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HomeMy WebLinkAbout0037 SEA MEADOW CIRCLE - Health 37 Seameadow Circle Centerville A= 246 227 UPC 12534 No.2.153LpR MARTIN®a.YM No. C ' � Fee TH CO�_•MONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for Migpo!5ar *rae tY Comaruction VCrrait Application for a Permit to Construct( . )Repair( )Upgrade(v )Abandon( ) El Complete System El Individual Components Location Address or Lot No. R eQG�DwtI rtA2 Owner's Nam ddress and Tel.No. W Nyannts�o�-r v15 �frre_l( A- Assessor's Map/Parcel Q 24 2t, 3 7 6.m M-C ad ow Gt r da w• N -y a n n l, In taper's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Zbcr.,- Gilfay- atG CxcaVaftor\ DC1v1D AlQsdn. _ DOG GmLronry_ l I`t 1;rabcf rN L-vV Ecisr 5Ctr\dW t c_.h 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 3 3Q _ gallons per day. Calculated daily flow gallons. Plan Date 1 2-1Zg 10-S Number of sheets Revision Date Title S i+e-r- Stg�ri 1 C,j1 Size of Septic Tank a Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has bee u d by this and of Health. ,, II Sig ed C) Date �-1 Application Approved by Date Application Disapproved for the following reasons Permit No. �P Date Issued No. f' LJ 5 6 4 9 Fee l 0 D T4F MONWEALTH OF MASSACHUSETTS Entered in computer: e Kes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplication for Miooar *pgtem Congtruction permit Application for a Permit to Construct( )Repair( )Upgrade(✓ )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. sj"' G c cl Cl UUJ( i t c.1 e. Owner's Name,Address and Tel.No. 1 Assessor's Map/Parcel VV ��Ci�' l5 i U r^T (e l (Gc- -�2 37 St.GM-enclorlvrir Le w. I \finnniS' pk' l t l� �2� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. RClDCrf• C70fok/ — (3iG E'X( (loci liror) 1_3CIVID kkClSur) •- D13 En\1Ir-n(1ikQ�{G�� 1 `1 'fCct��f�6 �• l-.Iv bfF`c,icl- i �cl5r 5clr,cic+�l�h Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures r Design Flow Z)( gallons per day. Calculated daily flow gallons. Plan Date 121?_9. I a< Number of sheetsI I Revision Date Title 1�, a e Size of Septic Tank Type of S.A.S. ' Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been~issued by this"Board of Health. Sig,ed r 1� _ � � Q_�U Date I Ll - Application Approved by\ Date ----A'pplication Disapproved for the following reasons Permit No. QC) 5 �o.�( `� Date Issued AJ W S THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ✓) Abandoned( )by ;hi,r i /7 1' X �at %r, m ( � 4 V�1 I. aTi l ,. , -(-5has been constructed in ccord nce with the provisions of Title 5 and the for Disposal System Construction Permit Igo.,Aeln (4 W dated 0 Installer C!- t is k Designer 1 C r , The issuance o this pepnit shad not'be construed as a guarantee that the system will function as designed. Date (o Inspector4� No. a00 5_" t0 411 Fee 0 O.3 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ligpo5ar *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(V)Abandon( ) System located at 5, cl0 u, �_ 1� _ (, i n, . p iG, -T 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 rgust be co pleted within three years of the date,/oi this pe Date:_. 12/,A_Q Approved by-� i TOWN OF BARNSTABLE LO('ATION 31 S co. tit adQt.J C;rc,l L SEWAGE # 9aoS -G N 9 1 C-eitte-rv, c- L e-- �-T LAGE T ASSESSOR'S MAP & LOT 2yG -,PQ 7 INSTALLER'S NAME&PHONE NO. G Q Cxcaua-lion . N'7*7 - 04S3 SEPTIC TANK CAPACITY /Soo gCX-1l n ' LEACHING FACILITY: (type) Sn$!l4ra.+ors /SOo cA-4ize) 13 x 14 x 7- NO.OF BEDROOMS 4 BUILDER OR OWNER Re25crl V;cn o t r- PERMITDATE: 1,2 -P 9 - OS' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 'Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by /A1 - 31 ' A? - 39 ' BZ -q;, .. 83-38 ' C3 Ay- ys' t� -� Soo Town of Aarnstabxe Regulatory Services , ° Thomas F.CAW,Director - - = Public Health Division ' • . Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Fax: 508-790-6304 office: 508-862-4644 Installer&Desimer Certification_Form Date: Designer. g. c5 Installer: _ Address: :� �I�WG� Z �� Address: � - �, 64-1 nw1614 A'A t)Z57,,-;7Ts►dal� _ 9 0� •�O Sc r G o I- 'o - was issued a permit to install a On '1 (date) - (installer) - Jqsed on a design drawn by septic system at a 2O I BAN 1 M.a _ dated, 1 a 3`TG.,: /' above was installed substantially according to V I certify thate septic system references such as lateral relocation of the the design,wbich may include minor approved cringes distribution box and/or septic tack,. I certify that the septic syste m referenced above was installed with major changes.