HomeMy WebLinkAbout0809 PHINNEY'S LANE - Health 809 PHINYS LANE, CENTERVILLE
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Omrford, NO. 1521/3 ORA
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p / TOWN OF BARNSTABLE
LOCATION O �,�2,r�r!Q �i�. SEWAGE# 7
VILLAGE ASSESSOR'S MAP&LOT 2-61 1 1,06:Y-062
INSTALLER'S NAME&PHONE NOcPZcS—
SEPTIC TANK CAPACITY &J® /����/�/✓
LEACHING FACILITY:(type) size)
NO.OF BEDROOMS 3
BUILDER OR OWNER l6431
PERMIT DATE: 15-" COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by�
e
42
eel
No. ® � / — Fee
THE COMMONW/FAUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TLE, MASSACHUSETTS Yes
Applitation for Mispotruction Permit
Application for a Permit to Construct( ) Repair(Alf Up Complete System ❑Individual Components
Location Address or Lot No.rot, ��'%� s'
f Ow��e�sN�e,Address,and Tel.No.
1ot,%>ben* �Assessor's Map/Parcel ZX! 6- �°9 �'���,,,�
Installer's Name,Address and Tel.Noe-1 ./'�+ iir Designer's Name,Address and Tel.No.-Poir
a -a ,GLueti �= S 99 -�z�'i+b 1� 3 /Co/s�roeef� v'd, Ceril�aNi�/�
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3 gpd- Design flow provided 'M; _s gpd
Plan Date y�?v�i,� Number of sheets / Revision Date
Size of Septic Tank i.Luc Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the,provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date jL11�7 —
Application Approved by Date /3 /
Application Disapproved by Date
for the following reasons
Permit No. ( Date Issued 7`�3
No. Fee
—'' THE COMMONWEALTH OF M. SACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF B RNSTABLE, MASSACHUSETTS
.4
Rpplicatton for VI�tJoSal tP"C ,TYBtrUctlon permit
r n
Application for a Permit to Construct( ) Repair(U<Upgra ( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.0-p' Ow is Name,Address,and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address and Tel.No o�e_-1 i�ii� Designer's Name,Address,and Tel.No.s-,V- -?
riM r (�c � vo4/ F l0olfr rli�// "r t-�?1�✓!i��/rf
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
0
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3.3<n gpd Design flow provided
Plan Date Number of sheets / Revision Date
Title S,;c /., ry c��•� /joy
Size of Septic Tank /� p oa Type of S.A.S.
Description of Soil �'��%u M �a� ? low
Nature of Repairs or Alterations(Answer when applicable)
• wr�� y ' S-l�oit�
i
r
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 .,�'�-�.',�-'`'s'` Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
a -
Permit No. C) 7L Date Issued
--------------------------------------------------------------------------------------------------------------- ----------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(t111 Upgraded( )
Abandoned( )by
at d709 has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. Q - dated -( 5
Installer Designer "
#bedrooms Approved desi ow e3r3 0 gpd
The issuance of this permit sha 1 not be construed as a guarantee that the system will funct , as design
Date �-�- � � Inspector 1A, e,
---- ------------------------
--------------------------------------------------------------
O'U "� — ( / Fee /
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS
NspoSal 6pstem Construction J)ermit
Permission is hereby granted to Construct( ) Repair(✓S Upgrade( ) Abandon( )
System located at �4P ��,/�,��onr
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.^ r
'3
Date ( _ Approved by !
