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HomeMy WebLinkAbout0089 SHEAFFER ROAD - Health 89 SHEAFFER ROAD, CENTERVILLE A= 172 070 M"do QEcvc�Eo J 2 UPC 12543 % a o. 3LOR HASTINGS,MH TOWN OF BARNSTABLE 'A LOCATION- P l' ' '� �/� 10"0° SEWAGE VILLAGE C ASSESSOR'S MAP & LOTS " INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITYa'�S� LEACHING FACILITY: (type) (size) /. X�� •Z" NO. OF BEDROOMS BUILDER OR OWNERS PERMITDATE: �?--��--1614f— COMPLIANCE DATE: O 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 17 - 2aP' � . i 6 `I No. poa 8 — 3 6 y t r Fee I THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes flpfltation for MI8posal *pstrm ConstrUttion permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System [!Individual Components Location Address or Lot No. p�'f/f/�.q/f �`QL ,p Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 7 ® Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. a Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building �'!�/' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) O gpd Design flow provided .� �p gpd Plan Date Number of sheets / Revision Date Title Size of Septic Tank � .J'7-�d"'(l "'Oo® 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 He 9✓Jr Signed Date Application Approved by Date S Application Disapproved by Date for the following reasons Permit No. 7-CPP 0 3-.:ix Date Issued No.�oog. 37y 1° ... `' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered;ncomputer: PUBLIC HEALTH DIVISION`-TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpYication for disposal tipster"! Construction 3perntit Application for a Permit to Construct( ) Repair(1K Upgrade( ) Abandon( ) ❑Complete System [r Individual Components Location Address or Lot No. f,f/�.�/j�jtF`pL 'f Owner's Name,Address,and Tel.No. Assessor's Map/Pardel�7.3 — O 7 p Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. LE`D3o�G f- )fird yo `�j.•�'�i��v •C'i��sc�+� x-, Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Q ef' No,of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 0 —,-gpd Design flow provided .5,-0 gpd Plan Date Number of slidets / Revision Date Title Size of Septic Tank CX%1'T'�� moo o Type of S.A.S. l"'CH 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 He-a". � Signed Date _ Application Approved by ,-, Date s Application Disapproved by� Date for the followinglreasons /lam I Permit No. 7� Date Issued �j— S ,a -- -_P--------- ------------------------------------------------------------------------------------------------- -- - A , 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 �! -e at P9 � ���f ��� �'�. CeQ-��` has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.aoog 37�1c dated I Installer ���J t��f0�`Uf Designer. #bedrooms J Approved design-ow / J gpd The issuance of this p �t steal of be c nstrued as a guarantee that the system nc ion as designg-. 0 Date ��� �a Inspector --- ------------- v L� - ------------'----------------- No. �00 37 �--------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS Misposal bpstent Construction permit , Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be Wnpleted within three years of the date of this pe ' Date Of — ' Q Approved by 'Town of Barnstable "E:r° Regulatory Services ., Thomas F.Geiler,Director � SA•FtNST/18FE, � Public Health Division Fro Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: l�esigner:_-DAY I Q f2— , � Installer: Y_VA Address: . '(Z '�jl�� ��& Address: On was issued a permit to install a (date) (installer) ,A- septic system at based on a design drawn by ,- 11 (address) PAV I D , tq�'N �� dated (designer) 1-certify that the septic system referenced above was installed substantiall:. accc�rdin-� .Y g to she design, which may include minor approved-changes such as latera .relocation of the dutribution box and/or septic tank- 1 certif Ahat the septic system referenced above was installed with' a1or_changes, � greater thy.10' lateral relocation of the SAS or any vertical relocation of any component of the septic,;- but in accordance with State&Local_Regiilati'ons. flan revision of certified as-bu;l V designer to follow. r Af RS' — o g, (Insta er s jnature) cn MASON No.1fl66' -c. t3I3T�P _ aju�� THANK YOdJ. SgN1TAAIP� . , (D er s Signature} (Affix er's Stamp Here) PLEASE RETURN TO B__ STABLE`PUBLIC HEALTH.DWISION. , CERTIFICATE OF.. CQAZLIANCE WHX: `NOT,DE`_ SSUED` BOTH=-TRitS`�FOR ' BUII�T C.A D ARE RECE"" IRCTT�:BAIL< STABI:E PUBLIC AI; DTi�ISi®1�1: ' Q:Hea1ti/SeptcDesigner Certification Form i •, rb,, P# Town of Barnstable oaTME Department of Regulatory Services ' Public Health axe RS.r� t Division Date MAes. A 163p ��u _ 200 Main Street,Hyannis MA 02601 " ;Date Scheduled �"� 0` ' �X?rme Fee Pd. Soil Suitabilty'Assessment for Sewage Dispos ' Performed - "Witnessed By: B " LOCATION& GENERAL INFORMATION Location Address ��.f'i e�%'/r�� —o O, C ems,,.? Owner's Name tr Address F 9�Q041.. �r�CJ[�� Assessor's Map/Parcel: ®?O Engineer's Name 0i4'o+`,,o NEW CONSTRUCTION REPAIR Telephone# Land Use .