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HomeMy WebLinkAbout0043 THREE PONDS DRIVE - Health 43 Three Ponds Drive Centerville P A - 193 185 No. 4210 1/3 ORA Pendaflex f 10% COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION . e% MAP � PARCEL • 1 LOT �. r TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: G�4 Owner's Name: Owner's Address: 1a RECEIVED Date of Inspection`: o Name of Inspector: plea a print) `'�� _ C7 1 NOV 13 2003 Company Name Mailing Address: T�W HEALTH N OFrp., PT.STABLE D Telephone Number: g 27/- Qj CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on nay 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 ails Inspector's Signature: Date: /,7 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. Notes.and..Comments _. .., t ****This report only describes conditions at the time of inspection and under the conditions of use at 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 l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 \'&2 , ZV Owner: .deho� Date of Inspe ion: Inspection.Summary: Check A,B,C,D or E/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 CMR 15. 003 or in 310 CMR.15.304,exist. Any failure criteria•not.evaluated-are--indicated below- Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or-the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a.complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection.if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water.level in-the di-stribut-ion box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1'l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: J � �Cs? 6� 7✓tC y Owner. Date of Inspe 'on: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass.unless Board,.of Health determines in accordance with 310,CMR 15.303(t)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a.manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100,feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile or compounds indicates:that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A-copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: V-2A , Owner: ��— Date of Inspe ion��� 6 03 A System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to'each of the following for all inspections: Yes No Backup of sewage into facility or system comporient,due to overloaded or-clogged SAS,or.:cesspool Discharge or ponding of effluent to the surface of the around or surface waters due to an overloaded or clogged SAS or cesspool 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 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 SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy 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 water supply well-with no acceptable water quality.analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] 0 (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 31.0 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large'systeni 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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered.a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM E: PART$ .;. CHECKLIST Property Address: P Owner: ul _ Date of Insp ion: Check if the following have been done. You must indicate"yes"or"no"as to each of the following: _ Yes No -PumpingJnformation.was provided by the owner,occupant,'or.Board'of Health f /Were.any of the system components pumped out in the previous two weeks? l/ Has the system received normal flows in the previous two week period? _ __(,/6ave large.volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) v Was the facility or dwelling inspected for.signs of sewage back up — Was the site inspected for signs of break out? (� 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? owner),provided with information on the proper — Was.the facility owner(and occupants if different from )p p p maintenance of subsurface sewage disposal systems? The size and iocation of the Soil Absorption System (SAS)on the site has been determined based on: Yes no jExisting information. For example,a plan.at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15302(3)(b)] 5 Y 1 Page 6 of l l OFFICIAL,INSPECTION-FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE'DISPOSAL SYSTEM INSPECTION-FORM PART.C SYSTEM INFORMATION Property Address: an-OL 012,� Owner: �rnDateofInspe ion: � (jp 3 FLOW CONDITIONS RESIDENTIAL l� Number of bedrooms(design):. 