I
Town of Barnstable
.°� .� Regulatory Services
Richard V. Scali,Interim Director
• B MSfABLE •
9 = Public Health Division
16 Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date:_6 =6AO IS Sewage Permit# . 1 —8 0 Assessor's Map\Parcel G5_1 0-(3_0®'L—
Designer: W(9L ,'F, F 14%oCi Installer: Paxd_.MAttT-��
Address: `�a� `R >y- Address: le�l,
6 /P
61L3�- Lt,
d�Cv�.3
On /s- — gAJ,as issued a permit to install a
(A-ale) (installer)
septic system at IR41 aA�s 4l, P�gS�xA tom! based on a design drawn by
da(�dress)
dated --l2sl
(design )
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out(if required)was inspected and the soils
were found satisfactory.
a-
I certify that the system referenced above was constructed ' nce with the terms
of the I\A approval letters(if applicable)
(Installer's Signature)
mlm,
91
(Designers Signature) (Affix DesigHMONWip Here)
PLEASE RETURN TO BA TABLE 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 Rev 8-14-13.doc
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ypTMe,
4own of Barnstable P#
Department of Regulatory Services
Public Health Division Date
NAM
f679. �� 200 Main Street,Hy MA 02601
Date Scheduled / Time Fee Pd.—���`�� 1
rso
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S�yoi�yl��..!. uitabii+lity Assessment for Sew e
Performed By: �w'rG f'(�J t��a Witnessed By: ®' "
4^�
LOCATION_&GENERAL INFORMATION
Location Address Owner's Name P'a2
�c�r�K�tc
p Address
Assessor's Map/Parcel: 6.—L/VaEngineer's Name
NEW CONSTRUCTION REPAIR Telephone#
Land Use RES j� Slopes(%) 0-/• Surface Stones
Distances from: Open Water Body ZbD ft Possible Wet Area--f-�ft Drinking Water Wel✓ 0 ft
Drainage Way 7 0 It Property Line 7 1 0 ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes)
f
Parent material(geologic) 01 Ct01 �` e75� Depth to Bedrock
Depth to Groundwater: Standing: Iv Weeping from Pit Face / A
Estimated Seasonal High Groundwater Al/A.
DETER14INATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed anding 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_
PERCOLATION.TEST . Date Time
Observation ,/
Hole# d 7/ Time at 9" ry
Depth of Pere -I C�' Time at 6"
/Q
Start Pre-soak Time @ Time(9"-6")
End Pre-soak
RateMin.flnch
Site Suitability Assessment: Site Passed�� Site Failed: Additional Testing Needed(YN)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100'of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTICPERCFORM.DOC
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DEEP OBSERVATION HOLE LOG _. Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
n��1 L0"S k-09 t"(-311.,
5— �3 ib SkVN U pnrA toy,9-te(if
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
A ZD Skv'VN LoPdA
LI Zp -tom C MUS
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil on Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel
DEEP OBSERVA N HOLE LOG. Hole# _
Depth from Soil Horizon Soil Textur Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
Flood Insurance Rate Mal):
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 pervio s 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 ious material?
Certification Q�j
I certify that on �d 1 I (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 traini g t rtise�an xppenence described in 310 CMR I5.017.
Signature i- "" \ Date
C5(5 t6 ( v
Q:\SEPTIC\PERCFORM.DOC
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„ . COMMONWEALTH OF MASSACHUSETTS \
EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECT ON
RECEIVED
' V .
MAR,0 6 2001
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY:,ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
010 3.;)
Owner's.Name:
Owner's Address: S
o. p�► r�'1��ln�( �02
Date of Inspection: /b! _
Name of Inspector: please print) it
Company Name.
Mailing Address: Q. C
-0/
Telephone Number: S5 g0 , "77/_ �
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 Section 15.340.of Title 5'(310 cMR'15.000). The system:
/Passes
'
Conditionally.Passes
eeds Further Evaluation by the Local Approving Authority
ails
Inspector's Signatures Date: l
The system inspector shall submit a copy of this inspection report to..the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is,a shared:system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP..The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes:and Comments
****This report only describes conditions at:.the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different.
conditions of use.
Title 5 Inspection Form 6/1.5/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
rSUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 0/n
`
" r4-
_ .Owner
Date of Inspection: U
Inspection Summary: Check A,B,C;D or E/ALWAYS complete all of Section`D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass section need to be replaced or
repaired.The system, upon completion of the replacement or repair; as approved by the'Board of Health,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 exfiltration or.tank failure is imminent:System will pass inspection if the
existing tank-is replaced with a complying'septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation.of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a brokeri,'settled or uneven distribution:box. System will pass inspection if(with
approval of Board of Health):
broken'pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
_ .The system required pumping more than4 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
4
Page 3.of I I.