(i.e. greater than 10, lateral.relocation of the SAS or any vertical relocation offcomponent of he septic system)but in accordance wish State&Local Regulations. Or certified as built by designer to follow. _ (Installer's S gna kure) s fie) (Affix Desi: er's Stanaip Here) PLEASE RET[JRN TO $STABLE PXISLIC HI�ALTR D TICS��BE AS- $Ui[,TCARD ARE RECE]fVEI3 A T��ABLEB C$El1LTH DI' SI©N YOU. (� Heawse$kwesdgner Certification Form t. r TOWN OF B STABLE �TIO SEWAGE # -AGE }l /Q ASSESSOR'S MAP & LOT 7n,a.w+..�..� &PHONE NO. / ! C,O ' L/ 75 IC TANK CAPACITY /S7 o A LEACHING FACILITY: type I Lo Py.-' (6 / (size) NO. OF BEDROOMS ) Ck ) BUILDER OR WNE / 2 PERMIT DATE: C9NfftttNff DATE: Separation Distance Between the: . Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 0� l� Jt� I_- TOWN OF BARNSTABLE • ATION 37 Seq m Sdoc) it fCL SEWAGE # LAGE Cep ZS V✓ e— ASSESSOR'S MA�P� & LOT NAME&PHONE NO. �r� t-�t N�•. o�(�°�ne'L� r �� SEPTIC TANK CAPACITY h LEACHING FACILITY: (type) ° \ (size) NO.OF BEDROOMS 41f �p 41 #V BUILDER OR OWNER as UL )k—1 'e i tQ- a PERMITDATE: COMPLIANCE DATE: e Separation Distance Between the: Maximum Adjusted Groundwater T'�Ie to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS r' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM J, PART C SYSTEM INFORMATION(continued) Property Address:37 Seameadow Circle,Centerville Owner; Luis Ferreira Date of inspection:October 18,2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch ofthe sewage disposal system including ties to a[least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. Seameadow Circle Driveway 9'z 41.5'z I'SAS 56 I 31 38 50 Garage N37 n—Ann 10 COMMONWEALTH OF MASSACHUSETTS R 3 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r d DEPARTMENT OF ENVIRONMENTAL PROTECTION � yve TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 37 Seameadow Circle Centerville MA 02632 Owner's Name: Luis Ferreira Owner's Address: 9 Bridle Drive Lincoln RI 02865 cs 3.3 43 Date of Inspection: October 18,2005 Job#05-322 Name of Inspector: PATRICK M. O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 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: ``011101cillIII _— Passes ` �• �� Conditionally Passes ` _X_ Needs Further Evaluation by the Local Approving Authority ATRIC .�ycGn Fai M. . coo Inspector's Signature: Date: 10/18/05 •••• Rr�l;1��'' '�`�� .. ��'ii�FS INSPE���•``�• The system inspector shall submit a copy of this inspection report to the Approving Authority(Board pf Health or���tttN��`� DEP)within 30 days of completing this inspection. If the system is a shared system or has a design fldw, of 10 000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional ffice of-i1�e DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, an the a r6vin pp g authority. y Notes and Comments: System is properly functioning, however is under designed for house�f nk cov s ' OU under paved walkway and recommend building covers through pavement. q are ; F ****This report only describes conditions at the time of inspection and under the conditions of use aat r time.This inspection does not address how the system will perform in the future under the me or da"Glerer conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION (continued) Property Address: 37 Seameadow Circle,Centerville Owner: Luis Ferreira Date of Inspection: October 18,2005 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 broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Titles S Incn—;— P.n m rii siinnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 37 Seameadow Circle,Centerville Owner: Luis Ferreira Date of Inspection: October 18,2005 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. I. System will pass unless Board of Health determines in accordance with 310 CNIR 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 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile 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: House has four bedrooms ands stem was desi ned for three bedrooms T41.f rnenai.tinn Rnrm�ii v�nnn 3 -- Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 37 Seameadow Circle,Centerville Owner: Luis Ferreira Date of Inspection: October 18,2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No — —X— Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped — _X_ Any portion of the SAS, cesspool or privy is below high ground water elevation. — _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. — _X_ Any portion of a cesspool or privy is within a Zone I of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma _No_(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—I WPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. T:tIA G fnena�tinn Rnrm 411;i10nn 4 Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 37 Seameadow Circle,Centerville Owner: Luis Ferreira Date of Inspection: October 18,2005 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ — Pumping information was provided by the owner,occupant,or Board of Health — _X_ Were any of the system components pumped out in the previous two weeks — _X_ Has the system received normal flows in the previous two week period ? — _X_ Have large volumes of water been introduced to the system recently or as part of this inspection _X_ — Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ — Was the facility or dwelling inspected for signs of sewage back up ? _X_ — Was the site inspected for signs of break out? _X_ — Were all system components, excluding the SAS, located on site ? _X_ — 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? X_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 _X_ — Existing information. For example,a plan at the Board of Health. X_ — 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)] Titles Q Fncm—tinn Rnrm 4/i canon 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 37 Seameadow Circle,Centerville Owner: Luis Ferreira Date of Inspection: October 18,2005 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 3 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms) Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Yes Water meter readings, if available(last 2 years usage(gpd)): 2003—31,000 gal.2004—43,000 gal.= 101 gpd. Sump pump(yes or no): No Last date of occupancy: Occasional weekend use. COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): 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): Pumping Records: None GENERAL INFORMATION Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_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): Approximate age of all components,date installed(if known)and source of information: Compliance date: 4/30/97 Were sewage odors detected when arriving at the site(yes or no): No T41. C Tnenart;nn Rnrm (./1 VNIOn 6 Page 7 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: 37 Seameadow Circle,Centerville Owner: Luis Ferreira Date of Inspection: October 18,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 16" Materials of construction:_cast iron X40 PVC_other(explain): Distance from private water supply well—or—suction line: Comments(on condition of joints, venting, evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 16" Material of construction:_X_concrete 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: 10.5' long x 5.8' wide—1500 gal. Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0" 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: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tees intact and clear tank has liquid only. GREASE TRAP: No (locate 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.): T41. Incnortinn Rnrm All si100n 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 37 Seameadow Circle,Centerville Owner: Luis Ferreira Date of Inspection: October 18,2005 TIGHT or HOLDING TANK: No (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: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): No solids or high stains liquid level at bottom of outlet invert PUMP CHAMBER: No (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.): Titla i Incnantinn Gnrm 4/1 ci10nn 8 i 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: 37 Seameadow Circle,Centerville Owner: Luis Ferreira Date of Inspection: October 18,2005 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _X—leaching chambers, number: Six infiltrators. (9' x 