� Slopes(',) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH.(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) Parent material(geologic) 47-_)r[kDa4,-1 0 - Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: __ _ in.. Depth to soil mottles: 1n. Depth to weeping from side of obs.hole: (n. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.ftiactor, ,q� Adj.draundwater Level,, e PERCOLATION TEST Date Thne.� Observation Hole# Time at 9" Depth of Perc Time at 6" Start Pre-soak Time @ - 2 TSme(9"-6") End Pre-soak Rate MinJlnch �� "i' ► ' Site Suitability Assessment: Site Passd_kL Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division'+, Observation Hole Data To Be Completed on Back----------- L***If percolation testis to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTICVERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. niceGravel), ;.� Af2Gn /o O DEEP OBSERVATION HOLE LOG Hole#. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% 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) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders., 1 Consistency. Flood Insurance Rate Mau: " Above 500 year flood boundary No_ Yes p� 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 ate 'al exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturall occurring pervi us material? ! ' Certification . I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environ ental Protection and that the above analysis was performed y me consistent with . the required training,expertis an per ence described in 3 10 CIvIR 15.017. 'Signature Date Q:\.SEPTIC�PBRCFORM.DOC TOWN OF BA TABLE -OCA:'ION Leg/ SEWAGE # l VILLAGE 62A CR V1 r e. ASSESSOR'S MAP &LOT o2 1--oic INSTALLER'S NAME&PHONE NO. 011 SEPTIC TANK CAPACITY AD6 o 6n LEACHING FACELrrY: (type) G5 �'� �� x (size) NO.OF BEDROOMS BUILDER OR OWNER PERMrf DATE: - 7�� COMPLIANCE DATE: _ 3 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 r - h g 1 o� h� f I 9 No. z 7, ��� Fee T—r— —0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Mi.�pooal,*poem Construction Permit Application is hereby made for a Permit to Construct( )or Repair(V�an On-site Sewage Disposal System at: Location Address o of N eo. Owner's Name,Address and Tel.No. - Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �— gallons per day. Calculated daily flow —v�C� gallons. Plan Date Number of sheets Revision Date Title Description of Soili4JL.S �n Nature of Repairs or Alterations(Answer when applicable) t��TA 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 Sigrie °' o Date 725- q-? Application Approved by Application Disapproved for the following reasons Permit No. ) Date Issued _ r i No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS a 01pprication for Migpooal *p5tem Cott.5trurtton Permit Application is hereby made for a Permit to Construct( )or Repair(Vj"an On-site Sewage Disposal System at: Location Address o {ot No. Owner's Name,Address and Tel.No. S k, Installer's Name,Address,and Tel.No. Designer's Name,`Address and Tel.N;o: Type of Building: Dwelling No.of Bedrooms a Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) " Other Fixtures Design Flow 'S gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil C-jq, Nature of Repairs or Alterations(Answer when applicable) Via-C`r A-(< <Rt7&� ,ter " ` —T i� o .r Date last inspected: fi li Agreement: a 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 B d a tit. ' Signe Q Date 3 Application Approved by Application Disapproved for the following reasons l Permit No. Date Issued _., h THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE FYy at t s to Sewage Disposal System installed-( )or repaired/replaced( �on 3 nos-`� by d� I��v for SN\-�voaV oni a4l y4yX as 1 , h en constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth below: "I _ ✓1 �� `. t� No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BAR, NSTABLE, MASSACHUSETTS lwigoal 6potem Conotructiou Permit Permission is hereby granted too to construct( )repair( L-)- On-site Sewage Sim located at S and as described in the above Application for Disposal System Construction Permit. The4applicantzes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must a com to thin two years of the date below. Date: Approved by CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONS'FRUGHON I,EltNif'l' (1V1'1'l1VU'I' DESIGNED PLANS) jIG-t , hereby certify that the application for disposal works construction permit signed by me dated '3—�� �o , concerning the property located at 7 '--1 c5 �rG� tom- C�a-� ' meets all of the following criteria: • Thcre arc no wcilands within 300 feet of the proposed septic system There arc no private