3 . Number of bedrooms(actual): �. DESIGN flow based on 310 CMR 15.203 (for example: I W gpd x#of bedrooms): Number of current residents: C;� _ Does residence have.a garbage grinder(yes or n ) Is laundry on a separate sewage System (Yes or no ` ' . ifyes separate inspection required] Laundry system inspected(yes or nt./-&— Seasonal use: (yes or no)• _ Water meter readings, �t available(last 2 years usage(gPd)): 01_5 l��� ®Z �� AM Sump pump(yes or n . �. Last date of occupancy). J� COMMER `CIAL/INDUSTRIAL Type of establishment:. Design flow(based on 310 CMR.15.203): gpd Basis of design flow(§eats�persons/sgft,etc.): . Grease trap present(yes or no): Indast:riAl waste holden tank present or- no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: J Dkc�o(� Was system.pumped as.part of the inspection.(yes or no) . If yes, volume pumped: gallons--'How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _:Privy _Shared system.(yes or no)(if yes,attach previous inspection records,-if any) Innovative/Alternative technology Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank —Attach a copy'of the DEP.approval —Other'(describe): A rozimate age fall components d to nstalled if known) nd sojurce o information: UAL 4? �j9s Were.sewage odorsdetected when arriving.at the site(yes'or no): 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Aao� Owner: l� • - A Date of Inspec on: 3 BUILDING SEWER(locate on site plan),IIX,6" Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain):- Distance from private water supply well or suction liner Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK: 1/ (locate on site plan) IV Depth below grade: C Material of construction: :,'concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: , Sludge depth: 7 )/ Distance from top of sludge to bottom of outlet tee or baffle: ZY Scum thickness: Distance from top of scum to top of outlet tee or baffle- Distance from bottom of scum to bottom of outlet tee baffle' How were dimensions determined: con Comments (on pumping recommendditions, irAet and outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert, evidence of leakage,etc.): ' �. O 4 ?r�� Vic GREASE TRAP;JUE(locate on.site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART C" SYSTEM INFORMATION.(continued) Property Address: Owner: _ Date of Inspec ion: oU TIGHT or HOLDING TANK (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): y Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches,etc.): ,DISTRIBUTION BOX: Z f present must be opened)(locate on site.plan) Depth of liquid level above outlet invert: e/ f Comments (note if box is level and distribution to outle s , s carryover, any evidence of equal any evidence of solid ,kzkage into or out of box, etc " / el (�"` t h121W PUMP CHAMBER(locate on site plan) Pumps working order es or no P (Y ) Alarms in working order(yes or no):. Comments(note condition of pump chamber, condition-of pumps an&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: ✓�G a Owner: Date of Insp tion: to 3 SOIL ABSORPTION SYSTEM (SAS): ✓(locate on site plan,excavation not required) If SAS not located explain why: Type ::?",eaching pits,number: leaching chambers, number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil;condition of vegetation, etc ): mao U ��- ..t�'mac - ..Pik ���•�/Q-�,v`Z�o (�'i ��2.�PiL- /��� ��1�8�-,-c.l,��n �� _ `. CESSPOOLS/ �(cesspool must be pumped as part of inspect i on)(locate on site plan) JJ '' �- YI . Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil;signs of hydraulic-failure,level.of p 0- nding,'condition of vegetation,etc.): PRIVY.)(lp—(locate on site plan) Materials of construction- Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 f Page 10 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: A Owner: Date of Inspec °on: iO 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. �3 y3 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: "Eft f{ Owner: Date of Inspe ion: o� SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water A—feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation-hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 Permit Number: Date: Completed by: S! HIGH GROUND-WATER LEVEL COMPUTATION Site Location:_ thine e �( � �.