41.5' x 11) 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, etc.): SAS shows no evidence of saturation. No dam soils or evidence of breakout. CESSPOOLS: No (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: No (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.): Titla C Incnartinn Rnrm AM C/7(1f1l1 9 i f Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 37 Seameadow Circle,Centerville Owner: Luis Ferreira Date of Inspection: October 18,2005 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. Seameadow Circle Driveway 9'x 41.5'x 1' SAS i 56 31 38 50 Garage #37 Title fncnortinn Fnrm rli;nnno 10 I Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 37 Seameadow Circle,Centerville Owner: Luis Ferreira Date of Inspection: October 18,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 10 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) _X_Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows high water below el. 10 and topo map shows property above el.20 I Titla 5 ►nenartinn 17^rm All v,)nnn ]] No. 9 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computef. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETT 2pprication for Mfi6poof *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. i/� n / Owner's Name,Address and T 1.No. 7 Assessor's Map/Parcel IV Installer's Name,Address,and Tel.No.!j / Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 'Lot Size sq.ft. Garbage Grinder Other Type of Building Zvi �s?Ge No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. " Zyl i/fr4�`ar$ Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue b t i oand of Healt Signed Date 7 l� Application Approved by - f Date e' -a Application Disapproved for the following reasons Permit No. Date Issued' -3 �� TOWN OF BAMSTABLE LOCATION 3 7 aSeQ Wmalaa' CiAc le SEWAGE # —/ VILLAGE /_ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. D/IT?�G� J i� 771—tW SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 6 (size) 9 IX y/J" X J NO..OF BEDROOMS BUILDER 0 OWNER r, PERMTTDATE: — 73 COMPLIANCE DATE: 1'I © "7✓I Separation Distance Between the: (� . Maximum Adjusted Groundwater Table and Bottom of Leaching Facility J t Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) q Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Jf 1 I n 'ot aF ,nS L£� Z Z -7 No. — Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTSr Yesl 01pplication for Migogal *potent (Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade(✓)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 7 Owner's Name,Address and Tel.N� Assessor's Map/Parcel Ste�e��wc ix- - � z IV/ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 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 114 gallons per day. Calculated daily flow gallons. Plan Date 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) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by t is o of Health. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. .-+ Date Issued �-^- . ; •-� �' THE COMMONWEALTH OF MASSACHUSETTS �y/_ ZZ BARNSTABLE, MASSACHUSETTS C/ (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( Abandoned( )by 7`D�d , 6 at 4/. n :� arT has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction ermit No. ,C dated '"A `� 57 Installer as/� Designer ' The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector �\ 1 -------------------- — --- ------ - No. / - 'Z../Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Digpogal *pgtem (Congtruction Vermit Permission is hereby granted to Construct( �)Repair( )Up/grade( ✓ Abandon( ) System located at 3 7 Jr�q /�f'OG7'D!,!/ %�/'1� JW. /1YIYIrI/.24 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 it. Date: iG y' �� Approved b r k ` � °w � yl 5 � � l .7 :4 rLt�-4�cw C-4!� . 0 000 ��i gA L,4i)VL,,O G I A C.