wells wiihin ISo rector the proposed septic system The observed groundn•ater table is 14 feet or greater below the bottom of the leaching racilily • There is no increase in(low and/or change in use proposed There are no variances requested or needed. Ver SIGNED: DATE: 3—�" 1'� LICENSED SEPTIC SYSTEM INSTALLER IN TIIE TOWN OF BARNSTABLE NUMBER n filer e e a certified lot plan, iAttach a sketch plan of the proposed system. Also if the licensed i sfa pos ss s p p , this plan should be submittcdl. C7 Commonwealth of Massachusetts x ecutNe Office of Environmental Affairs Ex q Department of pR 1 -, r� 19 Environmental Protection �` � � � WIIIIcm F.Weld 13wernor Trudy Coxe 8ecn EOEA David B.Struhs Commlaloner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /U C1 CERTI"FICA�TION Property Address: l—D+ (��— Srr rjj 0,/cv�Address of Owner: Date of Inspection: nJ- - y` `o 'Of different) Name of Inspector: Company Name, Address and Telephone Number: 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Pa�ssses t/�onditionally Passes _ Needs Further Evaluation By the Local Approving Authority ils Inspector's Signature: � - -�-f Date: ?6 The System Inspector shall submit a copy of'this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: . A] SYSTEM PASSES: I have not 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 completion of the replacement or repair, passes inspection. Indicate yes, no, 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 septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street 9 Boston,Massachusetts 02109 a FAX(617)SWI049 a Telephone(617)292-5500 Vented on Recycled Paper h r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup 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): broken pipe(s)are 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 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIROtiME\T: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface water suppiy or tributary to a surface water supply. _ The systerr ha• a septic tank and soil absorption system and is within 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 that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into faAA cility or system com one t due to a or oBged�S�T spy• overload due to an overloaded or clogged SAS or _ Discharge or ponding of effluent to the surface of the ound or surface cesspool. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: J a- 6' Owner: 5�� N� Date of Inspection: D] SYSTEM FAILS (continued): v Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the 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 large systems in addition to the criteria above: The design flow of 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 II 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 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7 Owner: S�4� h 1J Date of Inspection: 1 3- � c(-S�' Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. "As built plans have been obtained and examined. Note if they are not available with N/A. t_°MTh facility or dwelling was inspected for signs of sewage back-up. r7 Tt}e system does not receive non-sanitary or industrial waste flow 7 The site was inspected for signs of breakout. %he All,system components, excluding the Soil Absorption System, have been located on the Site. septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. t/ _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. t/ the facility ov,ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 33L gallons Number of bedrooms: Number of current residents: 3 Garbage grinder (yes or no):,7�7 Laundry connected to system (yes or no):I Seasonal use (yes or no):2 Water meter readings, if available: �z 6a v Last date of occupancy: COMMERCIAUINDUSTRIAL: Y Type of establishment: Design flow:_gallons/day — Grease trap present: no)_ Industrial Waste Holding Tank pr es or Non-sanitary waste discharged to the Title S es or.no)_ Water meter readings, if available: Last date of occupan OT : (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) ,o If yes, volume pumped /000 gallons, c�CLC �/r a Reason for pumping: _Scu..n � L TYPE OF31!STEM /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) Other(explain) �(< APPROXIMATE AGE of all components, date installed (if known) and source of informatio�i. Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) S J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: �ncrete _metal _FRP—other(explain) v Dimensions: 7 K Sludge depth:,// Distance from top of sludge to bottom of outlet tee or baffle:2�- Scum thickness: /49 ,• Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffler_ Comments: (recommendation for pumping, condition ' let and�outleo�eesoraffles, de h o liquid level 'n relation t�outlenvert, structural integrity, evidence of leakage, etc g .) � r GREASE TRAP:_ (locate on site plan) 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 Distance from bottom n+ ro- t- hotto outlet tee o affle: Comments: (recommendation for pumping, condition of inlet and outlet tees baffles, depth of liquid level,in relation to outlet invert, structural integrity, evidence of leakaee, etc.) 6 (revised 8/]5/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I Owner: Date of Inspection: TIGHT OR HOLDING TAN . (locate on site plan) Depth below grade: Material of construction: concrete_ tal _FRP_other(explain t Dimensions: k.' .t Capacity: Rallons Design flow: Rallons/ Alarm level: Comments: (conditi - inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: - (locate on site plan) i Depth of liquid level above outlet invert:�� Comments: (note if level nd istriburor. �> eq�a!, evidence of s !id! carn�Over, evidence o leakage into or out of box, etc.).- PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber ition of pumps and enances, etc.) (revised 8/15/95) 7 I f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):�� (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:—/ �006 leaching chambers, number:_ Ste. fpu✓R leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments, (not conditio of soil, igns of hydraulic fai ure, evel of onding, condition of vegetation,etc.) w CESSPOOLS: _ (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 (cesspool must be pumped as part of i pection) Comments: (note condition of soil, signs of hydraulic fai e, lev of.ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) (revised 8/15/95) 8 �4. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: ~c SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' X iL DEPTH TO GROUNDWATER Depth to groundwater: / feet method of determination or approximation: �4:,s , (revised 8/15/95) 9 J VN013 ... Fps...... ............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...........TQTM.....--------------OF...........BARNSTABLE.---------------------•------.........------------- App irFation for M-4pasal Workii Tontitrur#ion Vanfit Application is hereby made for a Permit to Construct ( g) or Repair ( ) an Individual Sewage Disposal System at: .........................ShaelfPx..Raadb...Ceatpxvillp............ ......................... -----....----------•-•------•--------.._...._..__..-....------•--- Location-Address or Lot No. .P� � .&_� ae ..I? igle. 7••Nashawena Rd�:W,..Falmouth ................... ----......_..................... Owner Address Gary..Wing-_•_ 171 Barlows _Land_ in Rd-: _•-Pocasset ------------------------------------------------- - • - - g..._. Installer Address dType of Building Size Lot....15x255----------Sq. feet V Dwelling—No. of Bedrooms.-_.....3...............................___Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons_--_-------- Showers — Cafeteria dOther fixtures ..--------•---------------•--••••-••••-•--------•• ...................................... W Design Flow__________________55_.____.__..._....__•_gallons per person per day. Total daily flow................ _ gallons. WSeptic Tank—Liquid capacity._]-©,&©_gallons Length---8.t.6!!__-_ Width.4_!_}Gt!-.. Diameter---------------- DepthS.!41� -----. x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area------_.............sq. ft. 3 Seepage Pit No...--------- Diameter.10 t.6!!--._.-. Depth below inlet......6-!.......... Total leaching area.....2&5......sq. ft. Z Other Distribution box (x ) Dosing tank ( ) '-' Percolation Test Results Performed by--------- •.-.Slav2rs y _____---___ Date. � g3a _ ...___.•_____________ Test Pit No. 1-_-_2_.........minutes per inch Depth of Test Pit-----144!!...._ Depth to ground water........................ LL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ...................................._....................................................................................................................... 0 Description of Soil.........gx•-avel...and--mediuta--sand..below--24"—,--medium.-sand-_below--b-0 ............................ W x -----------------------------------------------------------------------------------------------------------------------------------------------------------------.---------------------------.......... V Nature of Repairs or Alterations—Answer when applicable............................................................................................... ...............-.......................................-...................-..................................................--------------------...----------....••-•-•••••-•••-••_._..__.._...._..--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i ITI.i: 5 of the State Sanitary C de—The u dersigned further agrees not to place the system in operation until a Certificate of/Complianc has bee ss,�ed b th board of Health. n -•--•-- •-•-•--•--•-••._-....