�� �/j� Loyt No. Owner: ,eG'7(q'e� r-_ Address: y� Contractor: address: Notes: STEP 1 Measure depth to water*table l to nearest 1l10 i. .................... e �// �•�/'' 3 � ................................... month/day/year STEP 2 Using Water-Level Range Zone _ I and Index Wel'I'Map locate site and d'etemine: ® 7�� A Appropriate index well..........................•. ��,►✓ �. OWater-level range zone ............... �� STEP 3 Using monthly report."Current Water Resources Conditions" j determine current depth to •water level-for index well ::.. 1Olnu- ................ month/year S T `'P d Using ,Table of Water-level Adjustments. j for index well (STEP 2A), current depth to water level for index.well ('STEP 3)., 'and water-level'zone (STEP 2B) determine waterdevel .............................. 'STEP 5 . Estimate depth to hi.gh'water by subtracting the water- level adjustment (STEP 4) j rom measured'de'pth to water level at site (STEP 1)'............... .....................:........................................................................ / Figure 13.--Reproducible computation i form. i . . �,. �� . � ������s �� ... ._. � � .. . .. . ,R._ f i I I I I I TOWN OF BARNSTABLE LOCATION 7Z /4£E 00epW 4w, SEWAGE VILLAGE__ C .nTTT�.�Jtv.{ ASSESSOR'S MAP& LOT 1�—/I S� INSTALLER'S NAME&PHONE NO. � SEPTIC TANK CAPACITY_ / W LEACHING FACILITY: (type)_ z7 - �l Aj£r�1) 1 (size) 62- 16 NO.OF BEDROOMS— BUILDER OR�� Q J • ' I PERMTTDATE: COMPLIANCE DATE: �' ~ Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility — Feet Private Water Supply Well and Leaching• g Facility (If an wells exist y on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of le g faci '� Feet Furnished by f1r4 - 9qAd ���� tb -- TOWN OF BA.RNSTABLE 9 LC:CATION 16�''L SEWAGE # 9(1--- 14.17 VILLAGE ` ASSESSOR'S MAP& LOT A3 INSTALLER'S NAME&PHONE NO. VCY'tT7Ct00t_e7 SEPTIC TANK CAPACITY LEACHING FACILrTY: (type) Cl °y (size) NO.OF BEDROOMS - A _ BUILDER OR O Q J Q PERMITDATE: ���'?/ COMPLIANCE DATE:__ m" "' 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) /l J f Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of le ' g faci Feet Furnished by i o q s' i� 36 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Alip iration for Di-aipwiMl Workii Tomitrurtion 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair 0.6 an Individual Sewage Disposal System at: - �i� ...���n yes ��2` r CE^�� /�trees------------ -------------------- - /1 Loc tion- %dddrsss or Lot No. -u.(J ON11cSf� ------ - ----- - !a fin/�/J/S�/QIZ........................................................... F1.1 ec W �elt zr f�,/)7 �j(j/J�S')�.ef r/� C c`!��/'�/1/�Wr""Y/'+ 7 e Addr�esss r�✓� 1 ( 4-Z •................ ...........•-•------•-•----•._._...._._.............••••..................... ------------------------------•-••---------•--- ..........----•---------........................ � Installer Address d Type of Building Size Lot----SB.F..........Sq. feet Dwelling— No. of Bedrooms_______________�--.___-__--___------.-_Expansion Attic ( ) Garbage Grinder ( ) pa., Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures _... -- .................................... W Design Flow--------------------- ..._....gallons per person per day. Total dail fiow _30...............gallons. WSeptic Tank—Liquid capacitylQ� ___gallons Length___ t __ Width---------------- Diameter................ Depth___ x Disposal Trench—No. .................... Width-------------------- Total Length...---------1;------ Total leaching area....................sq. ft. Seepage Pit No--------.-/------- Diameter-------/0.-_.._. Depth below inlet___-_�........... Total leaching area..................sq. ft. Z Other Distribution box (bL-) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit-----------------__. Depth to ground water_-.-_.-._.-___--_-__.--- 44 Test Pit No. 2.............. .minutes per inch ' Depth of Test Pit.................... Depth to ground water------------------------ 9 ---•-----------------------------••....-••------•-••----••-••--•--••-•-•---•-•--••-•......................................................................... 0 Description of Soil.....