� r. NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL, WORKS CONS'TRUCTI®N PERMIT MT)F OUT DESIGNER PLAINS) I. RPA 17` (J ,&VV4� / , hereby certify that the application for disposal works construction permit signed by me dated y1 a147 concerning the property located at $CGt iyl�QG �G�Gfi"G`e /5, meets all of the following criteria: /There are no wetlands within 300 feet of the proposed septic system /There are no private wells within 150 feet of the proposed septic system /The observed Qroundwater table is 14 feet or treater below the bottom of the leachinc,facility J There is no increase in floe and/or change in use proposed There are no varian ces requested or-needed. SIGNED : DATE: 1//z1 4P,7 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert TOWN OF BARNSTABLE LOCATION c/2r ry �e� ad D w SEWAGE # V77.I.LAGE �e/� e r�'� �` ASSESSOR'S MAP & LOT t-' 1-4 SEPTIC TANK CAPACITY LEACHING FACII;ITY: (type 0 (size) NO.OF BEDROOMS PERMITDATE: MPLIANCE DATE: Separation Distance Between the: �® Maximum Adjusted Groundwater Ta�ee the Bottom of Leaching Facility Feet Private Water Supply Well and Lea`fit ing 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 ro 1 � e„ BORTOLOTTI CONSTRUCTION,INC. 765 WAKEBY ROAD,MARSTONS MILLS, MA 02648 e 508-771-9399 508-428-8926 FAX: 508-428-9399. lg SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFI AT10N Property Address: Date of Inspection: . Inspector's me: Ow er's Name and Address- 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 per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: Passes Conditionally Passes Needs Further Ev lion By the cal Aproving Authority Fails Inspector's Signature: Date:_ ��9� The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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. I INSPECTION Si MMARY- A)SYSTEM PASSES: I have riot found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One-or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. 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 exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due 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): - .t - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM //;, PART A r� CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed 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): Broken pipe(s)are replaced Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect the public health. safety and the environment. 1)SYSTEM WILL PASS UNLESS.BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I 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 free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)PSTEM 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 sho 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 SAS or cesspool. Discharge or ponding of efluent 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 outlet invert due to an overloaded or clog- ged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NO1,due 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 I of a public well. ' Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10.000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 11 of a public water supply well The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 GAR 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: _k-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. VAs-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. The 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, have been located on site. �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. The 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: allons Number of Bedroonts:_V Number of Current Residents: Garbage Grinder: Laundry Connected To System:'Zjk& Seasonal Use: Water Meter Rea gs, ' av dable: Last Date of Occupancy: COMMERCIALA ND USTRIAL: 4 Type of Establishment: 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 INFORNUkTION PUMPING RECORDS and source of inforniation System Pumped as part of inspection:,&.2a if yes, volhthe pumped: V gallons Reason for pumping: TYPE SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): APPROXIMATE AGE of all components,date installed(if known)and source of information: Sewage odors defectedwhen arriving4t the site: 2a -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction: P---C—Oncrete metal . FRP Other (explain) Dimisions:lQ'&Ar Sludge Depth: Scum Pickness: Distance from top of sludge to bottom of outlet tee or baffle: ,�y Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid 1 1 in ation to det invert, structural integrity,evidence of leakage,etc. '4::�V;y GREASE TRAP: 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 battle: Comments: (recommendation for pumping,condition of inlet and outlet tees or