OFFICIAL INSPECTION FORM.- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE:SEWAGE.D.ISPOSAL SYSTEM INSPECTION FORM
PART`A
CERTIFICATION(continued)
Property Address:
Owner• �c 4 Atklyl I a
Date of Inspection: a/.PCc/D/
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:publ,ic.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 1 of a public water supply.
The system has a septic.tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has aseptic tank and.SAS and the SAS is less than 100 feet.but 50 feet or more from.a.
private water supply well**.Method used to determine`distance
"This system passes if the well water analysis,performed at a DEP certified,laboratory, for coliform
bacteria and volatile 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.:
3
Page 4 of l l
OFFICIAU INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: &09 av&zaa 14yA
�xe
Owner:( ).?,ei o 2—z
Date of Inspection: (o �/,QJ
D. System Failure Criteria applicable to all systems:
.You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
/Backupof sewage into facility or;system component due to overloaded or clogged SAS or cesspool
711
Dischargeor ponding of effluent to the surface of the ground.or surface waters die to an overloaded or
clogged SAS or cesspool
_ Static liquid level in the distribution box above outlet inverrdue to an•overloaded orclogged SAS or
7cesspool
9/ Liquid depth in cesspool is less than 6"below invert or available volume is less than!/z day flow
Required.pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
e of times pumped
V
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
J water supply.
_ ✓ Any portion of a cesspool.or privy'is within'a Zone 1 ofapublic well.
Any portion of a cesspool or privy is within 50 feet of a.private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis.[This systerm passes-if.the well water analysis,
performed at a DEP certified.laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and.nitrate nitrogen is equal to or less tham5 ppm provided that no other failure criteria
are triggered.A copy of the analysis must be attachM'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 15303,the the system fails.The system.owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Lar a Systems:
g Y ,
To be considered a large system the:system mustserve a:facility-with.a%design>flow of10;000 gpd to 15,000
gPd•
You:must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any questibn in Section E the system is considered a significant threat,or answered
"yes"-in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15:304..The system owner-should contact the appropriate regional office of the Department.
4.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION-FORM
PART-B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the following have been done:You must indicate"yes"or"no'.'as to each.of the following:;
Yes No
Pumping.information.was provided by the owner,.occupant,_or.Board of Health
-AzWere.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)
V" _ Was the facility or dwelling inspected for signs of sewage back.up?
Was the site inspected for signs of breakout?
_IZ'_ Were all system components,excluding the SAS, located on site?
_tZ—_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction, dimensions,depth.of.liquid,depth,of sludge and depth of scum?'
_ Was.the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System:(SAS)on the site has been determined based on:
Yes no
✓/_ Existing information. For example,a plan.at the B of,o Health.
f/ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
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Page 6 of 11
OFFICIAL"INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS -
SUBSURFACE SEWAGE'DISPOSAL�SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: �l
Owner:
Date of Inspection: /
FLOW CONDITIONS
RESIDENTIAL v
Number of bedroorns`(design): 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):192 J
Is laundry on a separate sewage system(yes or no)� ,. if yes separate inspection required]
Laundry system inspected(yes or no) -
Seasonal use: (yes or no)Qj,0,
Water meter readings, if a ait� lable(last2 years usage(gpd)):
Sump pump(yes or no w
Last date of occupanc t-w-4 , kZa0&w
COMMERCIAL/INDUSTRIAI�
Type of'establishment
Design flow(based on 310 CMR 15.20'3): . gpd
Basis of design flow(seats/persons/sgft,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: Wy
Was system pumped as-part of the inspection(yes Y no)/-X&
If yes;-volume-pumped:- gallon"s'--How was quantity"lumped°determined?
Reason`for pumping:
TMYF 6 SYSTEM
V
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'ofthe DEP approval
Other'(describe):
proximate age of all compo a ts,date installed if known)and source of information.