----•---------------------•----....................................................................................................................... x c., E--- W ...................................... - - ------------------------------- Nature of Repairs or Alterations—Answer when applicable._.--_-. .-. -!S.. ..... f%?- ----------- - U P ���` c�/(/L.oUe-l1/J£sQ __/ ......... ..............•-- � `1 ' 'ill � Agreement: eS vrtc- cS y�5 l vd) The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environment Code —The undersigned further agrees not to place the system in operation until a Certificate of Complian�as ,issu he board of health. Signed ..... -- - - Date Application.Approved By .......... ... ----- ---------------------------------------------------------------- ....� Application Disapproved for the following reasons: .............................................................. -------------------- ------------------- -------..................._......._......_......---...----- ------------------ ------ -----...---- ---------- ----------.........---.....---...----....----...-- ---............ ---------------------------------------- Permit No. ...... _-'._1-�0.f�----..-..... Issued ................ ._/3...'""./. .. Dace ^7 �7 O a No-7, —.t`1-�i�-d. / Fps.........:................... 1� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I TOWN OF BARNSTABLE Applirativit for Di-ripuual Work.6 Tvastrnr#inn Permit Application is hereby made for a Permit to Construct ( ) or Repair (�>6 an Individual Sewage Disposal System at: ...... . CE ------------------------------------------------------------------ Location-ilddress or Lot No. ..................... -------------J...................... �O/lil . J� l�vi�S✓e`�1.. Address /� r ��1 I l�l S Installer Address Type of Building Size Lot__�.. 61)........Sq. feet .-, Dwelling—No. of Bedrooms______________-�3---------------------- Attic ( ) Garbage Grinder ( ) a Other—T e of Building ............................ No. of ersons..-._._._._-_........__-___. Showers a Other—Type g p ( ) — Cafeteria ,( ) Otherfixtures -------••------ --------------•----•-------------------------------------------------- --........................................................... W Design Flow----------------_---- _________gallons per person per day. Total daily flow.-_.........__...............�.3-0..............gallons. WSeptic Tank—Liquid capacity/0 a._gallons Length__%l Width...5-__-------- Diameter_----_-____-__ Depth....140'_'sa�5= x Disposal Trench--No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. ii Seepage Pit No........../....... Diameter......./Q-------- Depth below inlet..__.�o-_.---_.--_ Total leaching area..................sq. ft. Z Other Distribution box (J- ) Dosing tank ( ) aPercolation Test Results Performed by..................................... .................................... Date........................................ 1.4 Test Pit No. I.......... .....minutes per inch Depth of Test Pit__-__-_._.__________ Depth to ground water..................... 1-4 ( , Test Pit No. 2...........-----minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ----------------------------•-----.._.._._..._...----------'---._.----------•••'-'------•--•-'------......................................................... 0 Description of Soil........................................................................................................................................................................ n.. ---------------- ------------------ -- ------------------------------------------------ ---------___------------------------------------------------------ ------------------------- U Nature of Repairs or Alterations—Answer when applicable.___-__,A-- -----e°+-_______/.W b_�.•-•(N- � /•f _ viLLu� 1/Jj ley------ �= -----__._..�Nsit-1F ------- `S' C'`�f' �t g- ��--•''"!�- Agreement: ' ��4i[C, �S VJT-�kvi The undersigned agreesto install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environment 1 Code—The undersigned further agrees not to place the, system in operation until a Certificate of Compliance, as e issu by he board of health. Signed ...- '� -- . .. ::::..................................... Dare Application.Approved BY ---------(J ... . .. - ... ......