Loading...
HomeMy WebLinkAbout0075 THISTLE DRIVE - Health 75 Thistle Drive Centerville F/R A = 148 020 l��i �QECYC(E°C llll UPC 12543 No.53LOR �P�Sr.ccNs�� HASTINGS. MN DECEIVED Town of Barnstable APR 2 8 2004 BARNSTABLZ Regulatory Services DEFT BLE 9� '� `%%a Thomas F. Geiler,Director pTEO"AD�° Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Designer Certification Form Date: r l 2 7 S CCA- Designer: Address: '17 (VI PR(ry 91— -- 17Z On �- Y&L'C (d�i c,12.4r was issued a permit to install a (date) (installer) septic system at_ -7 t S4( Pa.i u C ��( I'P 4(address) based on a design I drew, dated I certify that the septic system referenced above was installed substantially according to the design. I certify that the septic system referenced above was installed with changes but in accordance with State & Local Regulations. Revision or certified as-built by designer to follow. Z'10F/,/A�cs� ASH OF Mqs ARNE H 9cycs o` ARNE �yG o OJALA �, �g H. R+ CIVIL C OJALA N No. 30792. o �No..26348P ' 0X' SG/STEM G��� e pESS\oa 0 (Designers Signature) (Affix PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form C L V��rq-CjLdCC I COr'J5 No. C) Fee _ THE COMMONWEALTH OF MASjACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS i ZlopYication for Migpoot *pgtem Construction Permit Application for a Permit to Construct( . )Repair(✓)Upgrade( )Abandon( ) O Complete System I'ndividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Tip fvr//e I `�/Q Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. `77/� Type of Building: Dwelling No.of Bedrooms 33 Lot Sizesq.ft. Garbage Grinder(�f Other Type of Building Sl No.of Persons Showers( ) Cafeteria( ) Other Fixtures -� / Design Flow gallons per day. Calculated daily flow rl 3e gallons. Plan Date Number of sheet Revision Date Title -& "i d 15,_. �, � /l . Size of Septic Tan ® Type of S.A.S. 7.i Description of Soil, 30X'I©XZ 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�Barf He Signed A Date Application Approved by Date VlqlbV Application Disapproved for following reasons Permit No. 2v o y—17aL, Date Issued No. )v _ 1-7 2- a Fee _ THE COMMONWEALTH.OF MAS;SACC.USETTS Entered in computer: = Yes { PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 2pprication for Migonl *pgtem Construction Permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) ❑Complete System ERJ�dividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 75- 1-41-51,l Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. L �. -77/-c/ Type of Building: r Dwelling No.of Bedrooms 3 Lot Size //� 44D sq.ft. Garbage Grinder( /�y Other Type of Building P GL No.of Persons Showers( ) Cafeteria( ) Other Fixtures / Design Flow_ . t gallons per day. Calculated daily flow 71 31.9 gallons. Plan Date q. Number of sheets / Revision Date Title �� 5/Yt' Q/1 O' 0/'. Size of Septic Tad lelfa 9✓'� l°�1'/S>' /�9 Type of S.A.S. SAD' 9V i 4 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.,,__. ---�--- '_ n>. Signed n C� //1Z�21,�-�`� Date ;661 Application Approved by f 4 le S Date 9 l q1 ,V r Application Disapproved for th following reasons Permit No. v U L/- l�o� Date Issued q//4 U q - ----. ———— ———— -- — THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance - THIS IS TO CE TIFY, that the On-si a Sewa$e,Disposal System Constructed( )Repaired(VII Upgraded( ) Abandoned( )by / Z2 at 7.5` ,15 r- D , r P has been constru t d mccaordance with the provisions of Title 5 and the for Disposal System Construction Permit No. D 0 u —/7.2 dated�7 t/ Installer Designer r- 1% The issuance of this pew' t shall not be construed as a guarantee that the sys em will func on as desi ed. Date 1 I J L Inspector - r - ------------------------------------------ No. Duo V— Fee S THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migool *pg;tem Construction Permit Permission is hereby granted to Construpt( ) epair ✓Upgrade Abandon( ) ( ) System located at 7 �y/%5 �� ✓ 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:Cons7/7 must be completed within three years of the date of this er it. Date: c) L Approved b °�. ► (.�. � PP Y TOWN OF BARNSTABLE �. LOCATION Zr /hu-64 b/1 SEWAGE # �&Vy 17.1 VILLAG ASSESSOR'S MAP &LOT Iqr-ORv CeK. INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Gd L LEACHING FACIL=: (type) fW, e41 66q&k. ta) (size) ALA 3a'61' NO.OF BEDROOMS BUILDER O R L PERMITDATE: h� �Y COMPLIANCE DATE: ,7 0 Separation Distance Between the:, Maximum Adjusted Groundwater-' round_wa�ter Table to the Bottom of Leaching Facility Feet Private Water Supply Well and)jeaching 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 -;/�Wvj e-note la.;£it:==V r S7-r---� ' 1 RrMoil4 L t l I I r - APR-27-2004 08 :05 AM DOWN CAPE ENGINEERING 508 362 9880 P. 01 Town of Barnstable Regulatory Services �..tx Thomas F. Geiler, Director Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790.6304 Des'ganer Certification Form Date: r I 27 C r-)I-I Designer: 6nLxj Nj o4 pe. we, [y,g 9 we> i Address: `1 n'l R c ry 51 _ gy 026?