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HomeMy WebLinkAbout0062 THISTLE DRIVE - Health 62 THISTLE DRIVE, CENTERVILLE A= 171066 _J No. 42101/3 ORA ESSEL.TE 10% 0 0 0 0 J No. �V Fee " / O® LT THE COMMO E 1 L H OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppYication for Thgpool *pztem Con5tructiou 30ermit Application for a Permit to Construct( ) Repair(elu*'pgrade( ) Abandon( ) ❑Complete System U Individual Components Location Address or Lot No.45 � Owner's Name,Address,and Tel.No. Assessor's Map/Parcel / /�/� ®�jf G 1y ® -5-6 7J Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 O gpd Design flow provided 3�9• gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank 6:' Jo o 4999'ype of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No.A 12 Date Issued TOWN OF BARNSTABLE LOCATION �� T�/,('�''L� ��j SEWAGE VILLAGE Cc--'y,721'OL 1//ZCCASSESSOR'S MAP&PARCEL Odd INSTALLERS NAME&PHONE NO. ��J91���®1`�/� 7-7 SEPTIC TANK CAPACITY ���,('T�� sl /®o o ��Z, LEACHING FACILITY:(type)UGC eLaGj/ yyAilrize)/3 X' S'X NO. OF BEDROOMS x OWNER c�I�J/y PERMIT DATE: / �io� 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 -- Ole 30 .6 1 / � TOWN OF BARNSTABLE OCA-PON �2 A1,5 ®�_ SEWAGE VILLAGE 1� r"IYUJ �U _ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY f tnn r;A LE:�CHING FACILITY: (type) In'0 2C.vi (size) NO. OF BEDROOMS BUILDER OR OWNER SATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i TOWN OF BARNSTABLE LOCATION toy S o lL� SEWAGE # VILLAGE r�L�t1TZt�..�r ���.=� ASSESSOR'S MAP &LOT IKSTALLER'S NAME&PHONE NO. dVg�A SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �f� � (size) J� NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 7 7::>. �,hy se-_ s �} 9j [ Y No. 7 00 Fe � Z8 �� �� THE COMMON_E� LTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS' Yes RpPlicatton for ni5po0a[ �&pgtem Con.5tructton Permit Application for a Permit to Construct( ) 'Repair(Upgrade-( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No.O �/�/f/r�C: ( / Owner's Name,Address,and Tel.No. AssessM Map/Paroelx "",'1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. /e J' Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building Ie4r:-p No. of Persons Showers( ) Cafeteria( ) Other Fixtures I p Design Flow(min. required) 3- 0 i( gpd 'Design flow provided ���. Je�. gpd Plan Date Numbei of sheets / \Revision Date Title f �t Size of Septic Tank .G�`JC/✓'T/may' '" /000�'1ype of S.A.S. ' Description of Soil L Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed `Date- Application Approved by Date f Application Disapproved by: Date for the following reasons Permit No.?D IZ — Date Issued Zo I Z - - - - - - - - - --- 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 �- at d�.��/„T,��� .C�OZ �'�/���,�{/liL�rias been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ;?012- dated Q 1 1 y Z0 tZ Installer lJ/,11& Cr.�Od`!/jC Designer.�/d' /l�+rj{�j'Cir .1` #bedrooms Approved design flow S�/�, ,9.r- gpd The issuance of is permitshall not be construed as a guarantee that the system will udl�//h as de igned. ^ Date 10 l j Inspector ,/B J Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS 'Wi5pogal *pztem Con tructton permit Permission is hereby granted to Construct ( ) Repair Upgrade Abandon pg ) ) System located at ��. ��f//_/'���r' e 1:00'A-176- and as described in the above Application for Disposal System Construction Permit.The applicant re ogmz,5s his/her duty to comply with Title 5 and the following local provisions or special conditions. ` t Provided: Construction must be completed within three years of the date of is permit. Date I /(/ 2'a /'L Approved by f Sep 18 12 07:01 p Colleen Mason 508-833-2177 p.1 Town of Barnstable �� ► Regulatory Services Thomas F. Geiler,Director W km • Public Health Division. 1639. a`�� Thomas McKean Director sa�,ar 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: q Sewage Permit#a f' a R? Assessor's Map/Parcel Installer&Designer Certification Form Designer: c"LIVID-F-Uk1'Cl Installer:�tF LXIT�T�F ICVMC Address: tti'c71 Cf7 .