_............................... Application Disapproved for the following reasons- --------------- ........... ........ . ...............................--- ............................ ;. ....... ................................................._..............._........ ...._............. .. ..... ...... --------------------------- ------- -----.----------- ---------------------------------------- Permit i ............_...... 77 Date No. ......�.�� -�-lr.�-.l� Issued -- �.....�;�....-'-.�-�c Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (1ertifirazte of C1lomplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( lam) by ---------------------------------- GfJ.rJ...-si---t.-1c+....---trN------------------------- h,ntuer _ at ----------_-------------------------------------y._........ 1<4 E �G"J✓js D�C� � ��G`'�-- ----Lt/i L-- has been installed in accordance with the provisions of TITLE 5 f The State Environmental Code as described in the application for Disposal Works Construction Permit No. _.....(�� _ ..(�. ..- dated ------- 7..--.../._�.. ...�5� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WI FUNCTION SATISF CTORY. DATE ram- ..`."... ....-- ....- Inspect r �ti' _ __ "c•'�i2 __- _ �,_-- .-_ _.c_________, _„_, THE COMMONWEALTH OF MASSACHUSETTS -� BOARD OF HEALTH TOWN OF BARNSTABLE No..7�,C......I.L ] 7 FEE--2d.-.... �tunuttl kn Tnn#rnrtinn Permit Permission is hereby granted................... ......... �'q.s .................................... to Construct ( ) or RepaiW _) an Individual Sew e Dis osal System at No. % R �c GN -------ig F----- �= ����/1�1i t;t .............. Street as shown on the application for Disposal Works Construction Permit No.9.����7 Dated_.__... j.-., _5:...... DATE........... �•—•----..----••-...... ---••-------- Board of Health 4. C ij �-'._�._-�--==--�----- FORM 36508 HOBBS♦!WARREN.INC..PUBLISHERS • f t /tip 6` y w j �d. ... .. No.. ..........._....... Fps..... ....................... �. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - ................OF.-.-..................--------........................................................... Applira Lion for Diipviiaal Workii Tnntitrurtiun anti# Application is hereby made for a Permit to Construct � or Repair ( ) an Individual Sewage Disposal System at: ....:�Q.f._... _.5�.1............ . ... Qs... ��e.................. ,,,,�z_____�_� ..-•4e---------...-----...........••-•••--------- Lgcation-Address or Lot No. 4eZ 9wnCr /� Addre ,Wa •-•-•.......... tll.�v-----�f_G,e X-----------------•--••------------__------- -..L.: l!'s! e..LAL.ie----.. .......... Installer Address dType of Building Size Lot............................Sq. feet U DwellingNo. of Bedrooms............... Expansion Attic Garbage Grinder — �----------------------- P g P-4-, Other—Type of Building !�!�^' ..___._.____ No. of persons_._eK`,e........... Showers (cQ) — Cafeteria (-t) a' Other fixtures ................................. W Design Flow................//C ...per person per day. Total daily flow____._._______9__-_._'_._____________gallons. WSeptic Tank—Liquid capaciV�Vq____gallons Length................ Width................ Diameter.............._. Depth................ x Disposal Trench—No..................... Width��� _._.___ Total Length.................... Total leaching area_._.................sq. ft. Seepage Pit No_____________d________ Diameter........ Depth below inlet___.__.Via_____..__ Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ( ) Y •-. Date_.______ ?----- f ?� Percolation Test Results Performed by......�t'i�Gt.�___.�4Pl..'�_ ______________________ �0 aTest Pit No. 1..... .____.minutes per inch Depth of Test Pit____________________ Depth to ground water_____________________,__. i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ W -•---••-•--•--------------••-••----•-•-•.........................................................-•.....--•-- -••.......•-••--•-•-•.........•••.._..--•-- 0 Description of Soil___- n?_f.__S'C! _ Q/ ................................ ........ ............ 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 IITILE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed....91e ? .. ................................. Date ApplicationApproved By....... ... ....................................................