�� to #,I=q— 17Z On was issued a permit to install a (date) (installer) septic system at 7� P(L k u Ile based on a design I drew, (address) dated I certify that the septic system referenced above was installed substantially according to the design. I certify that the septic system referenced above was installed with changes but in accordance with State & Local Regulations. Revision or certified as-built by designer to follow, ARNE H Esc ARNE OJALA H. CIVIL N OJALA No 30792 a No.28348 i 0,,�Fp�S,T•ERrc\�F, � OR ®B�O� (Designer's Signature) s (Affix PMLEAU RE URN TO RARNRTA PUBLIC! RVAT.Tff nTVTCTn%T CER CA OF C iAN wI BE D IL B I RM A - ILT AR EIV A S P TH DIYISION. THANK Y Q:HealdvSepdc/Desisner Certification Form C G Po rQr_�Lc-T T- i r O niS I— COMMONWEALTH OF MASSACHUSETTS Ch EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS , DEPARTMENT OF ENVIRONMENTAL:PROTECTION NV J. MAP 4 $� FAILED INSPECTION FARCE`" ; �20 LOT t - TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 75 Thistle .Drive RECEIVED Centerville, MA Owner's Name: Christine Little Owner's Address: MAR 16 2004 Date of Inspection: TOWN OF BARNSTABLE HEALTH DEPT. Name of Inspector.(please print) William E_ •Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (508) 775-8776 CERTIFICATION STATEMENT i certify that l have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: . Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Sigtiatu Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healthvr. DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the appro.ving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 r OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 75 Thistle Drive Centerville, MA Owner. Christine Little Date of Inspection:. Inspection Summary: Check A,B,C,D or E I ALWAYS complete all of Section D A. System Passes: -1 have not found any,information which indicates that any of the failure criteria described in 310 CM 15.303 or in 310 CMR 15304`ex1st."Any failure criteria not evaluated are indicated below. omments: B' System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or rep ' d.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer es,no or not determined(Y,N,ND).in the for the following statements.If"not determined"please explain. e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsouild,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existi g tank is replaced with a complying septic tank as approved by the Board of Health. •A ifietal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indt ating that the tank is less than 20 years old is available. ND xplain: I _ 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 ap val of Board of Health): broken pipes)are replaces obstruction is removed distribution box is leveled or replaced explain: LThe system required pumping more than 4 times a year due to broken or obsw cted s . s inspection if(with approval of the Board of Health): Pam ) The system will broken pipe(s)are replaced obstruction is rt=vcd .` 1 � ND explain: Page'3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 75 Thistle Drive " _. Centerville. MA Owner: claristinp T.ittie Date of Inspection: . 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 rs failing to protect public health,safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR.15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety.and the cnYiroanient:- 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 in . 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the sy tem is functioning Ina 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 frond a p ivate 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 Gee 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. Other: 3 Page 4 of 1 f f OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) .Property Address: 75 Thistle Drive Centerville, MA Owner: Christine Little Date of Inspection:. - D D. System Failure Criteria applicable to all systems: You must indicate'y+es".or"no"to each of the following for all inspections: Yes No _ Backup of sewage into facility or system component due to 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 clogge& AS or cesspool C _ 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'/3 day flow — _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped .eV Any portion of the SAS,cesspool or privy is below high ground water elevation. _i Any portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface water supply. c Any portion of.a cesspool orprivy is within a Zone 1 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 wain supply well with no acceptable water quality analysis.]This system passes if the well water analysis, perfermed'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.] (Yes/No)The system fails.1 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. L Large e g 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-IWPA)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 crosidered a significant threat,or answered "yes"in Section D above the large system has failed.The owner yr operator of arty 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 ov.-ner should contact the appropriate.regional office of the Department. 4 i Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.B CHECKLIST Property Address: 75 Thistle Drive Centerville, MA Owner. Christine Little Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No .Pumping information was provided by the owner,occupant,or Board of Health — Were any of the system components pumped out in the previous two weeks?. Has the system received normal flows in'the previous two week period? - --� Have large volumes of water been introduced to the system recently or as art of this .- Y Y P inspection? — Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out.? ,L- _ Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information on the proper inaintcnance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no — Existing information.For example,a plan at the Board of Health. — Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance . is unacceptable)[310 CI AR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION Property Address: 75 Thistle Drive Centerville, MA Owner. Christine LIttle Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): DESIGN flow based on 310 CMR 15103(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no) ' Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no):t,12 Seasonal use:(yes or no): Water meter readings,if ava Table(last 2 years usage'(gpd)): 2 0 0 3 94 0 0 0 sump P um :r\ 200 2 — 93,000 P(Yes or no)._ Last date of occupancy: C OMM CIAL/INDUSTRIAL stablishment: ow(based on 310 CMIt 15.203): tpd design flow(seats/persons/sgft,etc.): trap present(yes or no):al waste holding tank present(yes or no):itary waste discharged to the Title 5 system(yes or no): eter readings,if available: e of occupancy/use: OTHER(describe): GE ERAL INFORMATION Pumping Records n Source of information: Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TY OF SYSTEM Septic tank,distribution box,soil absorption system .P rP Y Single cesspool _ g P _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 77guents,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75 Thistle Drive Centerville, MA Owner: Christine Little Date of Inspection: BUI DING SEWER(locate on site plan) Dcp below grade: Ma rials of construction: cast iron 40 PVC other(explain). Dis rice fr private water supply wcIfor suction line: Co is(on condition ofjoutts,venting,evidence of leakage,etc.): SEPTIC TANK: locate on site plan) Depth below grade: Material of construction: C concrete me�- fi�bcirglass_polyethylene_other(explain) J, If tank is metal list age: age confumed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) X / o f� Dimensions: Sludge depth., ' 1 Distance from top of sludge to bottom of outlet tee or battle: `/�1 Scum thickness:�_ "'---TYY----- Distance from top of scum to top of outlet tee or baffle: L IL_ Distance from bottom of scum to bottom of outlet tee orbaffle: How were dimensions determined: _r2?6 a J kj^'S Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert{gvidlecnncce of leakage etc.): M'niY GREASE TRAP: (locate on site plan) Depth below grade:_� Material of construe _concrete._metal fiberglass_polyethylene_other (explain): — Dimensions: . Scum thickness: Distance from of scum.to top of outlet(cc or baffle: Distance m bottom of scum to bottom of outlet tee or baffle: Date o ast pumping: Comments recommendations,inlet and outlet tce or baffle condition,structural integrity,liquid levels as related to outlet invert, vidence of leakage,etc.): 7 c Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ve DdA Owner: the Date of Inspection: TIGHT or HOLD TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grad . Material of cons tion: concrete metal fiberglass ,polyethylene oEher(explain):: Dimensions: Capacity. gallons Design Flo allons/day Alarm present s or no): Alarm leve Alarm in working order(yes or no): Date of la pumping: Comment (condition of alarm and float switches,.etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: A.;,�� Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of x,etc.): - ► ©� � �\l -In to� PUAIP CHAMBER: (lo to on site plan) Pumps in workin order(yes or no): Alarms in working rder(yes or no): Comments(note c dition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7.5 Thistle Drive Centerville, MA Owner Chri St i nP Little Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation'not-require d) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: _1 -P1nUr2, Sh L Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): �.2 CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and c figuration: Depth—to of liquid to inlet invert: Depth solids layer: Dept of scum layer: Di ensions of cesspool: Ma o onstruction: Indicati of groundwater inflow(yes or no): Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (t a on site plan) Material f construction: Dimens' ns: Depth o Comments(note cond' on of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 r OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION(continued) Property Address: 75 Thistle. Drive Centerville, MA Owner: hri st i nP Little Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 10 f Page l l of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75 Thistle Drive Centerville, MA Owner. Christine Id ttle Date:of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: t ned from system design plans on record-If checked,date of design plan reviewed: rved site(abutting property/observation hole within 1SO feet of SAS) ked with local Board of Health-explain: ked with local excavators,installers-(attach documentation) ssed USGS database-explain: You must describe ho"ou estab i ed the high ground wateJ elevation: 11 71 DATE: _ 4/29/96 PROPERTY ADDRESS: '75 Thistle Drive RECEIVED Centerville,Mass . MAY 6 1996 02632 HEALTH Q IKE , ._ TOWN OF CAF,6e� On the above date, I Inspecied the s-eptic system at the above address. This system consists of the following: 1 . 1-1000 gallon septic tank. 2. 1-61x8l block cesspool. Based bn my Ins:'k-ctlon, I certify the following conditions: 1 . This is a title five septic system. ( 78 Code ) 2. The system is full. Should be pumped out. • 3. The sytem is in failure . 4. The system must be upgraded to a title septic system. 81GNATUR!7- : Name:_J . P . Racomber Jr;,__ Company: J . PTMacomber &— Son_Inc . Addrass:_-$-e-x-,66------"------ Centerville LMass_-02632 Phone:_— , THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY LJOSEPH . MACOMBER & SON, INC. nkrCer�poolrLeachf laid:Pumped L Installedown Sewer Connectlon:6' Centerville, MA 02632 0066 775-3338 775-6412 Argoo Paul Celluccl uavw u. muun• Corrvr>jsalornr LL'Go..mae ILIJ/ to . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Addrosarf 5 Thistle Drive Centerville ,MA Address of Owner. Date of Inspootjoa: 4/29/96 (If different) Name of Inspootor. Jose h P Maipm er Jr. Company Na:ne,Address sun Telepbone um r. J.P.Macomber & Son Inc. Box 66 Centerville ,Mass . 02632 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurat.s 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: Passes _ Conditionally Passes hLead Further Evaluation By the Local Approving Authority Fails . G c Ina toys 9lguat �"'�'�'���� � Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of complet te ing this inspection. U the system is a shared system or has a design flow of.10,000 gpd or greater, the inspoctor 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 9UW RY: Check A, B, C,or D: A) SYSTEM PA.SSE9: _Alj!� 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 evaluatod are indicated below. B) SYSTEM CONDITIONALLY PASSES: Ale One or more system component, nood to be replaced or repairod. The system, upon completion of the replacement or repair, passes inspection. Indicate yea, no, or not determinod(Y, N,or ND). Describe basis of determination in all instances. U"not determined",explain why not) &)o The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or ezfiltratioa,-or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. (revised 11/03/95) l One Wlnter Street a Boston, Massachusetts 02108 a FAX (617) 5545-1049 • Telephone (617) 292.5500 `� Printed on Recycled P+pu SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) PropertyAddroaa: 75 Thistle Drive Centerville,Mass . 02632 Owner: Romuald A. Lachapelle Date of Inspec00n:4/29/96 B1 SYSTEM CONDITIONALLY PASSES (continued) Q. 