� Address: kiLs On --i was issued a permit to install a (date) (installer) septic system at �Z based on a design drawn by -��� AP �/� �(, � (address) (designer) I certify that the septic system referenced above was installed substantially according, to I<Ce i the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &Local R -Lions. Plan revision or certified as-built by designer to follow. Stripout (if rP- -cted and the soils were found satisfactory. N OF Mqs� DAVID 9e" l; o y:';: MASON It (Installer s Si r z1f No.1066 !g7 P q / (Designe Signature) � I J PLEASE RETURN TO BARNSTABLE PUB ,.- �fE OF COMPLIANCE AVILL NOT BE ISSUED Ulf Alt, rsy i ri t tita t'ORINI AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gN,offrce forms\designercertification£orm.doc 4 Town of Barnstable P# Department of Regulatory Services 32�IZ Public Health Division Date �sr ��� 200 Main Street,Hyannis MA 02601 F Date Scheduled 9,11e +<' _ Tune ` 'Fee Pd: Soil Suitability Assessment for Se a e ` • ' Performed By� VIA yq. „�j'. . • ; . ' Disposal Witnessed,By: LOCATION&.GENERAL INFORMATION Location Address ���� , 1 n66's+Name �d Tif�ifTc� ��Address Assessor's Map/Parcel: /� r l7 6 Engineer's Name 1�/1� '/l��'�°j' NEW CONSTRUC77ON REPAIR Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet.Area ' \ , ft�_�Dr_inking Water Well ft Drainage Way ft Property Line ------__ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands in proximity t P o holes) Parent material(geologic] Depth to Bedrock Depth to Groundwater.. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLEMethod Used: Depth Observed standing in obs.hole: Depth to weeping from side of obs.hole: in.., Depth to soil mottles: in Index Well# g Index Well level in. Groundwater AdJustment ft, Reading Date: AdI,factor r Adj.dmundwaterl.evel,�, PERCOLATION TEST Date .s Time Observation Hole# �.,r—tl Time at 9" -- Depth of Perc Time at 6" Start Pre-soak Time @ �� Time(9"-6") End Pre-soak Rate MinJlnch A 1, , Site Suitability Assessment: Site Passed Sitc Failed: Additional Testing Needed(Y/N) Original:Public Health!Division Y Observation Hole Data To Be Completed on Back----------- ti '• percolation test is to lie conducted within 1009 of wetland,you must first notify the. Barnstable Conservation-bivision at least one(1)•week'prior to beginning. , Q:ISEPTICIPERCFORM.DOC 4 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon . Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell Mottling (Structure,Stones;Boulders. on istenc ravel 0 �r 1 ` �a DEEP OBSERVATION HOLE LOG `Hole# Depth from' Soil Horizon Soil Texture Soil Color Soil Other`r Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. � C nsi t %Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. C nsiste c o Grave x v , DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell MQttling (Structure,Stones;Boulders. Con i e t Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes Within 500 year boundary No ✓ Yes,„ J Within 100 year flood boundary Nor Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervio !-mataterial exisi in all areas.observed throughout the area proposed for the soil absorption system? --� '. /��'7'` If not,what is the depth of naturally occurring pervtous maCertal7 Certification I certify that on b q (date)I have passed the soil evaluator examination approved by the Department of Envir nmental Protection and that the above analysis was performed by me consistent with the required training,exper' e er' n e described in 310 CMR 15.017. Signatur Date ZO/Z. QASEPTIC�PERCFORM.DOC I � 'r0 RECvE� MAY 2 7 1997 COMMONWEALTH OF AWSACHUSETTS to OFeARNSTgg�E EXECUTIVE OFFICE OF ENVfftONMENTAL AFF H�tTHOEPT. tV DEPARTMENT OF ENVIRONMENTAL PROTECTIO ` ONE WINTER STREET,BOSTON MA 0210E (617)292-5500 Z WILLIAM F.WELD TRUDY CORE Governor Secretary ARGEO PAUL CELLUCCI DAVID B.STRul-Is Lt. Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A J -� CERTIFICATION Property Address:Q. ;'u �t.c t4Q r/y,. CL_ e, r,,, �� Address of Owner: Date of Inspection: �::5-1 S/ �[ (If different) Name of Inspector: 1'\.�y►o.`\ ` c'yitCt� ' Company Name, Address and Telephone Number. �C1�V.1T'�C....�t.�trt,�atic�.�a.�•"'�ta�_�b�N Z3�y �wa\-�e� CERTIFICATION STATEMENT—Mk� 1 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: XPasses Conditionally Passes _ heeds Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature:46LQ � LDate:S I SI,� 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, 8,C, or D: A] SYSTEM PASSES: _ 1 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 11/03/951 1 � ` a it C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 4 Property Address: Owner:, � v 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 Cj FURTHER EVALUATION 15 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 p;:blic 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. IF 2} SYSTEM WILL FAIL CTIONING IN LESS THE BOARD MANONERETHAT PROTECTS THE PUBLIC HEALTHLTH (AND PUBLIC WATER rAND SAFETY AND THE MINES THAT THE SYSTEM IS Fl.) 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 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 we!I is f ammonia nitrogen and nitrate nitrogen is equal to or less than 5 free from pollution from that facility and the presence o ppm- 3) OTHER (revised 11!03/95) 2 r r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �-CG:_ '�T l-e Y _ �.2n i-c.(/� Owner: /- Date of Inspection: D] SYSTEM FAILS: p S( G S� )7— 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 facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above 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 system serves a facility with a design flow of 10,000 god 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 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:/ �P / T(e- Owner: N_ Ldv�Sh � Date of Inspection: S -7 Check if the following have been done: J�- Pumping information was requested of the owner, occupant, and Board of Health. I( None 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. _L3�As built plans have been obtained and examined. Note if they are not available with N/A. IC 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 the site. The 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. 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. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11rC3,'9=) 4 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C s/ / SYSTEM INFORMATION/ (continued) Property Address: Owner: R / Date of In'specti n:� SEPTIC TANK:_ l (locate on site plan) Depth below grade: �14 Material of construction: concrete _metal _FRP —other(explain) Dimensions: tom$*-k Sludge depth: O, Distance from top of sludge to bottom of outlet tee or baffle: 3y" Scum thickness: O" e Distance from top of scum to top of outlet tee or baffle: la Distance from bottom of scum to bottom of outlet tee or baffle: I to Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) uo*Z�"�a��yun p try�T N �� 1.����..� 9 r2j..�-W416Q S �a l_Qe 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 baffle: 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 level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C //SYSTEM INFORMATION Property Address: Owner: 4 1 / _ - I - CC L"r.c S ia.P� Date of Inspection: lJ S�o 5"J�/ // FLOW CONDITIONS RESIDENTIAL: Design flow: .2,�t) _gallons Number of bedrooms: Number of current residents: 02 Garbage grinder (yes or no): 00 Laundry connected to system (yes or no):_4r Seasonal use (yes or no):_'x) Water meter readings, if available: 4a. Last date of occupancy: \ COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title'S system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: dvNvk-, »-ed System pumped as part of inspection: (yes or no)N0 If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tan 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 