Were:sewage odors-detected when arriving at the site(yes or no)
6
Page 7 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART:C
SYSTEM.INFORMATION(continued)
Property Address: J
Owner: � �
Date of Inspection:
BUILDING SEWER(locate on site plan);
Depth below grade:
Materials of construction; cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line: .=
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: i/ (.locate on site Ian)
Depth below grade:
Material of construction:✓oncrete_metal_fiberglass_polyethylene
other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate) / _ / .
Dimensions: s
Sludge depth:
Distance from top of sludge to bottom.of.outlet tee.or baffle: 2�.
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: . �, p�(►j,�
Comments(on pumping recommen atd ions7m1—et and outlet tee'or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.)* _
�!.
GREASE TRA�f(locate on siie 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
z
Page 8 of l 1
OFFICIAL:INSPECTION FORM—.NOT TOR.VOLUNTARY`ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address: 6
Owner:
Date of Inspection: sl:)&eo
TIGHT or HOLDING TAN}f Z! tank 'must'be pumped at time of inspection)(locate on.:site plan)
Depth below grade: ((
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/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: Z(if present must be opened)(locate orr 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
kage into or out of box,etc.):
Gz',daL
PUMP CHAMBER/JA=(locate on site plan) .
Pumps in working order(yes or no):
Alarms in working order(.yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,
8
Page 9 of 1 I
OFFICIAL INSPECTION.FORM.-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE.DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
Property Address: /k All ja,&X9
Owner'
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type --
aching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches, number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
Oy r
CESSPOOL! (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:
4e c
Indication of.groundwater_inflow(yes or no): _ ; s
Comments.(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIV (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
S.
Page 10 of 1 l A
OFFICIAL INSPECTION FORM NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address
04 .
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building.
i
96"
S"
10
Page 11 of 11
V
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 ��
Owner: e
Date of Inspection: CT/�
SITE EXAM
Slope'
Surface water
Check cellar
Shallow.wells
Estimated.depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-if checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with.local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
_J� r�,�>�� ,sue✓�r�7
oft!9 3X 5 Ge's
11
LCi CAT 10N�bc� SEWAGE PERMIT NO.
VILLAGE 1
0 INSTA LLER'S NAME i ADDRESS
-7_� . okv5C6(( Sam,
qBUILDER OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
a
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0
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p�
�y
0
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F�
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Fims... . .... .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ ........................OF.........................---.......-....--------......_....__...---:-.........._......__
Appliration for Uiipoiia1 Workii Tonotrnrtion lermit
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System at:
P
Locatio -Address or Lot No.
PkY/Ulav7r� 6A_ ,ate�E,ce P 1 .�
_r...-•----•..•--- r...._._.... ................................•-- ......... - •-•..........
'. - -
,�`tr � � �Owner Address
w _
W ...............
Installer Address
Type of Building Size ------Sq. feet
Dwelling—No. of Bedrooms................. ................_________Expansion Attic (X/o') Garbage Grinder
,u
Other—Type o g -----------------
f Building No. of persons
a ____________________________ Showers ( ) — Cafeteria ( )
.
Otherfixtures ------------------------- ...............-................................................
Design Flow___..,___._.._._...____:_.____.__._.._..._.gallons per person per day. Total daily flow gallons.
W ---------------------
4 Septic Tank—Liquid capacity_L_e®!__gallons Length................ Width................ Diameter________________ Depth................
x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........I----------- Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( `/) Dosing tank ( ) / /
Percolation Test Results Performed by____ (.S____°_�.��!✓ !'1 _...kp___kL.L yDate._._._.._/! / S.
a Test Pit No. 1....!4_.-',_._minutes per inch Depth of Test Pit____________________ Depth to ground water........................
GT,, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
M -------•----•---•------------•----•----------------•---••...---•-----........_...--•••-•-•-----__•--.........................................................
0 Description of Soil.........................................................----•--------•----------------------------•-•---------------------------------------------------•-----••••_---
W
U ------•----------------------------------•----------•-----------------------------..............._._.._..--------------..........----------•-- .........................................................