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(&)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 C1 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: Atp Cesspool or privy is within 50 feet of a surface water _4�01 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 ENVIRONMENT: AI 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. �Q 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 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. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 75 Thistle Drive Centerville ,Mass . 02632 Owner. Romuald A. Lachape7le Date of Inrpeotion: 4/29/96 D) SYSTEM FAILS: • I hays datarminod that the system violates ono or more of the following failur•s criteria as daflnsd in 310 CUR 16.303. The basis for this determination is idanti.W below. The Board of Health should be contacted to determine what will be necessary to correct the failure. - Backup of saw&P into facility or system component due to an overloaded or dogged SAS or ceaspooL AD Discharge or ponding of affluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool jd�g9t:• Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool Liquid depth in cesspool u less than 6"below invert or available volume is leas than 1/2 day flow. R.oquir•od pumping more tlusn 4 times in the lost year NOT due to dogged or obstructed pipe(s). Number of times pumpod Any portion of the Soil Absorption System, cesspool or privy is below the high gmuadwatar elevation. Any portion of a cnaspool or privy•ia within 100 foot of a surface water supply or tributary to a surface water supply. Any portion of a co, pool or privy is within a Zone I of a public well. Ayj Any portion of a cesspool or privy is within 60 feet of a private water supply well. Any portion of a cesspool or privy is lose than 100 feet but groater than 60 foot from a private water supply well with no aoceptabls water quality analysis. If the well has boon analyzed to be acceptable,attach copy of wall water analyst for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to lurgv systems in addition to the criteria above: The system servos a facility with a dwign flow of 10,000 gpd or greater(Lugo System)and the system is a significant threat to public health and safety and the environment bo.ausa one or more of the following conditions exist: the ryvtem is within 400 fast of a surface water supply . drinking PPIY &T the rte sm is within 200 feat of&.tributary to a surfacs drinking water supply the system is locatod in a ni'.rogea s.onsitive area (Interim Wellhead Protection Area(IWPA)or a mappod Zoaa II of a public water supply wvll) The owner or operator of any such system sha.l bring the system and facility into U COmpllana u'tb thr Vmdwdtar trut=Mt prov= requlrvments of 314 CMR 6.00 and 6.00. Plos_e consult the local regional office of the Department for further information.. S 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddre= 75 Thistle Drive Centerville,Mass , 02632 Owner. Romuald A. Lachapelle Date of Inspection: 4/2 9/9 6 Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. 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 rev atly or as part of this inspection. "As 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. JZAll system components,wiccluding 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 ap ted 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. • I (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddreaw 75 Thistle Drive Centerville ,Mass . 02632 Owner. Romuald A. lachapelle Date of Inspeotion: 4/2 9/9 6 FLOW CONDITIONS RESIDENTIAL• Design flow: `j .,Pca:^CONY • Number of bedrooms:_ Number of current residents:_1 Garbage grinder(yes or no):_dlp Laundry connected to system(yes or no):A 5 Seasonal use(yes or no): a Water meter readings, if available: 1 1 •Qao � , 414", e 7 n2 .v .si Last date of occupancy:&je,7:/ COMMERCIAL/INDUSTRIAL: Type of establishment: A.)4 Design flow:, J�1_,gallons/day 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)lb Water meter readings, if available: AM Last date of occupancy:•& OTHER (Describe) 90 V4 Last date of occupancy: ! GENERAL INFORMATION PUMPING RECORDS and source f..Wormation: �ii.Q��i}•,qlk,P System pumped as part of inspection: (yes or no)A10 If yes,volume pumped: 0 -gallons Reason for pumping ^ TYPE OF SYSTEM Septic tank/ box/soil absorption system t ,</D sine cesspool ,V19 Overflow cesspool Vk Privy 40 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: :�G✓ `1 •tl-/•!