information: } aO k1^-S Sewage odors detected when arriving at the site: (yes or no)�9 (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: �/ K [� c� / - Date of Inspection: S Gs m spas/� � TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons •Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solidi carryover, evidence of 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, c7/itionf pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4 Owner: t ,,�� Date of Inspection: (O SOIL ABSORPTION SYSTEM (SAS)./ (.S I excavation not required, but may be approximated by non-intrusive methods) (locate on site plan, if possible; e q Y P If not determined to be present, explain: Type: leaching pits, number:_ Vxb,� leaching chambers, number: — leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) r C � sb.\ �Awid sZ-rn lS G�„A��1re=ln..,.C-4— a,a �t��+ r CESSPOOLS: _�g (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: Indicatiom,of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (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.) (revised 1!/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: �� Date of Inspection: tion: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' a I� 6v 6-6 t A� - �z � �►� �a I°fJ" DEPTH TO GROUNDWATER Depth to groundwater: 1 a5 feet method of determination or approximation: (revises 1_, ._;'95l 9 MUNSELL ASSOCIATES HOME INSPECTION SERVICES 3179 MAIN STREET(RT. 6A) P.O. BOX 431 / BARNSTABLE, MASSACHUSETTS 02630 ( (508)362.4043 FAX(508)362-2992 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property; , 62 Thistle Drive Centerville, MA Owner' s Name : Mr. Gordon O'Reilley Date of Inspection: June 26, 1995 PART A CHECKLIST Check if the following have been done : X Information was requested of the owner, occupant, and Board of Health. X None 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:. N/A As built plans have been obtained and examined. Note if they are not available with N/A. ' X The facility or dwelling was inspected for signs of sewage back-up. X The site was inspected for signs of breakout . X All system components, INcluding the SAS, have been located on the site. SEE NOTE ABOUT DISTRUBITION BOX X The 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. X The size and location of the SAS on the site has been determined based on the existing information or approx- imated by non-intrusive methods . X The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. ' ' DUE TO A LARGE TREE IN THE AREA OF THE "D" BOX IT WAS NOT POSSI- BLE TO INSPECT THE BOX WITHOUT EXTENSIVE DAMAGE TO TREE ROOTS. Page 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ` SYSTEM INFORMATION FLOW CONDITIONS If residential : i 2 number of' bedrooms f 1 number of current residents NO garbage grinder, yes or no, YES laundry connected to system, yes or no i NO seasonal use, yes or no If nonresidential, calculated flow: N/A Water meter readings, if available: ' 13000 Gallons last 12 months CURRENT _Last date of occupancy GENERAL INFORMATION i Pumping records and source of information: N/A OWNER INDICATED HE HAS PUMPED THE SYSTEM EVERY THREE YEARS .' NO System,. pumped as part of inspection, yes or no If yes, volume pumped_ Gallons 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) Other (Explain) Approximate age of all components. Date installed, if known. Source' of information: 1973 OWNER NO RECORD AT BOARD OF HEALTH NO Sewage odors detected when arriving at site, yes or no Page 2 A - S-UBSURFACE 'SEWAGE DISPOSAL INSiRECT- I ^ °4 I PART $ SYSTEM INFORMATION" oont�O ' 'id, � SEPTIC TANK: 10,00 G'AI;16N' CONCRETE; TANK (locate on site plan) f, �e depth below gr�de : 1�8` INCHES material of construfct-i,on-: X concrete m1e air •, FRP other' dimensions : 4 r 6'.n "X 81 0 ri t n • X, 8r 6 0 sludge dep't;h distance from top of sludge to:., bottoi ,vf ;c filet ;tee or baffle 0 scum thicknes's t distance from top' of 'sc`um to' top of- ©u Left, ,9e, `Qrr ba