•---...-----•--...--•------ Date Application Disapproved for the following reasons----------------•----------------...-------------------------•---------------•-----------•-...•---•--------••---- •------•-•--••••••--•--••-....••-•-•--••••----••-••-•••-•••-•--•••-•--••••_...--•---------•--•-----••---•I--•--•----•-•--•-•-••-•-•-•••-•-•-••----•••-•••-•-••-•-•••--••••---••••--------•--••--•----•--- Date � 57_ PermitNo. Z9`............................................. Issued -------------�--t-�------------------------ Date I No...................... Fps.... ..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF......................................................................................... Appliration for Uhiposal ]Vorks Tonstrurtion ramit, Application is hereby made for a Permit to Construct ' _) or Repair an Individual Sewage Disposal System at:- ... ....................................................................... .................................................................................................. ,,,�catiojx-Address ,,5,�or Lot No r4 (") el,Vl.; V ��r �$7 A-le Owner Addr . ....................... ........................................ ...(............................................................................................. Installer Address d Type of Building Size Lot............................Sq. feet U 0-4 Dwelling—No. of Bedrooms..__...._... Z..........................Expansion Attic Garbage Grinder Ai C) A_1 ..... "176"e —2) —.Cafeteria 04 Other—Type of Building -----------------_--- No. of persons-----------­---_---------- Showers ( Otherfixtures .................................................................................................................................................... Design Flow______________________________ _____________gallons per person per day. Total daily flow............. ................gallons. 1:4 Septic Tank—Liquid capacir/j........gallons Length................ Width___..._......... Diameter_____________-__ Depth................ Disposal Trench—No..................... Width.................... Total Length..____.._........... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter..__... w Depth below inlet.._.._.(i........... Total leaching area..................sq. f t. Z Other Distribution box Dosing t '_4 V. / I/ Date.2�Percolation Test Results Performed by......... ....................................................... ............................. 1.4 �;Z Test Pit No. I................minutes per inch Depth of Test Pit._______..........._ Depth to ground water........................ rTq Test Pit No. 2................minutes per inch Depth of Test Pit.__.............._.. Depth to ground water....................... ............ ........ ........................................................ 46 1��*-----------------------------------*------------**------- 0 Description of Soil....................../'- So/ _ ........................................................................................................................6--,.. .................... W U ............................................................... �W�7 ............ ... ......... ................. ......................... .................................. ........... .......... ..........................................................................................-------------------­----- ................................................................................ U Nature of Repairs or Alterations—Answer when applicable----------------------......................................................................... I ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT ILE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed .................... ....... 7f j Application Approved By___..__�.,. A ap . ..................................................................................... ........................................ Date Application Disapproved for the following reasons:.......................................................................................................