W
x --------------------
•-----------
___......
U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
-•---------------------------------------------------• ._......----------.._.........._..........--•---------------------------------------------------------------------------•---------•--•--•-.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
o eration until a rtificate of liance has bee issued by these board of health.
Signed ' G�` .. ........... Date
ication pproved By---•------- ....... ........... .. ................................•
-D ate
Application Disapproved for t Mowing reasons----------------•-----------••--•-----•---.._._._.....---------•---------------...------------------------••••--
..................................................... ---------•---------•••---------•••......----•--•-'-----------------------...----•--•------------------------------•----------Date-.__...-•-----
PermitNo....................................................... Issued.......................................................
No....-I::� Fss.... .�� .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............................................O F..........................................--------._...........--•--......................
Appliratua for Dis" anal` Works TvnstrWlion rrrmit
Application is hereby made for a Permit to,:Consti uct or Repair („ ) 'an Individual Sewage Disposal
System at:
Locatio'�y Address or Lot No.
.......................7 ....
:4? .... !...�......EkOJti.L1...... !'....... ............................................. ...............................................
Owne Address
.c ...
Installer Address
Type of Building Size Lot... .....Sq. feet
_ Dwelling—No. of Bedrooms............................ .. .....Expansion Attic (�i) Garbage Grinder
Other—Type T e of Building ..... No. of persons............................ Showers
Q. yP g -------•--•--•--•------ P ( ) — Cafeteria ( )
Other fixtures ...............................................................
W Design Flow...........L�d
....:..........:........gallons per person per day. Total daily flow.........m 9........._............--.gallons.
WSeptic Tank—Liquid capacityl.PAf gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage /.......... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
See e Pit No..._.__._ _
Z Other Distribution box ( /) Dosing tank ( ) _
Percolation Test Results Performed by.. 4X&!S....F..��1Vl�1A. .. �..N'�_�'f�/Date..........!�y/F s`
a _
Test Pit No. I.....<..:Z..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............_.._....._..
x --------------------------------------------------------------------------------------•.:...-•------........---......---....-------------•---------•------•--
ODescription of Soil-........................................................................................................................................................................
W
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
•...............................................-•.......................•--•-•-----•---.....-----•-•--•---.......-•--••---•-----...1............---.................-----------------.....------....
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with
the provisions of TITLE: 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a tficate of C iance has bee issued by.the oard of health.
Signed. ._. --•- •--••--1�:�.- . .-•--------- ----------- ----•-- ............
Date
p cation PProved By........... --•-••--•.............••-- - ate f'
Application Disapproved for th f llowing reasons:..............................................................................................
...__
...................................... ....------..........------••.................................•.................................-----------•------...---•--. ..............
Date
PermitNo..................................................--.... Issued.. •- - ..... -...........---
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................................OF.....................................................................................
Trrtif rob of Tomplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
1
Installer
at........................... •---•-�-�„---------•-��-�-��-�-���'=-� • •
has been installed in accordance with the provisions of TITLE of The State S anitar y Code as described in the
application for Disposal Works Construction Permit No...... .......... dated..............r-------------_-_-.------------.--
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CON TRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTO'k*r..
DATE ...... ... ............. Inspector. 113 . ......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.... �J.'. .... ..........................................O F............ F=..... .�.... "`
r
Disposal 10orks Tonsfrnrtiort ramit
Permission is hereby granted........a•..... 1 . . .....................................:.........................................
....---
Ito Construct ( ) r R pair ( ).;,.an Individual Sewa a Disposal System
at No..............L d �..12E.N .....4.. N 'F .v l � ..........
Street
as shown on the application for Disposal Works Construction Permit No. : 1Z.`i 1.Dated..........................................