f'f le distance from 'bottom of scum:. to bottipa of te-e:` 5; or baffle f Comments : NO SCUM OR SLUDGE SYSTEM APPEARS WORXING RROPERLY TIMELY PUMPING COULD BE THE REASON FOR THE LACT� 0)F S=LUDGE '0R' SCUM. PUMPED LAST ABOUT THREE YEARS AGO: (recommendation for pumping, condition of i filet and otut1et "tee"s or baffles, depth of liquid level in relaation­% to° ;oatllet i-nvart., structural integrity, evidence of leakage, for repairs, etc . ) NO REPAIRS NEEDED DISTRIBUTION BOX: SEE `NOTE ABOVE', NOT U'N'C0VEREb,. (locate on site plan) depth of liquid level above ou'tle`t inVe:'t Comments : (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of b`ox, recommendation for repairs, etc . ) PUMP CHAMBER: N/A (locate on site plan) N/A pumps in working order, yes or no Comments : (note condition of pump chamber, condition of pVmgs and appurte- nances, recommendations for maintenance or repairs, etc. ) Page 3 SUBSURFACE SEWAG'E DISPOSAL SYSTEM fk'S'PFDCT'I kC FORM PART B f S'YS'TE"I INFORMATION cbnstinde+d. SOIL ABSORPTION SYSTEM., (SAS) 6X6 CONCRETE LEkCkl]I iG PIT (locate on site plan, if possible,* excavati:6h,- 'xo't' �rdiq�uiredf,; b+ut may be approximated by non-intrusive methods-=)+ If not determined to be present, explain: Type leaching pits and number 1 leaching chambers and number leaching galle'rie-s and Mur6ber leaching trenches, number, dimensions overflow cesspool,: number comments : (note conditions of soil, signs of hydraulic' f°"ai1'u'r`e', leveI Of ponding, condition of vegetation, recommenda'ti�dnis- 'f6r 'main�beiq+ancie= or repairs, etc . ) NO SIGNS OF FAILkURE, THE PIT HAD ONLY AROUT' 4''r' OtF'' LITQUIDS IN THE BOTTOM. CESSPOOLS (locate on site plan) : number and configuration depth-top of liquid -to, inlet invert depth of solids layer d�edpth of scum layer dimensions of cetsspaol materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments : (note condition of soil, signs of hydraulic failure',, Level 'otf ponding, condition of veg'e'tation, recomme-ndatiohisx `Eor� ' aintehiaiic,,e or repairs, etc. ') Privy: (locate on' site plan) materials of construction dimensions depth of solids Comments : (note condition of soil, signs of hydraulic fa�ilur'e, level of ponding, condition of vegetation, recommenda'tiot�s for 'maintenan,c,,e or repairs, etc. ) - Page 4 SUB SURFACE DISPOSAL SYSTEM INSPE`CT IdN F.dRm PART B SYSTEM INFORMATION dontiniVed SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at lea-st two permanent references landmarks: or benchmarks, locate all 'w-ells within 10;0 ' DEPTH OF GROUNDWATER NONE AT 12 FEET depth to groundwater method of determination or approximation: REVIEW OF SYSTEMS ON THE SAME STREET Page 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INtS±PE,C""ION FORM f PART C FAILURE •CRITERIA • I Indicate yes, no, or not determinQd (Y,N, o-r ND),'.. Describe" basis' of determination in all instances . If "not ddtye'rmined" , e,,)lIaih why not) NO Backup of sewage into facility? NO Discharge or ponding of effluent to the surface of the ground or -surfade waters? N/A Static liquid level in the distributi+an box ab`dv'e the outlet invert? , Liquid depth in cesspool <6" below, invert or available volume< 1/2 day flow? NO Required pumping 4 times or more in the last year? number of times pumped 0 NO Septic tank is metal? cracked? structurally unsfound? substantial infiltration? substantial enfiltration? tank failure imminent? Is any portion of the SAS, 'cesspool or privy,: NO below the high..groundwater elevation?' NO within 50 feet of a surface water? NO within 100 feet of a surface water supply or tributary to a surface water supply? NO within a Zane 1 of a public well? NO within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS), ? NO within 50 feet of a private water supply well? NO 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 analyz:ed to be acceptable, attach copy of well water analysis for coliform 