1................minutes per inch Depth of Test Pit............_....... Depth to ground water_---_-_____-_-_--.._.__.
Gr4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O Description of Soil--- D p� -. `l�'....:.....�SG�1t)/CQL( l 4!}/1/j� Z Yee a,'7
x . .,? ?
w
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'IIT!Lj 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss by the b and of health.
Signed -- �4l j ........................ 1.17.�1 _ .._....
T
Date
Application Approved By............ -- • ----ins:
-- ........-•........................••--••......
Date
Application Disapproved for the following rea ------•---------••------•-----••----•-•------•-•-----•-•-----------•-------•--•----------..Da e--------------
...............................•-•-•-----•--•-•••--...--•-------------•---...........----------•-...--•-----•-----•----.....•---••---------•-------•-----------------•-•-•----------•••-•---------------
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................:.. ..... .............OF..........................._.._....
AvAiratiun for Disposal Works Toustrurtion Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
---........ _ .................. ....: ............._..._....... .......----..... .... -
Location-Address or Lot No.
......................—....................._.._..... .---•--._....._.......-- -•-••-----•----....-••••--•--..
Ownerr Address I
W
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building
a —Type g ____________________________ No. of persons............................ Showers ( ) — Cafeteria
d Other fixtures --------------------•-••-----•--••----•--._....--
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter__.-_-_-_.______ Depth.................
xDisposal Trench—No_ ____________________ Width.................... Total Length..........._........ Total leaching area....................sq. ft.
Seepage Pit No-----------_-------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by----.................................................•................... Date......_............ ...................
a
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water----'...................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
------------ ==•---•--•-------- --=-•---•----••-•----•--------••----•------•••--•--•----.........---•---•-----..._......•--------•--._......._...---....--
0 Description of Soil...........--------------------------•---•------------------......-•----------------------------------------------------------------------------------------...__---_..
x
U .--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-----•--•--
w
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----•------.._........_.
,V Nature of Repairs or Alterations—Answer when applicable................................................................................................
.....-..............................................................................................................................._.......................................-..........................
Agreement
The:undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the proisions of TITILj 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 health.
ned.--- ....................................................................... •--•-------•-------••--•-----•-•
Date
Application Approved BY ...........
Date
Application Disapproved for the following reasons-------------------------------------------------------------------------------------------------------------•-
..--•...........................................•-•------••-.....--•--•---•------•---------------•-----•---------•...:--•-------•---•----•••-•--•--...................................................
Date
PermitNo......................................................... Issued.......................................................Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF............................N...........
Trrtifirtt#r of Tomplianrr
THI ki&CFe#j i tt & idual Sewage Disposal System constructed' ) or Repaired ( )
by----------- ----•----•--• •••••••-
at ----------•----•-•-----------------•-----•--•-------------------Installer
has been installed in accordance with the provisions of TITLE, 5 of. The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.tvt_!J�e.................... dated-...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIL FU44TION SATISFACTORY.
DATE... ...L�...�-d�-..-•----------------•-••--•----•-----------•---- Inspector... ----------...----------...---.......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'�rpt ......................................OF.__............._.._.__._._..___._..----..__.._.....__......___......._._........._..
No......................... FEE........................
Permission is hereby granted.
to Constru or divl uaa S� a Dis osal S stem
at No
� �ly)1��� � p Y
Street
as shown on the application Disposal Works Construction Permit No_____________________ Dated..........................................
Z
/ �(„� oar-- -- Health
---------------------------------------------------------
DATE..... ---••-•. -----•-----••-•---
.. FORM 1255 A. M. SULKIN, INC., BOSTON
Lot J
IV
IGO % Uj
r 1 8-Y ( z
4z7C — I
CIO C,
04
V1
!vim j Lot 1 • It i
ri e
!'I"CT 0,"e d Ga
r a r D
3
T_
�j
r
d Ga
0"
0 211876 SF�t "�'V 00,
P141AIAJE Y
.4 AJE �A I
Scale Horiz/Vert.
00
Fx)a r,Pj 4rg A 0 P.-
71
t
TTT 77/L 0U.40AT101a 1!!�
F.,TAI,,,
-ME T C H OF LAND IN CENTEP_VT ILLE IIALA S S .
for
Gary W. Hudson.
Beim- Lot 2 as s h o,..;n on a plan done for
Albert A . 5caramelli , dated 10/11/83 by
.all Care Engineering, Centerville, 141ass.
Ele.vation shown are in, feet above M-S.L.
Date : 2-2-84
----------------------- -------------- ------------
Date : e n t Barnstable Board of 11-:,-e:�lth
'rest Pit P-2073
bony
op
c.-D ur s e
FRANK
r- CONERY
No, t232.
clean '
or
FRANK
no water encountered
Icst made 1/30/84
John Jnccb�
1%?:1t.ner,sed by
:r? AL
WITHIN
ACCESS COVERS,MUST BE INSPECTION 9 MINIMUM, t N VER T EL E VA T l ONS : DES l GN CR l TER l A : GENERAL . NOTES : :. .
6 OF FINISH GRAB PORT 3' MAXIMUM COVER
INVERT OUT SEPTIC TANK: 96.0 DESIGN FLOW: ,. T
FIRST 2 TO 1. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION
BE LEVEL MIN 2' OF PEASTONE INVERT IN DI ST. BOX: 94.67 3 BEDROOMS AT //0 G.P.D. PER ,
INVERT OUT DI ST. BOX:, 94.5 BEDROOM EQUALS 330 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY.