/ .rlJ Sew odors detected when arriving at the site: (yes or no) (revised 11/03/915) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) PropertyAddreaw 75 Thistle Drive Centerville ,Mass . 02632 Owner. Romuald A. Lachapelle Date of Inspeotion:4/2 9/9 6 SEPTIQ TANKZl 1e0 a1"4' (locate on site plan) Depth below grader Material of constriction: concrete_metal_FRP,_,other(ez'plain) Dimensions: Sludge depth: Distance from to of sludge to bottom of outlet tee or baffle: Scum thickness:g Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Z'> Comments: structural integrity, (recommendation for um u�y condition of' gt and outlet tees or baffles de th ofe aq i Slevel in a eti n aridtle0 Ut 18 t t 8 8 S a r e evideaceofleaka eptc.) p rump septic tank every I — in place ; 7" Se is an is s rue urall sound. No evidence Septic is full and should be umn d GREASE TRAP:A,�K,4e- (locate on site plan) Depth below grade Material of construction: concrete_metal_FRP _other(e:plain) . Dimensions:,_ Scum thicl¢-ess: Distance hvm 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 DIS PP ART CSYSTEM INSPECTION FORM SYSTEM INFORMATION (oontinuod) propeyAddrees: 75 Thistle Drive Centerville ,Mass . 02632 owner. Romuald A. Lachapelle Date of Inspection: 4/2 9/9 6 TIGHT OR HOLDING TANY,& t,eel (locate on site plaa) Depth below Fader metal__FRP —other(explain) Material of oonstructiow/jeoncrete OIL- Dimensions:_ Capacity: ons Design ilow: onslday Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) � C•�f1i< "' 'I DISTRIBUTION BOY-Zi 11e- (locate on site plan) i Depth of liquid level above outlet invert:_ Comments: over, evidence of leakage into or out of box,etc.) (no{,e if le�;el and distribution is equal, evidence of solids carry PUMP CHAMBER:/j-'A (locate on site plan) Pumps in working orden(yes or no) 'ElrZ- Comments: and appurtenances.etc.) (not?co a of pump chamber, coadition of pampa PP ------------------- 7 (revised 11/03/95) - U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) PropertyAddre" 75 Thistle Drive Centerville ,Mass . 02632 Owner. Romuald A. Lachapelle Date of Inspection: 4/29/96 SOIL ABSORPTION SYSTEM (SAS)Z non-intrusive methods) (locate on site plan,if possible;excavation not required,but,may be approximated by . e If not determined to be present,explain: Type: leaching pits,number: Iaachin chambers, number. leaching galleries,number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number:, Comments- (note condition 9f soil, signs of hydraulic failure, level of pending,condition of vegetation,etc.) CESSPOOLS: (locate on site plan) Number and configuration:� jy(L,K Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer- Dimensions of cesspool: ^ Materials of construction: Z Indication of groundwater: part inflow(pe" n l Medium to�f ine sand. Loamy •san ., CommentsS note oo tiOn. #oil, signs of 4draulic failure, level of pending,condition of vegetation, etc.) Loamy and ,Fine sand. No si ns of h draulic failure o A vege a ion is norms e Cesspool is in faijUne— t—i T Te— ive. PRIVY:61kke_ (locate on site plan) ���• Dimensions:— MR aria 1.of constructpa. Depth of solids: Co (note ooaditie of soil, signs of hydraulic failure, level of pending,condition of vegetation, (revised 11/03/95) $ ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropertyAddreaw 75 Thistle Drive Centerville ,Mass . 02632 Owner. Romuald A. Lachapelle Date of Inspection: 4/2 9/9 6 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Centerville Osterville Water Company 428-6691 ) 1s/Hl _�G i ,0 I , I 11 1 DEPTH TO GROUNDWATER Depth to groundwater. 16 1 feet method of determination orapproximation: Installed many systems in this area. Have never observed the water table at these depths . (revised 11/03/95) 9 •rn-ri--r:•r--.r-1-r-rr.:-��-r.s---•.r,::•--rcr:-z.----.r...ter._=.-rr...—.._ .-....._ ._-. ._ ._... ._-.. . .-. -... .�i�-..r.T_�r-r..r. ..,_ _ TOWN OF Barnstable BOARD OF HEALTH SOBSORFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION •---.—.r..--z.—•.•:•-:--,..-�-....----..'z.--.—rx-rrs„:rrrrrsrrsa-zr::r�r�a+sr.'+ar.�-•rarrarrsrrr..•.-rrr•r.•-io•- -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 75 Thistle Drive Centerville ,Mass . 02632 ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Romuald A: Lachapelle PA11T D - CERTIFICATION r NAME OF INSPECTOR Joseph P. Macomber Jr.. COMPANY NAME J.P.Macomber & Son Inc. COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City Stat• LIP COMPANY TELEPI4ONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : Systeui PASSED The inspection t4hich I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 - CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . XXXXXXXXXXSysteru FAILED* The inspection which I have conducted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date 4/30/96 One copy of this t.ification must be provided to the OWNER, the BUYER ( where applicable ) and the 130ARD OF IIEALI'II. * If the inspection FAILED, the owner or "O� P' erator shall upgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in ''310 Ch1R 15 . 