`__S_ ....................................................................................................................................................................................................... Date PermitNo.......................................................... IssuedL....................................................... Date --tHE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................................OF..................................................................................... (9rdifiratr* of Tompliaurr THIS IS TO CERTIFY, Tat the Individual'Sewage Disposal System constructed or Repaired by........... ............ .................................................................................................................................................... ..... Install A0 k, C , ,i _,*4, at................... ............................ . .....................................................................................................................4 .................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the 'T ................. dated. !?�- 0- 7F application for Disposal Work4 Construction Permit No.' ...................... ........................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL UNCTION §ATI;SFACTORY. DATE... ................. = Inspector...... AZ&.............................. THE COMMONWEALTH,g,MASSACHUSETTS BOARD OF HEALTH ................ ..........._OF......... e........................................ No..........Z q ............ I FEE........21.2 Disposal Iforks TWImitrudion "panfit s. Permission is hereby granted_.._. / e�4 ..'. C .............................................................................. .............. ..................y tipConstruct or Repair an In Sewage Disposgl System W_...,'n t Iq 0 di AP i, 01444f .......... A&A.If ZS................................................................................................... Street ­­'_ 4- /f 4 77 as Shown on the application fpr6i`s�p6 sal Works NO__ Dated..._..r---- o ................... ----- - ------- ----�oard o__ .1...... .......�H_ealth.......................................... DATE. 7 ,It.......................................... FORM 1255 HOPES & WARREN. INC., PUBLISHERS LOCATION SEWAGE PERMIT NO. VI/L�LAG E 'IN.STA LLE ,R''S NAME & ADDRESS j 0 U I'L-D E RR OR- OWNER C P I . DATE PERMIT ISSUED D - DATE COMPLIANCE ISSUED �� '-y. � J Lo,� 341/ - TyR�-L- ,vo;E,' S./�I. /S TEST ,�/ot E ID 37''` SAN ZOT 4z G Pill Rao IT S /Oppy ; ZG 0E/VGo TE!`� UAj , E 1:FAG,q; TEST" 1-/ OL, • ' REs U � T as�, . S #1 PCR TO WN R,5,II. I D ATE SCALE . / „ 3 TO1 G•/A/ WA:-.rEP.- /.S /l VA / L A L G T .4d - L3 L E //vSP. ,age �lv,C'iPA M. III o.;,:SU/LDlI�lG SETC3fjC/< RE0U/ RE&7,Eol7-5 000vr DReIVEL�/r9"V`-`";I '::, N07' 7-40 23 E li7.-EZ:) OSEZD 3 ,6T.) OM$ 3 O_VE1E? SAE* Sys �',E/"! UNLESS DES/G/v F4-O k/ F 3 O G.9L �DAy ICES /,G•/V .,LOA2� /ti;/G /S usED . peoPOSED LEACH �A/2EA Zvo SEPT/C S yS`TE M. CONS-rR UC T/ O/�/ S//�9,L�(- 0OAIPo ,2/�,.:.TO. /"/ASS. ENV/� O/�/ME/VT�9C.. PE/CCOL .�T/O�/ TEST CODE j� l�e9 T E•D .Tvc;Y /, 9 77 F;�/�/D 7-Oh//V ,�F RES LILTS M/ fh/C',f-tr Z4,ceti- 7-,9e4-g'. H E i L Ty - REG L/L A T/ O/Vg. SILL ELE V. TO f3E > — FT. /980 VE T' Y P / C, A L P R O F I L E Top of ! ' c s>T-o.tr�c GRIT 409sovE ka�c FO u ND F1T/o,^l A/ O S C A ,C. E //Od-QQ'��' Cljl,J�-•D, - /MPE,2VlOUS COVE I/ MAN oLE eovER To EXTEND TO To 'p,eEVENT F/NE5'; GRRDE M/N/MUM I FROM /NF/LT,2�T/N(a' /O'M/N/MUM---� 5T0,vE 2 " Or /"To �.. 116,_,� .Z4"'Z'oVE,25' _a ,yt.,t D/ST. 8 �t _►{ Oov�,e WASf/ED sT 4"c+AST BOX r /✓/aE r9LL. f�,eou 6"M/n/•ON 4 D/� M /A/ , T 4 ' Dl�. �P/T�iy ry FLoi✓ L/NE M/M. P/Tc - 2- I 3� ,q `FOOT to - /4„ ttl Fool: M/�/. P/TCH /00 �•q -/�z 2 x_ MIA/ ,6� �¢"�FooT � GALLON W,49 SHED /000 _y /�JVE,eT .3to LEAeH STD NE a?,Q O GPL. LO/V T Ce v ALL. /NVERT CA PAC /Ty �C (p /9,e p uND Sol TANK 8963 g9 J 9 n'C ZOCJ �SLJL �Wf�rEPar/GHT) //vVE;er ` � � (c+ZS 9 //V vE,eT Z. E/vC H f /A I 7- C r^ 48"M /V•O GAR8AGE GRlNDE/e /9,2E,9 20 /01/N/M UM < 1 >` 6 x 1' > OF �y 4' /"/ / A/. D/ST. TO Al .: P/. O T PLA9 RONALD yN A •A4OC ; , ARTHUR 4. SCALE : / "r'� O . , DATE: /9���'J/L /7 / 7c9 GIFFO 3 ,2 E oll RE NC E !'19 E/N!a' 4 O.'7T . 9/ As sNOc✓�! Ivo.so3 OA/ A P,G .9/N/ R E e 40 D E D; //V 7";/ E BA,en/- S'�NirARRPN ' STi98LE CG� U'�/ti/TY, ,2EG / ST,ey OF DEEDS ? 