•••--•••-•--•-•-•-•....•-•••--•-••••-•••••••••--••• .._-----•••Application Approved By....: -------------------------••.....----_---- Date Application Disapproved r reasons-...-............................................................................................................ ........•---••-•--•.................••••...•••-•••-•-•--•---••••--•--•-•••-••--•••-•••••--••-•-•--••-•---•••••••-•-••••••••••---••--------•-------•••-•-•••------------•••••--••----•---••-••--••••-••-- Date PermitNo......................................................... Issued....................................................... Date rg JNo... -2 �_ FEB.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................................... ....... ........_OF Appliration for Kh5paiial Workii Tomitrurtion rprmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ........................J-d-.02........................................................... _g 14) ................... ,4!o 7"- catiiion-Address /I or Lot No. la - - • Owner A ress ..........15.a. . .....4.14& ................................................. ...47L PQ 6:11nstaller Address U <11 Type of Building Size Lot... feet Dwelling—No. of Bedrooms.................Z.....................Expansion Attic Garbage Grinder a Other—Type of Building ---------------------------- No. of persons........_.._------------ Showers Cafeteria Other fixtures ......................... ------------*---------------------*--------------- Design Flow..................... ._........._gallons per person per day. Total daily flow................33A.................gallons. 04 Septic Tank—Liquid'capacity/,000._gallons Length Width...._ Diameter................ Depth-31.....41 Disposal Trench 'No. .................... Width....._....._...___._ Total Length__....._.........._. Total leaching area--------_---------sq. ft. Seepage Pit No...........I--------- Diameter_,/0,-'_&..~.. Depth below inlet.....4........... Total leaching area...'717J.'*..sq. ft. Other Distribution box ()( ) Dosing tank ( ) Percolation Test Results Performed by._......__. ................... Date......V,-Z:?n_Jr-3------- Test Pit No. I......7.....minutes per inch Depth of Test Pit----- Depth to ground water........................ rzq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_...._..._....__...._... ........................................................... 0 7 ................................................ Description of Soil....... 4", ................... U ...................................................................................................................................................... W ---­----------------- ........................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ...................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Co ft— The" ersigned further agrees not to place the system in t operation until a Certificate of Complianc has beenk by; h board of health.sth igned....... ......................................................................... ........... Application Approved By--- .....(_ .................................................................. ........... Application Disapproved f t1h following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo--------------------------------------------------------- Issued.................1..................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF............................................... wrtifiratr of ToutIttiaurr IS 'ERTIFY, That the Individual Sewage Disposal S-stem constructed IF Repaired .. ..... .. ......... . .......... . .I....................... ...... .1.................................... by-------- -- -----­ - ...... .................................t..........1. ............ at................... . . .............../I ......... .. .. ....................... ....... .................... ..... ..................... ..... ....... has been installed in accordance with the provision TIT " 5 of The State Sanitary C S e *bed in the application for Disposal Works Construction Permit 1 o.-- 3 -21 JF/............... dated---fX­.... ................................ THE ISSUANC OF THIS CERTIFICATE SHALL NOT B�EC/ONST D AS A GUARANTEE THAT THE SYSTEM W�I ION SATISFACTORY. .ft,;�F,14CT t ........................................ DATE....�7. Inspector. /............................................................. ............... r ... ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. ...........................................OF................................................................................... FEE..... ................... orkii Tomitrurtion "Prrmit Permission is .­............... .............