305 . F� Z L S�'1V 3r�1 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION DE IT KNOWN THAT Joseph P. Macomber, Jr. .s Has satisfied the Department's qualifications as required and_.is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 2 1A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the '"On of Water Pollution Control TOWN OF BARNSTABLE CC- N LOCATION yT /�o,�� /�/� SEWAGE # `/ 17A ASSESSOR'S MAP &L wo INSTALLER'S NAME&PHONE NO. 0iv�IA' 6- l-SI 2 SEPTIC TANK CAPACITY i�600 G� L CHING FACILITY: (type) 00 ect 66ewhz� Cad (size) /oLA3a NO.OF BEDROOMS _ BUELDER ORI/0WNfR77 U PERMITDATE: N1y��/ COMPLIANCE DATE:—.,, , oT 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 '),Wy 4,0r g ,iY-.�V • 4 cal(a d-4 1 S� r i �a�o7J�L f G y TOWN OF BARNSTABLE LOCATION TtlS>��� .bf- SEWAGE # 70 'k!LLAGEd1.'e w 4cr?Z! ASSESSOR'S MAP,&LOTM- O 26 _INSTALLER'S NAME&PHONE NO. he O'n n C. SEPTIC TANK CAPACITY I O D 0 LEACHING FACILITY: (type) 3 Ze Q-A A M!�r Cr S (size) 3 30 NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: '4 — R ' q& COMPLIANCE DATE: —L 7— 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 P � �. / ., ` Z C . � \�y �`� �1 3� �� l r TOWN QF.BARNSTABLE LOCATIO'1 SEWAGE# ! �II,LAGEe2-117 � —� ASSESSO 'S MAP &LOT INSTALLER'S NAME&PHONE NO. �` Z � ' SEPTIC TANK CAPACITY ",LEACHING FACILITY: (type) ���� -5-!57 (size) NO.OF BEDROOMS ��� BUILDER OR OWNER - �1� PERMPTDATE: � 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 existo e within 300 feet f leac 'n aFeet Furnished �� ��/� ® o '� T#is rz e �P o 0, C� ( No. Fee 40.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 01pprication for �Digpoe;ar *pgtem ttConmructton permit Application is hereby made for a Permit to Construct( )or Repair�[X)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No.4 — 75 Thistle Drive John Kelleher Centerville,Maes. 02632 321 Nye Road Centerville,Mass . 026312 Installer's Name,Address,and Tel.No. 5 0 8—77 5—3 3 3 8 Designer's Name,Address and Tel.No. J.P.Macomber Jr. Box 66 Centerville,Mass. 02632 Same Type of Building: DwellingXXXNo.of Bedrooms 3 Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) A d d 1 Pa.e h t r A n e h 2 8 t x 11 t 3—3 3 0 rechargers with drip pipe . Existing tank a.nd nPgQ:paol 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 issu by this B' d,¢f Hea Signed o Date 6/1 3/9 e Application Approved by - s, Application Disapproved for th following reasons Permit No. 'O- Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS r, Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(X )on by J.P.Macomber Jr. for John J. Ka,11p'.nar as 75 ThistleP ha n 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 belo ti ,ter 15 " ----- -- — —�——————————————————=—, —------ $ -- �.�_. 7NNo. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Mi,5po!6ai *p.5tem Congtruction Vermit Permission is hereby granted to J.P.Mae 0 mb e r Jr. to construct( )repair Z X)an On-site Sewage System located at 75 Thistle Drive Centerville.Mass. i and as described in the above Application for Disposal System Construction Permit. The applicant recogniz s his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction st be mpleted within two years of the date below. Date: Approved by 1 No. Fee$ 40.00 � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS ♦' i ZIPPYtcatibn for Mtoogai *pgtem 'Cougtructiou Permit Application is hereby made for a Permit to Construct( )or Repair'(CX)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No.-4 — 75 Thistle Drive ` John Kelleher Centerville,Mass. 02632 321 Nye Road Centerville,Mass . 