3g'•,5'O 7� FO,2 .. __.._ _: Iq�19�8 SEPTI c Tfl NK TD 8.E /9 M/,l/- S'Ui� T/ Tyr' !Js "� , 7- /MUM OF /O Ff�'O/"!', FO UND,q- O. T/ O N 9 v 4Ef90HI/vS P/ TS 7701 SE � M/ so. y/`31Q` A' C:J 7"/-6 /YJooq s /M U/"1 O F / O' F/e O M P)2 O PE)2 I CER7- THAT ' THE :641/4-01 ✓G ,,��, L SHO Wn/ 0& 77H I.S. P,L/9 N / S o<;-A? 7-4:F4 P ''';,4, ,t, or, ;�<r ON T/-/E G R'O Un! r A .5 SHOW,,) flEREO/v ' G0, -r: �- i�o v,V.c�f�T/off 9�z 0 '9= 3 ,Op• - _ = 6z 3' 'S> /OU,G�' ,¢SSUflED LOAM FN> O.Z S Bso i G�4 i LOT• 4z ✓� d�� o k' /O p0S , •� 0 w,gT.ER ,E�/c a vw,--,E-,QE TES T H O L �1 PER TOWN /2 E G'O le i, 4P/ell- /z/!S7 Toll^/N WA 7'E J�. /S �.VA /'L �J 8 L E L G T .ga //VSP. f z�vt/l- i'-lU"° q M//V/'m U/`9 o : 3U I,L Z) A/6 6 E r6 i9 C K RE 0 U/ R E ME/l/T.S. F,2On/T :;p00: �' • ' ' pe0Po 'sED r3EDRooms D,eI vE wf3Y i' NOT TO , 3E. LOCF-�TED 0VE/e SE,�/�,��2f�pE SyST,EM UNLESS DES/Gti/ FLOW 330 G�9L�DA H-eo - ZEES /•G.N I-oAD1"c7 /S , USED . P,eOPOSED LEACH Rp-EA Z0. SEP7T/0 Sy5 TE M Co�/STRUCT/ OA/ SHALL- PERCOLAT/OA./ TEST CONF'O ,2M-' •TO. /`MASS. L- /�/ Vl� ONME/VT9L. , /e ES C1�L TS -� C O D E -4)/9 T i5 D . V 4 Y /p' /9 77 FEN //l/� �D TO/AF ,evs7'�9,�G HEAL Tf-� /2EGULAT/ O/1/S'. SILL ELEV. TO f3E — FT. IgBOVE ToP FO UNDAT/O'Nl N O S C �" E / p,2V/OU.S COVE2 MAN oLE eovaR To ExTE�IID 7'o To �,eEvENT FIVES 'W/Tl4//V l OF F/it/ISHED GRRZ)E F,2pM /n/F/LTRAT/NG M/N/MUM /.D'M/N/MUM—� STONE 2 " or- / 'rc . ►,� -24-" *oVE�eS �'t D/sT. $ �t _►i eov�,e tvl9SHED ell Sox __ 4 CASTIRON -6,.-M/a �Y 3npq N. ,4„ D/�. wA,g p� 'j ^ - 2 /aHr -4 D/,9. /O I`'J1N/M UM �b p/7- —FLOW LINE /IW. piTC -" 3 `FOOT /¢" /4' Foor 14 'IFoor �¢, GA L L ON 'e h/A SHED Y_ M/,v •6z 3rO p LEACH STo IV /0 00 ALL 09 �'00 G/gL:LO/V Y //JVE.eT 4 INVERT P/ T �2e INVERT CA pig C /Ty !.. (oO uND SEPTIC TANK �9?63 �9, !9T �Od �Wf�rERTIG KT� /,V Vag rr IN VE97' INVERT /t/'O GA,eBHGE GRINDER' A,2 EA A/. D/ST. TD 1. •;.i;;. ! OA G, . ND OF MA�S9 L ,eOU " WigTE,e EL p/. O T, PL / /Q o� cy ;� . ; c ARTHUR L O C A T/ O Iv,�' BAiP,�IJ�s'Ti9,BLE , �•^ GIFFORD S C r9 L E: I c.�O'. D A T'E: /9P�/L !7, /978 } No.603 ,e E A'E,0E NG' E- 'i 23 NCB - 0 q� f�S SHOG✓N ISTEa`�� pN A C oil D E D; /N TINE SARN` SgNITAR�PN t $TABLE C-0U..":7 AEG / ST,eY 4F DEEDS �a D N L SEPT/ C Tr9 NK T o 8.4' . A 1v61 T/�r' UST' /MVM OF /O' OM'.. FO uND E h9 C H //N G P/ T'S ;rQ 73 E A M S �• yi'-?R•A1 o u. 7 /-6 /M um OF / D' F)e O M P)e O PE C E i2 T/ F y.�• TN A T'' T f-/ �E3 !'G ©y A16 ,j'•� I E L/ ,. .. ^ P1-,q AJ / S ,�v.ewA ?'Eo " �','�'" or,�,,''�` flND ZO' F'�' OI�-I F DUNS 7 ON THE G R"o UN D ,95 S HO tVN f-lE,eEoN f t� GEORGE 14) �'S C D N FO,2M pow,�a. j DATE T/ T L_ E ._. _ 7-0 T�/ E 23 U./'l. D 1 NG SET F3,-?e K REQv/�E SOIL L 0 S yI /o% -7 �Xy;I7��ll�:Y�\V i,uy- IK cxi.isvu���u�/.��i_ .CTx 2".PEASTONE LOAM a FILL 12 MAX. GvOOb.0 .a," ° Sa. L 4"C.I. DIST. BOX �a ° e° °° c nD '�I 6�BiEc %c5T 98.7 .o'MIN. 1000 _I e24"MIN. 1000— GAL. �oI GAL. ° °o PRECAST OR c ° SEPTIC 6•100� BLOCK TANK ° SEEPAGE PIT f� i'e'° ' ' Arraof Sld!s= 1886E o° Rrca of Eo JA, - °79" °� o c' 20 MINIMUM +i°,° °o Tofa1_2 75•F 01 ` FOUNDATION I° ° i g----� I I % WASHED STONE ELEVATION SKETCH 10, P1NC. R A T 9 .t...��v.�i.�wy SCALE: 1"= 4' TEST BY TOWN INSPECTOR: BACKHOE OPERATOR : s.ZQ ' .{�rpG-rca Desl /7 L'r"I*r1,,q TEST MADE ON , .v.ra.�/ �s fima dui iy " iwf(3 BIifwms) 2 x 1 t4 = 220 2)Raxlm u/n a//owa6le daffy �/ow r�r fh:s syskm- I 5j4dV gal/s ' 188 s,F- X 21 sty gpd/s°r = �17Ogpd. V f 8of om 79 sF x f.00 y*Isx- 79 Tafa/ _ 49,E -17 1 �•/77, /O o,o o ' /�•ss v.ar�D X \' Ial c o- ' ti 3 I Y s • 'V N 1 �� y �r,� N , ,1 V• 0 . 1111 c 0rn a 69x FA (b0 °to C ---g w w.q-rid I or- ELEVATION SCHEDULE PROPOSED SITE PLAN lk I. INV. AT FOUNDATION = lQ . SEWAGE SYSTEM DESIGN 2. INV. INTO SEPTIC TANK = IN 3. I NV, OUT OF SEPTIC TANK = ion, BA R/V,5 f ABZ-C, , MASS. 1 I I (CEN<7'�/,?V1L<4"a} OF 4. INV. INTO DISTRIBUTION BOX SCALE 1°- ,30' Alarch201978. oDANA�Sss �• 5 INV OUT OF DISTRIBUTION BOX = C— 652 W. l © MCKECHINIE -' CAPE COD SURVEY CONSULTANTS C3 °i 6. INV INTO SEEPAGE PIT = � ,A .pNo.t4704�0 Q • ROUTE 132 7. BOTTOM OF PIT = 94.00 HYANNIS,MASS. A DIVISION BOSTON SURVEY CONSULTANTS, INC. �� s•, B. BOTTOM OF STONE LAYER = ' _ r s E` 1