4' DIAM PIPE INVERT IN LEACH CHAMBER: 94.4
3/4' 1 1/2' DIA.
q DOUBLE WASHED STONE BOTTOM OF LEACH CHAMBER:, 92.4 NO GARBAGE GRINDER 2. VERTICAL DATUM IS ASSUMED. FOR BENCH MARKS
6 0 94.5 124' SET. SEE SITE PLAN.
.r BAFFLE -9-� iP ADJUSTED GROUND WATER: N/A SEPTIC TANK REQU
GAS
4 94.4
3 INFILTRATOR 3050 OBSERVED GROUND WATER: N/A IRED:
3 OUTLET 330 G.P.D. X 200x - 660 GAL. - 3. ALL CONSTRUCTION METHODS AND MATERIALS AND
EXISTING D-BOX SEPTIC TANK PROVIDED: 1000 GAL. .EXISTING CHAMBERS W/4 ' STONE AROUND BOTTOM OF TEST HOLE #2. 86.8 MAINTENANCE OF THE SEPTIC SYSTEM SHALL
-
/000 GAL 12'v x 29 '1 x 24'd CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL
SEPTIC TANK 6 CRUSHED STONE OR
SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS:
COMPACTED BASE DESIGN PERC RATE l 5 Ml N/I NCH
N
SOIL TEXTURAL CLASS - -1 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER
PROFILE : NOT TO SCALE `� EFFLUENT LOADING RATE - 0.74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER
�> 330 GPD / 0.74 GPD/SF 446 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH
STANDING H-20 WHEEL LOADS.
J, PROVIDED: 3 INFILTRATOR 3050
��
CHAMBERS W/4' STONE AROUND. A-5/2 S.F.
5. ALL SEWER PIPE SHALL BE SCHEDULE 40 OR
,
`� APPROVED EOUAL.
pt���i' 512 S.F. x 0. 74 - 378 GPD P
A, 1t
' \ '7- 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED
SOIL TEST P I T DA TA ® PRECAST CONCRETE AND WATERTIGHT. D-BOX SHALL
�\ BE WATER TESTED TO CHECK FOR LEVEL WHEN THEREINDICATES INDICATES
PERCOLATION - OBSERVED IS MORE THAN ONE OUTLET.
TEST GROUNDWATER
TP*l D-BOX _- 1 N I ��
96.e l 7. BEFORE CONSTRUCTION CALL 'D I G-SAFE'.
\8 1 I TP P+�1/833 Tp +�2 1-888-.DIG-SAFE AND THE LOCAL WATER DEPT.
, �` \ FOR LOCATION OF UNDERGROUND UTILITIES.
/ t7 � 3-fXFI L7ATOR 3050 HOR/ZON TEXTURE COLOR HORIZON TEXTURE COLOR
� a CHAMBERS wi4• \ �� 0- 96.8 0' 96.9
I---
Ag SOO !; , / �'> rSTONe AROUND - LOAMY l O YR LOAMY !O YR
6p° A A 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE
� " / � � `�' � SAND 3/4 SAND 3/4
TP.z `� ~�. DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION
STI i a� �\ �` /2- 95.8 /0' 96. 1 OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE
. ... ...
,_ ExIST/Nc PIT' O : LOAMY IOYR LOAMY JOYR
\ 8
SAND 4/6 SAND 4/6
B CONSTRUCTION INSPECTIONS.
:-
P6- ............ 94.6 24 ......................................... 94.9
4%, ;e oAK4 .--"� i 9. EXISTING LEACH PIT TO BE PUMPED DRY AND
- •_ MED l UM I 0 YR MEDIUM I 0 YR
C I BACKFILLED.
\o ++ yc•� 4 SAND AND 5/8 SAND,AND 5/8
LAP EXISTING QPt ry \�\C� GRAVEL GRAVEL
TANK
o Fo f VP $41��1
/ 54-/rB.OQsGl ,`
J BM-CORNER BULKHEAD i PAVED CRIVE f
EL - 98.33 t GAfrDEN� I i -
EE G I 6UY� RE
\� O
\ �f G t�a�,\,\� ` f/ r r
911E \ / ry O
ooM (rl f,'v0oo "1\o Al 3�I l20- N0 WATER 66.8 /20` NO WATER 86.9
Z�F NK ll �/ f 5 6® DATE: JULY 13. 2007
TEST BY: STEPHEN HAAS
CATCH BASIN WITNESSED BY: DONNA MIORANDI
'
PERC RATE: C 2 MIN/INCH
A
G f
A.
✓ / J pus
r
LOT 2
21 . 876 - S.F. Q
P
1 S EP 7T / C SS TE M E S / G/V
.5,3-5 PH / /V/ViT ' S LANE . MAP 230 . PARCEL / 67 - 002
tSA ,�''C IV S TA SL jF , < CE/V TER V / L L E >
PREPARE-D F'OR
L EGEND
CB CONCRETE BOUND
. JE> ER Y CO /VRA L�
.I wE0UA0UET LAKE
_W WATER LINE SCAL E : It 20 A UOUS T 20 2007
HYDRANT
GAS LINE EAGLE SURVEY I NG a NCB
OHW- OVER HEAD WIRES
LIGHT POST 923 R o u t e 6 fx
-E- UNDERGROUND ELECTRIC LINE Y a r mo u t h p o r t MA . 026 7
E i L5
-T- UNDERGROUND TELEPHONE L I NE ��i %�� I i ��� 5 0 8 3 6 2-8 1 3 2
IDutE 28 -CTV UNDERGROUND CABLEVISION LINE 508 � 432-533`
+40.4 SPOT,ELEVATION
, __40- EXISTING CONTOUR
PROPOSED CONTOUR
L O C U S MAP 0 /0 20 40 JOB NO: 07-056 F I EL D:CFW/EEK CAL C ; SAH/CFW CHECK: CFW DR,N: SAH
}
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