02632 Installer's Name,Address,and Tel.No. 508-775-3338 Designer's Name,Address and Tel.No. J.P.Macomber Jr. Box 66 Centerville,Mass. 02632 Same Type of Building: DwellingXXXNo.of Bedrooms 3 Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow .. gallons. Plan Date Number of sheets "' Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) Add leach t r e n 6 h 2 R 1 x 1 1 t -3-3 30 rechargers with drip pipe. Existing tank And r-A$,Q}2on1 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 issuV by this Bod�Heal Signed /: o Date 6/1 3/96 Application Approved by 4 n c Application Disapproved for th following reasons Permit N �- 70e o Date Issued Front Existing 1000 gallonM Proposed 3-330 septic tank. Rechargers New Distribution Box T---4- i Existing cesspool 75 Thistle Drive Centerville ,Mass. I CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANSI I, J.P.Macomber Jr , hereby certify that the application for disposal works construction permit signed by me dated 6/13/96 , concerning the property located at 75 Tbi Q+l a D �l'p^+Pry=� l�gTl`4ass meets all-ofthe 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 v he bottom of the leaching facilit • The observed groundwater table is .4 feet or greater below t � Y • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. g SIGNED : > c DATE: v— 1✓ 7 LICENS EPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER_,0j2!,-. [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. TOP FNDN. AT EL. 62.9' SYSTEM - PROFILE TEST DOLE LOGS - ACCESS COVER TO WITHIN 6" OF FIN. GRADE (N OT TO SCALE) PROVIDE INSPECTION PORT WITHIN ' 6" Of FINISH GRADE AH OJALA, PE ACCESS COVER (WATERTIGHT) TO ENGINEER: MINIMUM .75' OF COVER OVER PRECAST /� WITHIN 6" OF FIN, GRADE 2% SLOPE REQUIRED OVER SYSTEM DAVID STANTON, RS go 62.0' WITNESS: I_ 9y�} �'41` 2" DOUBLE WAS HED PEASTONE DATE: 4/5/04 st ELEV. 60.2' < 2 MIN/INCH RUN PIPE LEVEL ( �' FOR FIRST 2' 3 MAX EXISTING 1000 X. PERC. RATE _ GALLON SEPTIC 58.8'f 59.1 CLASS i SOILS P# 10695 TANK (H- 10 j GAS 58.45' BAFFLE 5$.62' ""� a-.a n.n O.. o a._o a.. 9s �o�a� (RE-USE) C3 58.3' QCDC7Q M 0M0M " 4- AROUND ��yc+ • 6" CRUSHED STONE OR MECHANICAL o o a a a_ o a-a o.. ELEV. COMPACTION. (15.221 [2J) 8 - 2' � � � El 0 0 0 0 0 56.3' � 4 A 61.3 LOCUS � DEPTH OF FLOW 4 MIN. ( 1 3/4" TO 1 1/2" DOUBLE WASHED STONE SL SLOPE) TEE SIZES: ( % SLOPE) /, unsuit. INLET DEPTH = 10" 8" 10YR 2/1 OUTLET DEPTH = 14 B LOCATION MAP NTS LEACHING /SL unsuit. FOUNDATION EXIST. SEPTIC .TANK 9' D' BOX 17' FACILITY 5' 36" /10YR 6/4 ASSESSORS MAP 148 PARCEL 20 Cl "THE INSTALLER SHALL VERIFY THE �I- unauit. LOCATIONS OF ALL UTILITIES AND ALL / BUILDING SEWER OUTLETS AND ELEVATIONS *59.37 10YR 5/6 PRIOR TO INSTALLING ANY PORTION OF ` SEPTIC SYSTEM �`� 60" 56.3' 9 51.3 � 99.33 l/' EXISTING SAS C2 1�f-59.7 APPROX NO DIMENSIONS GIVEN ON AS-BLT PERC MCS & +6 �' �,Fo GRAVEL i 171-F,�9:�q'�,$•33 5' REMOVAL OF UNSUITABLE SOIL REQUIRED 10YR 6/6 I4 0 - AROUND PERIMETER OF LEACHING:FACILITY, +6 �'9 i' �' �F. DOWN TO SUITABLE SOIL LAYER (TO C2 LAYER , i t� `�� - SEE TEST HOLE -LOG)._REPLACE .WITH CLEAN 120 51.3 PAVED ,�' `�\ os - �.` MED. SAND.DRIVE NO WATER ENCOUNTERED i 59.35 BENCHMARK: USE C. NOTES; h�, I DRAIN MH "' BASIN AT EL. 59.0 +�i9.35 , SEPTIC DESIGN: (GARBAGE DISPOSER IS NOT Ai„j QWED ) 1. DATUM IS APPROX. NGVD 62s0 \ \ 1 DESIGN FLOW: 3 BEDROOMS ( 110 GPD) = 330 GPD 2. MUNICIPAL WATER IS EXISTING 14" OAKS- USE A 330 - GPD DESIGN FLOW " FO'OT, , -I-6 TH� 0 3. MINIMUM PIPE PITCH TO BE 1/8 PER /+6 . SEPTIC TANK: 330=GPD ( 2 ) = 660 . 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO 11- .1 tih � r9 USE A 4S 0.41`. 1000 GALLON SEPTIC TANK- (RE-USE EXISTING) 5. PIPE JOINTS TO BE MADE WATERTIGHT. _ +60 EXIST, a'Box 1, - ____ 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. 62 EXIST. ST. (REMOVE) 0.90*59.44 LEACHING: ENVIRONMENTAL CODE TITLE V. = EXISTTNG - (RE-USE) 29 1 . 2 30 ) 2 .74) 118=+ 9.83 TEL ( ( 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS N& DWELLING, 7=629' W G ca RISER SIDES: 30 x 9.83 .74 TO BE USED FOR ANY OTHER PURPOSE. R�EP�N G�o BOTTOM: ( ) 218 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. DECK TOTAL: 454 S.F. - 336 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT' +62.09 USE (2) 50D .GAL. _LEACHING CHAMBERS ACME OR INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED FROM BOARD OF HEALTH. � EQUAL) WITH 2,5' STONE AT SIDES, 4' AT ENDS AND 5' 10. PUMP & REMOVE (OR FILL- W/CLEAN- SAND) :FAILED SAS , LOT 80 GAS METER BETWEEN UNITS 15,00.0.SFt _ WATER METER *WATERLINE NOT MARKED AT TIME OF PERC TEST; ASSUMED LOCATION SHOWN. TO BE CONFIRMED PRIOR TO INSTALLATION OF SYSTEM , +62.68 LEGEND G E N D �h TITLE _5 SITE . PLAN - , 100.0 PROPOSED SPOT ELEVATION OF 75 THISTLE DRIVE 100x0 EXISTING SPOT ELEVATION _ IN THE TOWN OF: 100 _PROPOSED CONTOUR ( CENTERVILLE) BARNSTABLE 100 EXISTING ..CONTOUR_ PREPARED FOR: BORTOLOTTI CONSTRUCTION/ VAN FOSSEN 20 0 20 40 60 BOARD OF HEALTH APPROVED .- DATE MA SCALE: 1" = 20' DATE: APRIL 5, 2004 off 508-362-4541 fox 508 362-9880 I -jvk OF �SN OFs� down cape =engin eer'ing, in c. ���'� �+� ,���� ARNE H. 9cyN o ARNE o OJALA H. CIVIL y CIVIL EN-GINEERS OJALA No. LAND SURVEYORS No.2634 ��o � s IsTe Z f� s s 0 SOON N 04--092 939 main _st. Yarmouth, ma 02675 A JALA, P. ., P.L.S. DATE-