-- to granted...... r to Constr or Repair Indi I 5eegre isposal System,.a jej t "?eIr2l................. . ... ................................................................................................. at Street as shown on the application for Disp5i: orks Construction Permit No....................Z,Dgelljo---------------------------------------- .......................... ------------------------------------------ th DATE................................................................................ FORM 1255 HoBBs & WARREN. INC.. PUBLISHERS OCA'TION NS SEWAGE PERMIT NO. ./, O t JqV3 -AR VILLAGE ,nI INST LLER'S NAME AND ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 1 �• �^ m � � � l ��� �z�..� `` ,,^w ,��.�e if .trc+E cr✓E�4 0/.s T ,era,' ±vim _ - _ f f/v f ' '.� jr.�- e Cl t M wr /040 z S �--- i 8S�.'7- FLU. r .. r.S'7'"h?1$r. `r , ,i v A940X /N.S'T "7/—L 10 N �r � - 4 X,f .-I { ( q�z 's .sJ �= ,v . ,w tis ca ,.� �ISiG. =;� _ AV 7' 1-9 {�7e L: ��2� Ac`.G A)';l0e s !�✓ �r`'S'-' S"�-e.c-. J 1�-�►t. ,.,� ?" a�- e-Fr s? o. 'fin f h+`.,cOt�'4� 1.:."�./i/sS7`�''LI�::"T'i':a.rt✓' %a e:'`t��41'.�'C.� ;Td�:y J%,4','c.'"�•�' OAS.3 ZW VAV 77 " ;mod?'"-- .� ' "f7�'7' .^dN qn rr ;;.v�� ^✓✓,::E�S -'� �,-,�,,/,5 �4 Fr+/1/f^'sci sT � h'�s.4� 4v46[3 AwN'c. /vd. Y 7.YF.' 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A`` �_ •� �` * '�'�`�'�'./� ;ter nriM e/ IAMTS oc:117- f� ORTRAtij) �i C No. 2olr ? 94 / Al— ax,'` °"�'Y_. fh✓y't` 7.. _w``�Sa �r� ,mow• .r /�.� f•tfAAL.S cn'j 2608a 9S'3 _ _. _-..-. _ .w ._ ___....r tQ ��4r �/ _ _ .T__ ._....». ._._x� '+�w'.�E" �` /.5"L +r J L 3.5� S GJ,4 H✓ Y+/�d((i //v c i _.,. ,.�,., .....,».�..�i....•..m.w��,.,.�.._,.,�,.�«.�.-�.,.................,.,�..«..�....-,.,.m.....�.«..,.w..,................�,..e.�..,..............,...,...................._.�. ..._.. _..�q».,�....r�.«,..,.,.......,...._.,.......,.........M,w.,....... ...,_,,..»,r�.:..-...._ ._.�-.a.�,..,..�._..«a...,...a,..«_...�..,...,...�...,...-M.�,,,.......»,.,�.....,.....,_..,, _.. ,,, .... .. .�.,.... S.� sAr ASSESSORS MAP : 177, TEST HOLE LOGS PARCEL : # -7+c� ..._..., ..� -_.. NOTES: , \ �.._ FLOOD ZONE: " G`� � �/4 PjPL 1 G 14 R SOIL EVALUATOR: i ! I �Lr - �.. .. .__.. WITNESS : U . C)i� REFERENCE: PID7 DATE: ` 1) The installation shall comply with Title V and Town of Barnstable Board of /_._.. ... .._ ® PERCOLATION RATE: G lMl & Jt Health Regulations. 2) The installer shall verify the location of utilities sewer inverts and septic -- ° ----�-•. --• components prior to installation and setting base elevations. �J TH- I TH-2 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first a 0 �� � two feet out of the d-box to the leaching shall be level ,,.,i 4) This plan is not to be utilized for property line determination nor any other `� Z %A41 k ,0 '1' purpose other than the proposed system installation. •. ,, !f? '� � b /D ,€' S by 5) All septic components must meet Title V specifications. �� 6) Parking shall not be constructed over H10 septic components. LOCATION MAP �~" "` �•�� � 1 � G� 7} The property is bounded by property corners and.property lines. IT 8) The property owner shall review design considerations to approve of total 1� design flow and number of bedrooms to be considered for design. Receipt r H of payment for the plan and installation based on the plan shall be deemed ���. ���,� p Y p t Dj ij/ approval of the design flow by the owner. 1 9) The existing leaching or cesspools shall be pumped and filled with material Q — �.� �� '�, __ _� ��' per t procedures. Those within the proposed�" M _ r Title V abandonment ure sed SAS shall be removed along with contaminated soil and replaced with clean sand per - Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends routed if SEPTIC SYSTEM DESIGN g j applicable. The proposed SAS is being installed below the water service FLOW ESTIMATE line. The line is to be sleeved as aforementioned and maintained in place. 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. } BEDROOMS AT GAL/DAY/BEDROOM - GAL/DAY 12)The installer is to take caution in excavation around the gas line. 13)The installer shall verify the location, quantity and elevation of the sewer s SEPTIC TANK lines exiting the dwelling prior to the installation. GAL/DAY x 2 DAYS - GAL ALL° USE GALLON SEPT I C TANK6t . t SOIL ABSORPTION SYSTEM Q 01 SIDE AREA: 2-4 1 Z. )C BOTTOM AREA: -`--a , A CA �c I C SYSTEM SECT I ON -- � + mow. : _,.,.,y:::,c,�,"3'rxq.!/.},�..,:- . . >::• �. � `4 - - 4q1kNIZ0 �?. Mom: �,�JY'C'4 u"l �'�./'/V Q [i � .YY - f �!C 10 R iD ., . rc �Y �JC G'J � D BOX 1 CSC () GAL 10 � SEPTIC TAN a,, �;- � _,(--max`►`- � __ � -i-- ` ' , r� A I bo54 ,C� - - , -. n.. . ...� — -74 S 1 TE AND SEWAGE PLAN q, � LOCAT ION : PREPARED FOR : 0 SCALE: f = DAV I D B . MASON , DATE: ce DBC ENVIRONMENTAL DESIGNS z EAST SANDWICH . MA W DATE HEALTH AGENT 3 .( 508 ) 833- 2177 W Z MIA�GCF DATA . Large Format Box # I TI Doc # . Image #