.w
!i w rre t
I--
DATE............. IRS-•--------
FORM 1285'A. M. SULKIN, INC., BOSTON
- cli INSTALL RI5ER5 COVERS TO PIPES TO BE LAID LEVEL FOR INSTALL 2" LAYER OF DOUBLE WASHED
N m WITHIN G"OF FINISH GRADE 2'OUT OF DISTRIBUTION BOX PEA5TONE OVER Y4"- 1�° DOUBLE
r r. W tD (SEE PLAN VIEW FOR LOCATIONS) WASHED STONE ALL AROUND
0 uj - .k1 WATER TEST D-BOX FOR
( LEVELNESS 4 FLOW
:-CC;, f� ;l &}r yr 1 m as EQUALIZATION
' e,� � N
" rt O `� EL. 50.5 __ EL. 5I.0 EL. 51.0 _
" _c` ) O d -
{i .LOCUS ct" ,n it m T.O.F. @ 4°5CH
z EL. 5 1.5 O PVC TOP @ EL. 48.0
500 GAL.
50 ,� - If IL O " 1O• 14• >:�. t " (2)DR.YWELLS HR20)ST BOTTOM @ El. 45.30
/ INSTALL GAS`BAFPLE 47.87
cv w / \ IN OUTLET TE 48.00 47.30
Q N / `` INSTALL DI5T. BOX
(EXISTING) ON G'LAYER OF CRUSHED
' 52 EX15TING DB-G STONE 5.3'
� 1000 GALLON.PRECA5T (H-20)
52 SEPTIC ITANK
51
BOTTOM TEST HOLE
i'-
�� DAILY FLOW: (3) BEDROOMS x 110 GPD = 330 GPD @ EL. 40.0
5EPTIC TANK: 330 GPD x 200% = GGO GPD
USE: EXISTING 1 000 GAL. PRECA5T SEPTIC TANK
DISTRIBUTION BOX: DB-G (H-20)
y!___ � `� ! SOIL ABSORPTION SYSTEM:
USE: (2) 500 GAL. PRECAST DRYWELLS (H-20) LINED
51 ?8 9' ` IiF�.9Y W/4' OF DOUBLE WASHED STONE ALL AROUND
CAPACITY:
�-' TH#2 ` `.` 51DEWALL: 7G x 2 x 0.74 = 1 12.5 GPD '
REPLACE EXISTING TH#I / ♦ `�� `� BOTTOM: 13 x 25 x 0.74 = 240.5 GPD
DISTRIBUTION BOX / `\` � TOTAL: 353.0 GPD GENERAL NOTES
WITH DB-G (H-20)
EXISTING LEACH / Ar �` I . SEPTIC SYSTEM 15 TO BE INSTALLED IN ACCORDANCE WITH.
PIT - PUMP DRY
4'0 3 10 CMR 1 5.00: TITLE V
50 1 FILL WITH CLEAN 2. THI5 SEPTIC SYSTEM 15 NOT DESIGNED FOR THE U5E OF A
@)Uj GARBAGE DISPOSAL.
5,AOF _SAND 4(,. \• I 3. THIS PLAN IS NOT TO BE U5ED FOR PROPERTY LINE DETERMINATION.
1 !�� �' ``� 4. CONTRACTOR SHALL PROVIDE 48 HOUR NOTICE TO DE51GN
633E + ENGINEER FOR ANY REQUIRED IN5PECTION5.
ry
5. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION OF ANY
R UTILITY, ABOVE OR UNDERGROUND, PRIOR TO ANY EXCAVATION
No. 1140 '
-.� / OR CONSTRUCTION.
RUCTION.