battles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:_concrete_metal__FRP_Other(explain) Dimensions: Capacity: gallons Design Flmv: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarin and float switches, etc.1 DISTRIBUTION BOX:_ Depth of liquid level above outlet invert: ��% Comments: (note if I el and distribution is_equal,evide a solids carryover, evidence or1ge. ' to or out of box,etc.) PUMP CHAMBER: , Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) -5- I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS):_j,�-' (Locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. ._. . Leaching pits, number: Leaching chambers, number:Leaching galleries.number: Leaching trenches, number, length: _ Leaching fields, number,dimensions: Overflow cesspool, number: Comments: (note condition of soil signs o ydraulic failure level of ponding, c ndition of vegeta 'on, etc. _ y . - 024 'a CESSPOOL S:—A.20 Number and configuration: Depth-top of liquid to inlet invert: _ Depth of solids layer: Depth of scum laver. Dimensions of Cesspool: _ Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) _ Comments: (note condition of soilk, signs of livdraulic failure. level of 1'�onding, condition of vegetation. etc.) -- -- ------ _—. �_ PRIVY: Materials of construction: Dimensions:___ Depth of Solids: — _._. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) -6 - _t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 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. 0 3 DEPTH TO GROUNDWATER: ' Depth to groundwater: g Feet r � M od of Det tion or A proxi don: ®X/f?�l% JeVf ��A6r el" oeV a� a 7 y. TOWN d OF BARNSTABLE LOCATION 37 J�Q /��l�dea" C;Ah SEWAGE # VILI..AGE ° ffy�r� i��o�� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. DR7�� J�� � j isop SEPTIC TANK CAPACITY -- LEACHING FACILITY: (type).L+4/ta,5 60 (size) 9 �e y1,J- X J I NO.OF BEDROOMS BUILDER O OWNER c(� PERMIT DATE: '"Z 3�Q? COMPLIANCE DATE: Separation Distance Between the: S Maximum Adjusted Groundwater Table and Bottom of Leaching Facility f Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 4114 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 37 _. - 31 34 O 10 r I I I � i t° TOWN OF B STABLEPY, LOCA71ON 4SEWAGE# VII.LAGE����� /�� �2- ASSESSO M^LA-P/ &LOT 2 7 /3 jN5k-CM R'5 NAME&PHONE NO SEPTIC TANK CAPACITY ATOO aj LEACHING FACILITY: (type) - Cy size) NO.OF BEDROOMS BUILDER OWNER PERMITDATE: CO L DATE: Separation Distance Between the: 1 Maximum Adjusted Groundwater Tabl an Bottom of Lea ng Facility Feet Private Water Supply Well and Leachin F any wells exist on site or within 200 feet of leaching acility) Feet Edge of Wetland and Leaching Facility(If any wetlands.exist within 300 feet of leaching facility) Feet Furnished by "' -9 �� �- ���� - �` �, � . . f ��� �� �i ��I I ,11-0 CAT ION / SEWAGE PERMIT NO. ,, YILLAGE ��ann,soc�fi I N S T A LLER'S NAME A ADDRESS JOHN A. AAL i 0 BACKHOE SERVICE 150 W�I!,r it S,-reet _ .West Barnstable, Mass. 02668 S U I L D E R OR OWNER sea DATE PERMIT ISSUED DATE COMPLIANCE ISSUED (/ Ap- a m, E-: ••� 1t ti, f � - Q No. -- d Fx ....� 0.•..�... THE COMMONWEALTH OF.MASSACHUSETTS a" BOA locc.v ................ ................... . . lira #ion for M_qpnoa1 Vorko Tonstrnrtiun .rru�Wit7. ^Application is hereby made for a Permit to Construct (v") or Repair ( ) an Individual Sewage':-Disposal System at: L• ation Addr s or Lot No. r .11 �....... W ......................................... Owner Addres a •��/, ......--- v .��-.`s •--- ' '��'� � -- ..................... ----.......------------------------ Installer Address U Type of Building Size Lot...1162.r-----Sq. feet a Dwelling—No, of Bedrooms_____________.__..__..______._______.___Expansion Attic ( ) Garbage Grinder ( ) Other.—Type e of Building No. of ersons_________________________•._ Showers, W yP g ---------------------------- P ( ) — Cafeteria ( ) P4 Other fixtures _.._•••••--•----••-•---•----•-•- W Design Flow..............5'S......................gallons per person per day. Total daily flow_________%,33!_.......................gallons. W Septic Tank—Liquid capacityrSCJ__gallons L�ength.__/.V__.__.. Width._.'. ._ Diameter................ Depth...J`__._._-. x Disposal Trench—No. _.__.....1_______._ Width____._��__.___._ Total Length......30........ Total leaching area___ y_:®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_4�D r ___.__..__._____-. � �, / t - .r Test Pit No. 1___ __ ____minutes per inch Depth of Test Pit.... Q______ Depth to ground water:�__rem.__...__. 44 Test Pit No. 2___.............minutes per inch Depth of Test Pit.................... Depth to ground water........................ - _ ODescription of Soil..................... ..f�'...�!ll _...-------•--•---•---•--------•-------------------•••---=•-•-----•-------------• ---•-------- x w ......................................a. V Natu're 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'21"LE 5 of the State Sanitary Code—The and igned further agrees not to place the system in operation until a Certifi�°f Co e ha6bbeeissued by t and of health. 2 S ned ------ �--L-------••------------- ---/ lM6Da eApplication Approved By--....• •-- -----------------------------•- --__--•�- l ?' .... ..._ D e' Application Disapproved for the f follows g easons:---------••---•--•-----------------------•-----------•-------------------------••-----•••-•-•-•••••------•---- ----•----•-•--------•-•••-••-----•----•••••--•••---•••................-......................................................--•••------•--•--•--•-•-------•---•-•-••-•-•------•••••-•-•-••-••-----•--- Date PermitNo......................................................... Issued....................................................... Date r Iiw eiG SO�`--- 0 F:m$.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... ...........................OF............................_........... Appliration for Disposal Works Tonstrnrtiun Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Seww Dis l System at: T��`` ................_...... .......--.................-- ........_.. ............. ... •-....... Location-Address or Lot No. ......................—........................O ------------. -- W Owner Address a --••-•------------•-•-•-•-••...........................•----•--....-----...--------•----.......... ..............--•-------•.....---.....------............ •--------••••---•----•-------------...•. Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `A e of Building PA Other—T yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ............. 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....................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........................................ 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........................ 9 .....--•---•••••••......----•••---•••-••.......•-••-•-•---....-•------------------------•------------------------ -•---------------- ••--------------------- ••- 0 Description of Soil........................................................................................................................................................................ x c.� ....................................._.................................................................................................................................................................. UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation u it a CI;rt4ote,of Co n e has be issued Liy th rd of health. in .••-- - .................... . �`':.------•-•---•-•---• ate Applicatiox/Approved By........... ...........s_...' -----------------------•--.._..--••---•-------.....----- ................ ---------------------- Date Application Disapproved for the following a ons----- -------------------------•---------...------------•----------------....................................... ---------------------------------------------•---•-----•---•----------•--....---------...._..---•••-•--...---...-•••--•-------•••---•-----.............................................................. Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrtif iratr of fl OMpliFanrr THIS IS T .C T Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by..- ----------------------= C staller has been installed in accordance with the provisions of TIT F 5 f The State Sanitary Codp. as dff scribed in the application for Disposal Works Construction Permit No.___.__ 'cam •..__. ... dated_...__._....I�_.?/1�, .