'bactera, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. Page 6 SUBSURFACE S.EWAdE DISPOSAL SYSTEM INS>P'E`CT'ION FORM PART D CERTIFICATION. Name of Inspe,c-tor: .David .P. Muns7e:l l Company Name: Mu-nselh Associates' - Company Address: 31,79 Main Street Barnstablfe,, 30 Certification Statement I certify that I have: personally inspected the °s`1eW!age dis.pois(a.1 system at this 'addi�e'ds and that the info;rma.tiQn :�,`epoet` ed is t-ruse, accurate and 'commplebe� as �of the time of the inspection was `performed and: any rel ormrme :�nda ofr,&`reg&rd�ing up a grade, maintenance an'd repair are cio-nsis'tenit 'trainsjng and experience in the pr'ape-r function: and ma <nten+WT(7ie` `of bn-si 'te A sewage disposal 4sy9t4ms . Check one : X I have no't found any information `vrhi.ch i.n�d cates that; the system fails" to adequately protect pub,, i�'& =hea. l't`h or �t-he environment as defined in 310 CMR c15 303 . Any fail-ure'- criteria not evaluated area as stated in the FAILURE • CRITERIA section of this form. ,.'. I have determined that the system fails >to` p'rote'c't publrc health and the' .environment as defined` in 31,0 'CMR 15 30,3. The basis fdrr -this determination is provided in the. FAILURE tCRITERIA section fo,,f `this, fo,rm. : Inspector' s signatUr(�(__ ` .'. Date : June 27, 19915 Original to system owner: Yes Copies to: Buyer. (if applicable) Approving authority Barnstable Health Department 1 Page 7 ASSESSORS MAP: -41 1 7/ NOTES: PARCEL : TEST HOLE LOGS SOIL EVALUATOR: ! A �y 1 The installation shall comply with Title V and Town of3j�,j�P W J3oard of FLOOD ZONE: L � ' , ' ) PY W I TNESS s ?-1;2 Health Regulations. D oe�� �, r 0 I jr REFERENCE: ATE• � ,� _ 2) The installer shall verify the location of utilities, sewer inverts and septic .-,I� PERCOLAT I ON RAT : .�'.. 2,.P1W, "4 components prior to installation and setting base elevations. -.-- ._. ' �._ p 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first l� � J y - two feet out of the d-box to the leaching shall be level. _..-._ TN I �, TH-2 4) This plan is not to be utilized for property line determination nor any other �/! , �I purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over H 10 septic components. ` 7) The property is bounded b roe corners and roe lines. Y property rt3' property rtY L 0 C A T I ON MAP T� � (� p1� 8) The property owner shall review design considerations to approve of total � � ' l•" design flow and number of bedrooms to be considered for design. Receipt P of payment for the plan and installation based an the plan shall be deemed approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall , "T 10 be removed along with contaminated soil and replaced with clean sand per Title V specs. UT 10)System components to be 10 feet from water line. Sewer lines crossing the r r _ 7 water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if / / ( vl� 0 applicable. The proposed SAS is being installed below the water service ` e, S E P T I C SYSTEM DES I G N 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. FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such BEDROOMS AT 110 GAL/DAY/BEDROOM -i`OGAL/DAY exists. I , 13)The installer shall verify the location, quantity and elevation of the sewer -- lines exiting the dwelling prior to the installation. 14) -- ----______ SEPTIC TANK This plan is representative only that a system can fit on a property meeting VE, &OI ��( Title V requirements. GAL/DAY x 2 DAYS - � GAL - �`', -_ USE I=GALLON SEPTIC TANKID --- ( SOIL ABSORPTION SYSTEM V)i �� ° Zo �1-f✓Ib� SIDE AREA: 2� �-I' Z��� li,X ��� ( � �H O� �' ---- � DAViD BOTTOM AREA: 7iTp . k i. g + � MASON 0 p l .1066 `Y ,--SEPT I C SYSTEM SECT I ON �, „ ✓ �crP off' 0: _ o ,,b ,, a ,►Asp s GAL jg1 �t 1� S �� �o SEPTIC TANK hi :I� �� S 1 TE AND SEWAGE PLAN LOCAT I ON : PREPARED FOR : _-'�W Ioock)f:` 6en,P. M SCALE: LOU W DAV I D B . MASON 9 DATE: 12 Y, z DBC ENVIRONMEVAL DESIGNS a W DATE HEALTH AGENT CAST SANDWICH . MA ( 508 ) 833- 2I77