5EWAGF PLAN
IVIT R%�� 50 �V
2 EXISTING 1000 / FOR
DEEP 055ERVATION HOLE LOGS i� GALLON SEPTIC _.... 809 PH I N N EY15 LN., CE NTERV I LLE, MA
DATE: 04-02-2015 P-14G51 S9, TANK - INSTALL -
TE5T BY: D.MEYER,R5 � V PREPARED FOR
RISERS TO WITHIN
WITNESS: D.MIORANDI,HEALTH AGENT � V' / '
PERC RATE: <2 MIN./INCH G" OF FI NI5H GRADE
�ti�o� PAUL *- KIM13EKLEY GIAMMA51
DEEP 055ERVATION HOLE#1 EL.5 I.O SCALE: DATE: DRAWN BY:
DEPTH SOIL SOIL SOIL COLOR SOIL // 30' 04- I 0-20 15 TMW
FROM HORIZON TEXTURE (MUN5ELQ MOTTLING OTHER /1j '
0 - 3 A LOAMY SAND I OYR3/2
' 5' - /
- B SANDY LOAM IOYRG/4 / JOB NUMBER: REVISION: SHEET NUMBER: cJ.P-
43°- 1 32• C MEDIUM SAND 1 2.5Y
/ WELLER * ASSOCIATES
DEEP 055ERVATION HOLE#2 EL.51.0 i 1 G45 FALMOUTH RD., SUITE F9
SOIL 501L 5011-COLOR SOIL
5 RFACE HORIZON TEXTURE (MUN5ELU MOTTUNG OTHER / .� P.O. BOX 417 CENTERVILLE, MA 02G32
0.-G. A I LOAMY5AND IOYR3/2Y PERC@42• i Q TELEPHONE: (508) 328-4G92
4 9
2° B SANDY LOAM IOYRG/4 Is GAL. <2 MIN - EMAIL: trl5Weller@cjmail.com
42'- 132• C MEDIUM SAND 2. /
NO WATER ENCOUNTERED �! REGISTERED LAND SURVEYORS ENVIRONMENTAL CONSULTANTS
Traverse PC
E _I
., ice.. r .y ':= r,—.• :' "',•-., - ------ _....---
DESIGN DATA
STRUCTURE 3 P3D�M 5� QeS��Etitc�
DESIGN FLOW
LdT I I I o GPp / f3DO_M x 3 = 330 PD
• 1 1 o
19 0. SEPTIC TANK U5- I,- SAL (MIQ �
I/ .•/ LEACHING RATES, SIDE AREA 2.5 GPD/SF
BOTTOM AREA I•o GPD/SF
LEACHING FACILITY :
� �� ` I ti \� N �i� C � � L USE (I ) Co' � x � o L.P. w 2�s-r-or�i✓
f��r-raM AP A = Tf 5� �8 S,F.
.� 1I = — �n1 s1DE Ak�A : 2 77 s C. _ ► SE) s.F
� / �''� / Dp• .f\ ( Ia0
U9 _ 1,45 U' PLAN REFERENCE
G�� �r3 �"� �-' _._ _.i
V
Q i� / 5T N I ASSESSORS LOT NO. MA-P /L E I GAL
NOTE:
N 1. ALL MATERIALS AND CONSTRUCTION METHODS
TO CONFORM WITH COMM. OF MASS. TITLE M
ENVIRONMENTAL CODE
b` L A-L-=—A -L S Sri I S F
4 /
tv r rz.
2 n. S9 .
\,iH OF�gss9 � N V' P44 gCti
LoT 3
. 1 � moo D�ID � JOH
o T ULI.
n o FS
PLAN. 299 6 " 29874 0
-
e SCALE I TEST PIT NO. TEST PIT .NO.
n+l______----------- I •P Gt E. gfCISTER�'Sp��
ELEV. Sa, o ELEV. I (S iL 1���
p,Fes. f 5 �r ooD LA,4 hA
Et- a a SOIL OBSERVATION PITS
�oo0 4b I 4�'� 4-7. DATE OF TEST -f'-,/ 4 19 55
6AL(a�J 4�•0 LA-t��s o� ENGINEER E�wA-Lb F_ : L_UELL��'
45 cof��S� aN�D B.O.H.A G E N T -)A M aS 'D Q"L I_
EXCAVATOR .AL_
.c tea,. -7 PERC RATE IN T.P. NO. I AT�FT.= 4 L MINJIN.
L.P. w rn-4
•4I.o
?L L P_.A�I�C- LoT 2
4.0 4o c Ls
� CA.N� D>=val�P. av�
ELLIS & THULIN, INC.
LAND SURVEYORS AND CIVIL ENGINEERS
EAST SANDWICH, MASS.
•
SECTION THRU SEPTIC SYSTEM Fay. I = la ' : -