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FU C 1 1 ,SATISFACTORY. DATE _ 1�R_ ..................................... Inspector.......1w ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........................................OF..................................................................................... J �> G No..........��� °� : . FEE-------- .............. i � Akto�a ��lntt Permissionis hereby granted----------------•.-----•-----------._......-----•-------------------------..._._._-----------------••-•------------•----...._........-•-•--- to Construct/(� or Repair ( ) an I ualoS -v rah isp sal System f f J O j, I..... ...J--Vz ' Street as shown on the a lication for Disposal Works Construction Permit No. j --------------•--••---•- c, t: Board of Health DATE....... = = ....................... FORM 1255 A. M. SULKIN, INC., BOSTON 43 i � I 1 tJ - ' I - - - - -_ -- -- _ - ---- -- - -� -- -----— - - T f- � i / i 0 7"-F ' EK7 rV r-1 L<'_ _ ._ xisffr-ry ground prod/✓e t44J2/Z SC_ALE- � � VE /27: SC/9L� 9tilf- ©LLC© Vi=)2S ?~o w!7-,Lt/l-1 SCHF ¢0 PVC. oe Crnfnrmum f t 2 I Yer ` /g per �O01c� / PerzS,Qn / EQUAL 7-0 5EP`r/c� Li -44 3 f /6©o 5'EF-'r/C 7-,9Nk W�Sh sfore vd/�` r _ 3�4,x5 S --- / G1J/7-A- 6 +` ;Y ,_ _-,. •'- /`-7/IV.//Al C H _ ,5• - _, /� w Rr9TC— GALS,/?3A'S'r E P 7'-/C 7-/9 A-I A- "'� �%'_ 9 /. 5: 4 /8 -c, t2E,q ec-. ��,. v S�t4fsls_.. 24 DE _ Bo k' o. 9(a r�,5 j 1 �2 o c; p. D. FRO OCT ro,--II = /© x 30 {, o r= 00, o N o 3 p)z u t3 HIGH wA7EQ 1 h J nj;c PST/r—Y 7"HF37- 7-14& BU/L-D1^JG r� Pl2aGC�sE U 0A-1 7-HE G/20UfuD FPS ,5 / 7 � � � / �� �.. ,� �.� S A4 0:. AJ 0 A l T/-H 1 S ,o L A tV ZD cv E 5 r " L !�„ N !�/�tti(1�. f 7" �^ ?cam THE 5L//L_D/n1G SET- NSF_A M�ADO PJ FOR . Ty E3 FCC K i2 E=G2 U/e��MENTS O� TNE• F�0 LA/A! A 7' - - �16/•1�t/, k' , P f B L G7 G. S r3 �)C t .'1.?Q / ? " r ;r'°; Q Cl//Q F- E f?J7-6 F'f',2 0 V ED - I" to 1^ 8 ASSESSORS MAP: � z9 67 t TEST HOLE LOGS aP� t PARCEL NOTES: Gro- SO I L EVALUATOR:�A G i FLOOD ZONE: _:�LST---__ .�'1G'48t.�----- -- -- WITNESS: t 1� ` �7 o Ave a`in : = 5 C o REFERENCE: - 1 � __ DATE: �` I 1) The installation shall com 1 with Title V and Town of Barnstable comply Board of w G gtzr Ft Pen RL67 - F LAie, J �6 Paep � Health Regulations. \. My" - ---- PERCOLATION RATE; 1�, I St - Cco�e�•E (,Ditt�� �L �� , oZ 2) The installer shall verify the location of utilities, sewer inverts and septic ' g y nis dN' �L, 0. - _ � components prior to installation and setting base elevations. � o TH- I TH-Z 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. 4) This plan is not to be utilized for property line determination nor any other purpose other than the proposed system installation. Loftt4 �,.u� 5) All septic components must meet Title V specifications. ;Qj/3 6) Parking shall not be constructed over H10 components. septic P ` ,► r o% 7) The property is bounded by property corners and property lines. LOCAT I ON MAP e TS) 8 ) The property owner shall review design considerations to approve of total' Vw design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. l 9) The existing septic tank must be 1500 gallons as depicted on the BOH as built septic card at a minimum. If it is less than 1500 gallons i b �P g s t should be replaced 7" with a 1500 gallon tank when 4 bedrooms are installed. r:= l (fewo, 6.�VUL 10)System components to be 10 feet from water line. 11) If a garbage grinder exists it is to be removed and is the responsibility of the - owner to ensure such. Ji _ - i SEPTIC SYSTEM D E S G N 12)The proposed SAS is to be attached to the existing SAS. FLOW ESTIMATE �3 BEDROOMS AT//O GAL/DAY/BEDROOM -330 GAL/DAY SEPTIC ;TANK ' 1.1(Ar of YN g L ._ . l 'Zo GAL/DAY x 2 DAYS - �.GAL . : 4 'USE ItO GALLON SEPTIC TANK aL $DN t)tCS� SOIL ABSORPTION SYSTEM,v \ f g 10,401 � i l j 0 w ►, . b ,,,� �,�,� �-tbti W LAG - -__ i�1G 3 i room M� `DE AREA: — --TG -1 _ X 273 &JTTOM AREA: Q Ls. 1 1 - _k :1-11.17— 6s of SEPTIC:' SYSTEM SECTION 1 f1 OF of >`oulQAn0 -� ..y"`.="°�..u....wr.:�:`S. .. �.'•�'.r^54Lvre.oexw.-,,..,...•..,....-.�:.. • ��✓ �� A M I A!ZZ 0 D-BOX GAL 1207 9 12,86 _ - _.y SEPTIC TANK t _ . _ r- SITE AND SEWAGE PLAN 1 LOCATION : 4 -6F,a4 E4t�o� �P-Ll.Ff. MA PREPARED FOR : (5C7)9 ►`?EZ4&JLO LOOT TLur o . lA 06 A�/ SCALE• � "' DAV I D B . MASON-124'; DATE: 5 DBC ENVIRONMEN�fAL DESIGNS W EAST SANDWICH . MA W DATE HEALTH AGENT ( 508 ) 833- 2177